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Chair:  Robert DieterleViet NguyenAnupam Goel

Scribe: Dana Marcelonis
 

Attendees

Present

Name

Affiliation

  •  
Enablecare
  •  
Stratametrics
  •  
Point of Care Partners
  •  
BCBSAL
  •  

Emily Calvert

CMS
  •  

Erica Ross

CMS
  •  
Heather McComasAMA
  •  
Optum
  •  

Kelly Anderson

BCBSAL
  •  
InterSystems
  •  

Mark Mundt

InterSystems
  •  
Megan SoccorsoCigna
  •  

Mike Funk

Humana
  •  
Nancy SpectorAMA
  •  
Terrence CunninghamAMA
  •  
Tori WillowsWellcare
  •  
BCBSFL
  •  
Aim/ Anthem
  •  

Marci Maisano

Cigna
  •  
Edifecs
  •  
Edifecs
  •  
United Healthcare
  •  
Anthem
  •  
Christy Dodson
  •  
BCBSAL
  •  
Laura Hoffman
  •  
WPS Health Solutions
  •  
Optum
  •  
Edifecs
  •  
CMS
  •  

  •  
CAQH
  •  
Raj
  •  
Ray WilkersonScope Info Tech
  •  
BCBST
  •  
Taha AnjarwallaCAQH
  •  
Tom
  •  
Sonja Ziegler
  •  
Intersystems
  •  
Nandini GangulyEMDI/ Scope Info Tech
  •  
BCBSM
  •  
Kasi
  •  
EMDI Team
  •  
Anthem
  •  
Bart CarlsonAzuba
  •  
Cambia
  •  
Duane WalkerBCBSM
  •  
InterSystems
  •  
Tibco
  •  
Louis BedorCognosante
  •  
Anthem
  •  
CMS
  •  
CMS
  •  
IBC
  •  
Anthem
  •  
Rian
  •  
Palmetto gba
  •  
Sandeep
  •  
Sreekanth PuramMettle Solutions
  •  
Allscripts
  •  
James Gallagher Jr.Premera
  •  
Joseph Figueroa
  •  
Tony LittleOptum
  •  
Pallavi TalekarEMDI/ Scope Info Tech
  •  
Thomas KesslerCMS
  •  
Todd Omundson
  •  
ZeOmega
  •  
Emily TenEyckCAQH
  •  
Mark Taylor
  •  
Julia SkapikCognitive Medicine
  •  
Michael BrodyCME Online
  •  
Michelle ZuttermanHumana
  •  
Surescripts
  •  
Laurie DarstMayo
  •  
Marianna SinghCAQH
  •  
Labcorp
  •  

  •  
Mariana SinghCAQH
  •  
Madhuri
  •  

  •  
Bob THompson
  •  
Ben LangleyMITRE
  •  
Michelle PriestAllscripts
  •  
Michael Hurley
  •  
Cedars-Sinai
  •  
Roland Gamache
  •  
Dave HCRT INC
  •  
Barbara WoodPNC
  •  

  •  
Padma KondaveetiMettles
  •  
Unknown User (meryl_bloomrosen)Premier
  •  
Cambia
  •  
Judy Williamson
  •  
Matthew Maurer
  •  
Smitha HarishMettles
  •  
BC Idaho
  •  
Michael LunzerAltegra Health
  •  
Rush
  •  
Shilesh NairGdit
  •  
Steve Favilla
  •  
Optum
  •  
Texas Health
  •  
Keya ShahCasnet
  •  
Epic
  •  
Josh Lamb
  •  

  •  
Edifecs
  •  
Max MD
  •  
Allen SaundersChange Healthcare
  •  
Molly Malavey
  •  
Rich BlochLumedic
  •  

  •  
Thomas GrannanAzuba
  •  
Beth ConnorCMS
  •  
MA Health Data
  •  
Kellie Ruff
  •  

  •  

  •  
Mark Fleming
  •  
Kumar Elubandi
  •  
Daniel CawoodMCG
  •  
POCP
  •  
Availity
  •  
MITRE/ CodeX
  •  
Sharon Hensley Alford
  •  
Tarun KumarVizlitics
  •  
MITRE
  •  
Tyler HigginsCerner

