2021-10-29 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)

Formulary - MITRE and Onyx tested the new work.  Edifecs came and tested as well. 

Discussion about the lack of client (vs. server) testing that we have seen on this IGs and the cause of that. 

One payer spoke up ans said that Care Evolution and few others have already connected to their Patient Access APIs. It may be more of a business resource focus and decision to come test vs. implementing.  You could go to the CMS.gov site and see the certified apps. Optum is working on their app to connect as well.   

Call to Community: If you are a payer and see apps connecting to your APIs, you are likely getting feedback.  If any of that feedback is valuable to this community and to the improvement of the IGs, please send it to us via Zulip chat (broader) and/or JIRA ticket (if pertaining to a specific part of the IG). 

Mark N. will send some feedback, including a question on Versioning. Thank you!  

Provenance two parts: 

1) Source - how you as a payer received the data, it's how you received it (claim, CDA, transaction, etc. )  

2) Transmitter record - "As a payer, I am sending this to you"  I am the transmitter of this data to send it to someone else.  

If you have "assembled it from" you are no longer the author.  If you have a lab that ran a test - the lab is the author.  Unless you collect it directly through the care management process, it would be rare for the payer to be the author.  Ex. Payer Nurse that recorded goals for the care management, then they would be the author.  If the data is coming in from a claim, then it's still sourced from the provider or source of the claim - Payer is not the author.  

Discussion about when a patient is looking to get their data. 

1) When you enroll as a new payer, during the enrollment process you would request the data. 

2) Consent as a member to control the data.  

The question from EQ is about the personal rep scenario and request my mom's data to consent to exchange from old payer to new payer. I'd do it through the new payer.  "The member or authorized representative" - the process for being the authorized representative comes to play here.  That relationship would need to be established and includes many scenarios.  Parent of minor, grown adult for parent. etc. 

Authorized representative

Next Step: ask CMS - If person is an authorized rep with the new payer, is that sufficient to request information form the old payer on your behalf or do you also need to be an authorized rep on the old payer?  

• we think it would fall as a covered entity under Operations and so wouldn't need it.  
• what does the old payer need for documentation? 

Whether the auth. rep. should be appointed on the previous payer side

Discussion about if its a HIPAA tx. or not.  They are sharing more than minimum necessary data. We are doing it as a HIPAA Tx.  Min. necessary only applies without the member consent. 

Because it's part of a regulation, it falls under operations likely. 

Including Provenance in the EOB for the Prior Auth. information - for discussion at 2pm call. 

Question on Provenance for EOBs 

• Need to support Provenance Records for EOB?  That would be defined in the Carin Blue Button Guide. 
• PDex is about USCDI clinical data.  See CARIN.
• The reg - if you are exchanging EOB data, you should remove the financial info, so it likely wouldn't apply. 

Next Week

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