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Short Description

Payer Data Exchange (PDex) is preparing an STU2 version of the IG. This will incorporate changes to support anticipated regulatory changes related to Burden Reduction. This track will be testing out the changes to the IG made for the STU2 Early May Ballot Submission. 

Long Description

Testing of changes to the Payer Data Exchange IG that have been incorporated into the balloted STU2 version of the guide.  With an impending NPRM that may address Payer-to-Payer Exchange this will be an opportunity for payers to test their exchange solutions with other payers.  There will also be the opportunity for apps to test the Prior Authorization Profile that was added to the IG to support regulatory changes related to Burden Reduction.

Type

Test an Implementation Guide

Submitting Work Group/Project/Accelerator/Affiliate/Implementer Group  

Financial Management

Track Lead(s)

Mark Scrimshire <mark.scrimshire@onyxhealth.io>; Bob Dieterle <rdieterle@enablecare.us>; Co-lead : Ezequiel (EZ) Morales <ezequiel.morales@evernorth.com>

Track Lead Email(s)

mark.scrimshire@onyxhealth.io; rdieterle@enablecare.us

Related Tracks

Payer Data Exchange is aligned with PDex Plan-Net (Provider Directory) and PDex US Drug Formulary. There may also be overlap with the CARIN Blue Button IG. PDex also leverages profiles and operations from the Health Record Exchange (HRex) IG. The Prior Authorization profile is based on data elements from the CARIN Blue Button IG and the Da Vinci Prior Authorization Support (PAS) IG.

FHIR Version

FHIR R4

Specification(s) this track uses

http://build.fhir.org/ig/HL7/davinci-epdx/ 

http://build.fhir.org/HL7/davinci-ehrx/

Artifacts of focus

Addition of a Profile in support of the exchange of Prior Authorization documentation. Payer-to-Payer Business to Business Exchange.

Expected participants

Payers and Technology Vendors will be the primary attendees for the PDex Track. 

Zulip stream

PDex: https://chat.fhir.org/#narrow/stream/235286-Da-Vinci.20PDex


Track Kick Off Call

April 22, 2022 12:00pm Eastern

PDex Track Orientation Recording_2022_04_22

Track Details

Patient Access API

System Roles:

  • Data Provider
  • Consumer App

Scenarios to be tested:

  • Register Consumer App
  • Cross IG data referencing (Clinical → Directory, Clinical → Formulary)

Payer-to-Payer Exchange

This sub-track will test a modified Member-Match Operation that has an added Consent resource.

System Roles: 

  • Operator: Member-Match (with Consent Resource)Operation
  • Submitter: Member-match operation transaction submitter

Scenarios to be tested:

  • Submission of Member-Match operation at enrollment
  • Submission of Member-Match as part of concurrent coverage requirement (bi-directional sharing with continued access)

The Track will also feature an evaluation of the pre-requisites required to perform Payer-to-Payer Exchange using the Patient Access APIs. We welcome Payers wishing to test these scenarios.

PDex STU2 Additions

This sub-track will test the addition of content to PDex to support Prior Authorization requirements for sharing of data with members

System roles:

  • Payer Source System
  • Consumer app

Scenarios and profiles to be tested:

  • Extensions to support Prior Auth use cases
  • PAS ClaimResponse
  • EOB (without financials) 

Stretch Goals for Track:

  • Bulk FHIR capabilities
  • Payer-Provider Attribution