Present

Name

Affiliation

  •  
Rachel GoldsteinCAQH
  •  
Ralph Saint-PhardHealow
  •  
Susan LestinaAHA
  •  
Briana BarnesScope Info Tech
  •  
Cerner
  •  
Cassandra Bell
  •  
Deepthi ReddyMettle Solutions
  •  
Cognosante
  •  
Humana
  •  
Prashanth Golconda
  •  
Rajesh GodavarthiMCG
  •  
Rim Cothren
  •  
Scott LawrenceCMS
  •  
Chris JonesHumana
  •  
Christina BorgLumeris
  •  
Julie MaasEMR Direct
  •  
Kathleen Connor
  •  
Matt ReidAMA
  •  
Mike BerkmanCoverMyMeds
  •  
Monse SerenilHumad
  •  
Rian RaineyCoverMyMeds
  •  
Sandra StuartKP
  •  
Sheryl TurneyAnthem
  •  
Wanda Govan-JenkinsHHS
  •  
Chris HutchinsonCoverMyMeds
  •  
Anna MeisheidCMS
  •  
Cyrus PeyrovianFastAuth
  •  
Janice BakosAetna
  •  
SureScripts
  •  
Gevity
  •  
Melanie JonesCMS
  •  
eClinicalWorks
  •  
Tammy SchreinerWPS Health Solutions
  •  
Amy PetersonHumana
  •  
Dave Trotter, MD
  •  
BCBSIL
  •  
Renee FullerIBX
  •  
Helina Gebremariam
  •  
Cambia
  •  
Intepro
  •  
Carradora
  •  

  •  

  •  
MaxMD
  •  
Cindy Monarch BCBSM
  •  
Dawn PerreaultBCBSM
  •  
Cognizant
  •  
Mitre
  •  

  •  
Missy BoserSurescripts
  •  
CAQH
  •  
Phranil MehtaeClinicalWorks
  •  
Dylan TuggleBCBST
  •  
JPSys
  •  
Mario JarrinChange Healthcare
  •  
Jim AdamsonArkansas Blue Cross
  •  
Brian PoteetBCBST
  •  
Tony LaurieNoridian
  •  
Optum
  •  
Bonnie SirottZeOmega
  •  
MCG
  •  
ESAC
  •  
Geeta KrishnanEdifecs
  •  
Katherine LuskChildrens
  •  
Michael NovalesBCBSIL
  •  
Tracey McCutcheonKPMG
  •  
Anupam ThakurBCBS FL
  •  
Cathy PlattnerKP
  •  
Srinivasarao EadaraesMD
  •  
Availity
  •  
ZeOmega
  •  
Dennis ZanettiNantHealth
  •  
Haris BegCambia
  •  
Kishore MetlaMettle Solutions
  •  
Sunitha Godavarthi
  •  

  •  
C-HIT
  •  
SriniesMD
  •  
Anthem
  •  
Kumar SourabhGRSI
  •  
Julia ChanCW Global Consult
  •  
Ric LightHumana
  •  
UHC
  •  
Anil VezendlaMCG
  •  
Ken LordBook Zurman
  •  

Scott Robertson


  •  
Christopher GraconIndependent Health
  •  
Gary GryanMitre
  •  
Mitre
  •  
Marty StaszakVoluware
  •  
Stephen ReckfordGRSI
  •  
Joe HamiltonUnity Point
  •  

  •  
Dave Foster
  •  
Betty SullivanAllscripts
  •  
Cigna
  •  
Juzer KhorakiwallaUHC
  •  
Celine LefebvreAMA
  •  
Eshaa DhalleClinicalWorks
  •  

  •  
Aakash DeliwalaeClinicalWorks
  •  
Chris JohnsonBCBSAL
  •  
Megan RileyMITRE
  •  

  •  
Crystal HyattTransunion
  •  
Epic
  •  
AEGIS
  •  
BCBSM
  •  
Pawan RegmiRush
  •  
Rajesh GarlapatiRush
  •  
Rush
  •  
Scott HoltItiliti Health
  •  
Cigna
  •  
Cigna
  •  
UHC
  •  
Steve KirbyCoverMyMeds
  •  
Neena DakuaWPS Health
  •  
Evicore
  •  
Med Allies
  •  
Laurie Henson
  •  
Healow
  •  
Bapi Beshara
  •  
David DelanoMA Health Data
  •  

