2021-09-17 Payer Data Exchange (PDex/Formulary/PlanNet) Implementer Support Meeting

Call Structure & Name Changes

• Friday 12noon ET - Payer Data Exchange (PDex/Formulary/PlanNet) Implementer Support Meetings
• Friday 2pm ET - Payer Data Exchange (PDex/Formulary/PlanNet) Version 2 Meetings (formerly the PCDE call)

New 9/16/2021 - CMS Enforcement Discretion

‒https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index

‒https://www.cms.gov/faqs#122

Specifically of interest to Da Vinci Community are updates in the FAQs reinforcing move to APIs and the use of Our FHIR APIs 

Question. Will CMS enforce the payer-to-payer data exchange requirements on January 1, 2022 as finalized in the CMS Interoperability and Patient Access final rule?

Response. No. CMS is exercising its discretion in how it enforces the payer-to-payer data exchange provisions (85 FR 25564-25569) of the CMS Interoperability and Patient Access final rule (CMS-9115-F). As a matter of enforcement discretion, CMS will not take action to enforce compliance with these specific provisions until future rulemaking is finalized. CMS’s decision to exercise enforcement discretion for the payer-to-payer policy until future rulemaking is finalized does not affect any other existing regulatory requirements and implementation timelines finalized in the CMS Interoperability and Patient Access rule finalized on May 1, 2020.

CMS continues to encourage impacted payers that have already developed Fast Healthcare Interoperability Resources (FHIR)-based application programming interface (API) solutions to support payer-to-payer data exchange to continue to move forward with implementation and make this functionality available on January 1, 2022 in accordance with the CMS Interoperability and Patient Access final rule policies. However, for those impacted payers that are not capable of making the data available in a FHIR-based API format, we believe this enforcement discretion will alleviate industry tension regarding implementation; avoid the risk of discordant, non-standard data flowing between payers; provide time for data standards to mature further through constant development, testing, and reference implementations; and allow payers additional time to implement more sophisticated payer-to-payer data exchange solutions.

Discussions the last few days, two options:

1. Business to Business
2. Patient/Member Mediated

Consent requirement for beyond minimum necessary data to be shared under OCR for TPO.  

Bob and group of national payers working through who will manage the trust network around Payer to Payer exchange.  

Will the Payer verification be solved under the trust framework?  Yes, that is the intent. Ways to solve that now are reliant on payer to payer agreements... intend would be like how sequoia works - trust framework agreement that all sign up for. 

Connectathon Read OUT

MIRO Board linked that captures the 30-40 Participants feedback - see attached!

• membermatch
• provenance - payers want to see end-to-end examples of flow. 
  • can a provenance user search using provenance identifier instead of ID, the revinclude wouldn't work with this.  Experimentation was informative. 
• Discussions on patient record - link from another payer.
• Hrex - next steps:
  • add to the demographic profile : birth, sex, gender 
  • relax 0...1 instead of 1..1 on gender. 
  • you need either sex or gender. don't need both.
  • Add Dependent Number for 
  • Feedback that said: we have two coverages - old and new.  The old with not have an ID for patient but the new on is.  the profile needs to allow for an Identifier on coverage But cannot mandate it.  But constraint for: when pointing to old - it cant be there, when pointing to new - it needs to be there.  
  • Patients want to do payer to payer via patient access. 
    • Scope is USCore and PDex Scope. 
  • Changes to Coverage tracker has been updated per Lloyd. 
  • Open questions are captured in Confluence.  Some may be clarifications or changes to IG. Some may just clarify to the community (via this call or confluence)
• Pdex and Cdex - many discussion items captures.  Bob will investigate with CMS. 
  • Discussions covering what happens if one payer supports and intermediary vs. B2B, ramifications? 
  • If someone passes you data, what are your obligations if you have no use for it? 
• At the right indicators in PDex to HRex so IG readers of Pdex know where to look. 

Formulary:  Switching to InsurancePlan from list to allow for many to many relationships between drugs and plans.  Test Scripts updated and very useful - found some validation errors and formulary STU2.  Capability statement.  IBM Watson was there, Server exchange info - drug searches and compare plans.  Another participant needed!  

Call to Community: If you are implementing Formulary or PlanNet, please let us know if you're willing to come test with us!  We are looking for more testers to meet HL7 Requirements for publication and balloting. 

Plan-Net: see below. 

Learned from the Connectathon:

• Touchstone test with Capability Statement. 

• Active Field and Period for PractionerRole. Active Flag is True/False and providers showing up as active, but not in the period that the user if looking for and then an issue of having multiple periods of coverage.  

  When would you have multiple periods? Shouldn't be overlapping coverage periods. 

Daniel Venton to Everyone

Our legal analysis said, "All information retrieved, whether we have a use for it or not, must be stored and exposed on subsequent queries."

12:32 PM
Yukta Bellani (Evernorth/Cigna) to Everyone

did not follow the comments on Consent and trust framework

12:32 PM
Yukta Bellani (Evernorth/Cigna) to Everyone

can you pls elaborate on that

12:34 PM
Daniel Venton to Everyone

In a nutshell, "I'm a payer, I get a request from company X and I'd like Patient Y's chart." How do I know it really is company X, how can I trust that they really do have paitent Y's consent?

12:34 PM
Me to Everyone

https://confluence.hl7.org/display/DVP/CMS+Final+Rule+Questions+and+Answers+log - See The last 3 questions on the page for the questions that Bob is describing right now  on Payer to Payer to CMS and OCR.

Next Week

Cancelled due to WGM.  Next Call: 10/1

PDex IG Companion Guide List

PDex IG Companion Guide - Laboratory Reporting Resources

Latest draft CARIN CPCDS Mapping document: CARIN Mapping to FHIR interim 2020 0818 v2.xlsx

DRAFT - PDEX US Core Mapping from CPCDS source: ResourceMappingUSCoreCPCDS-2020-05-29-v26.xlsx

Find initial questions and corresponding answers shared from our colleagues at CMS here

• Links to Published IGs

• PDex STU 1.0.0
• Plan Net STU 1.0.0
• Formulary - STU 1.0.1

Implementer Resources

Da Vinci Implementer Support Page 

Implementers can take advantage of tools: See the Reference links on the Payer Data Exchange (PDex) page to access links for Reference Implementations, sandboxes, test scripts, and more!

Da Vinci PDex for Patient Access API Frequently Asked Questions (FAQs)

CMS Final Rule Questions and Answers log

ONC FAST National Healthcare Directory (including end points) solution page that includes links to everything (solution doc, Connectathon, HL7 workgroup, etc.): https://oncprojectracking.healthit.gov/wiki/display/TechLabSC/National+Healthcare+Directory

For questions, reach out to us on Zulip:

• PDex: https://chat.fhir.org/#narrow/stream/235286-Da-Vinci.20PDex/topic/Implementers
• Plan Net: https://chat.fhir.org/#narrow/stream/229922-Da.2BVinci.2BPDex.2BPlan-Net
• Formulary: https://chat.fhir.org/#narrow/stream/197730-Da-Vinci.20PDex.20Drug.20Formulary

Formulary - Searching by DrugName.docx

Recording of Formulary Tickets for STU 1.1.0 Overview