  •  
Vishnu
  •  
Carmela A. CoudercMITRE
  •  
Daniel C
  •  
Swapnil
  •  

  •  

  •  
Connie SchmidtCerner
  •  

  •  
Mary MartinCancer Linq
  •  
Dave DelanoNEHEN


Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

Decision Link(if not child)
ManagementReview ANSI Anti-Trust Policy



Reminder: conference call structure & name changes
  1. Burden Reduction (CRD/DTR/PAS) Implementer Support Call - Wednesday, DTR time slot (11at ET)
  2. Burden Reduction (CRD/DTR/PAS) Supplemental Examples - Friday, PAS time slot (3pm ET)
  3. Burden Reduction (CRD/DTR/PAS) IG Updates/Future Requirements - call to be scheduled, Mondays at 1pm ET


HL7 Sept Connectathon, Sept 9-11 (Virtual)

2020-09 Connectathon 25

Connectathon Information Session on Tuesday, September 1st at 4:00 PM ET - registration



CodeX to present/ explore potential examples


CodeX Home

CodeX team:

  • Carmela Couderc
  • Dr. Jim O'Connor
  • Anthony DiDonato


  • Oncology clinical pathways, in relationship to Prior Authorization
  • Leverage mCode specification to improve cancer care and research
  • Camino demo - pathway application that uses mCode branch criteria
  • Pathways are evidence-based, generally created by National Comprehensive Cancer Network (NCCN)
  • Potential CodeX/ Da Vinci collaboration:
    • Option 1 - PAS bundle
    • Option 2 - explore whether Oncology Clinical Pathways could supplement or replace CRD and DTR
  • DTR is pulling business rules from payer - those rules could be different than what the clinical pathways recommend
    • E.g., cheaper drug recommended by payer, but not present on oncology clinical pathway
  • No requirement for SMART on FHIR app - could be native to EHR
  • CRD - could be similar to appropriate use criteria for advanced imaging - could go to some other reference source (e.g., something from oncology society) to determine what's collected and submitted
  • Explore imaging (e.g., PET, CT prior auths), labs as example options
  • Chemotherapy regimen - that produces greatest burden in terms of cost because of manual back and forth right now
    • Also a lot of fraud related to chemotherapy being prescribed for patients
  • Oncology office tries to get to the prior auth cases beforehand so it doesn't have to be done at point of care
  • PA reponse time varies by payer
  • Order entry is what kicks off medication request for service...CRD comes back with whether you need prior auth 
  • Prior auth becomes part of order approval process, not a scenario where it's planned in advance?
    • Assumption that you prior auth something that is currently being ordered or happening right now
    • Also thought we needed a mechanism independent of orders that could be invoked, so that you could understand if prior auth is required in advance of ordering process
    • What happens in oncology practice right now?
      • Could be in advance planning process as well as during order process
      • It's possible for oncologist to go through a pathway and see what the applicable regimens might be, and then decide what might be the appropriate regimen that they want the prior auth for, given that there could be multiple regimens that are recommended for the patient
    • Could be a great way to explore the non-order driven scenarios
  • Laurie shared LabCorp form - Screening Hereditary Cancer FINAL_FORM.pdf
  • Scenarios where prior authorization happens outside of the clinical workflow
    • What do we do when this is not driven by an order, but is driven by something else
    • Need to get the people invovled in this discussion who initiate that process
    • Rachel Foerster chat comment: MK's concept also applies to ortho, etc

  • Laurie Woodrome/LabCorp would be intereted in participating in future discussions
  • May Terry insterested in genomics aspect
  • DV team will raise topic at next Operating Committee meeting, and find out if DV members are interested
    • If there's interest, next step would be to set up additional calls to determine example and scope


Next agenda

 Adjournment

Adjourned at 4:06pm ET

Outline Reference

Supporting Document

Minute Approval



Tasks

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