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Chair:  Larry Decelles

Scribe: Vanessa Candelora


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Minutes Approved as Presented 


This is to approve minutes via general consent. "You have received the minutes. Are there any corrections to the minutes? (pause) Hearing none, if there are no objections, the minutes are approved as printed."


Agenda Topics

Agenda Outline

Agenda Item

Meeting Minutes from Discussion

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




Links

DTR IG: http://hl7.org/fhir/us/davinci-dtr/2019May/

Reference Implementation: https://github.com/HL7-DaVinci/dtr 



Reminder: 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 Call - 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 FHIR Connectathon - Sept 9-11



Connectathon De-Brief

2020-09 Connectathon 25

2020-09 Da Vinci CRD / DTR / PAS

  • Track Highlights Report - provide a quick read out today
    • Reviewed the schedule as it unfolded.
    • Lots of great demos throughout!
    • If you send Pat an email you can get access to a virtual box.
    • AEGIS Test Scripts are available publicly - a lot of people didn't know this. So, if you don't already have one, reach out and get an account! 
    • Price and plan info to be discussed further.
    • Through testing and some improvements, there were able to get the respond very fast - sub seconds. 
    • Good discussion around how Payers are scraping lots of systems to get the data with Mary Kay

Discussion:

1) Question from Melanie Combs-Dyer:

 1.  how a provider can ask the question "I want to order X medication for this 

patient... does their payer cover X under the MEDICAL benefit or the DRUG benefit?" 
and
    2.  how does a payer need to set up their DRLS repository to be able to respond: 
"This plan covers X medication under the MEDICAL benefit. PA is not 
required. Documentation Requirements are listed here."

  • If a provider sends a CRD request for a medication and the payer doesn't have anything about the particular medication - the presenter said they would come back with "there is no PAS requirements"  - what if the patient has other benefits through Medicare part D?  how do we solve this problem? 
  • When the provider asks CRD, the correct answer is not: there is no PA or documentation requirement, there is no pa requirement under the part D medical benefit, but there good be under the drug benefit. Please check with the PBM. 
  • Should this be added to the demos or the IG?  It's declared in the IG that part D is out of scope.  Supplement to show here's how you would respond to this query.  Melanie is happy to help build out the supplemental guide with Bob on this.     

2) Note about CQL: The guide does not have a representation of CQL.  This is an option for payers that want to use CQL, it's not mandated or part of the IG.

3) Question 1: Are there plans to return things along the lines of co-pay, deductible or limits for the future? (somewhere in the CRD/DTR/PAS workflow, maybe Price Cost Transparency)

Is this the right place to put it?
For example,
•Yes, your wheel chair is ‘allowed’ and the patient’s deductible is 80%
•Yes allowed, requires XYZ form and is limited to 3 visits

Mary Kay is not on the call right now, but Melanie relayed: this is important, may need to be worked on in phases. Who should lead this work?  Bob mentioned that Patient Cost Transparency is a Use case being discussed by Da Vinci. We may want to table this until after the October Da Vinci event. Also, we could come up with some examples (like we did with oxygen) in a supplemental guide for CRD as a preferred response. 




Implementer Questions (CRD/DTR/PAS)

1) Requesting family history, e.g. cancer screening; BRCA gene. Alternative to support Family History? Are there options to avoid the provider needing to re-enter the info in the questionnaire?

  • family history may be in notes - Ask them to identify the note?
  • Family history resource - It doesn't hurt to check the capability statement to see if it's supported.  Probability is low since it's not supported by USCDI now.  


2) Reviewed the red text on this page: https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf.  

  • Need a map - will likely get SNOMED and rxnorm codes and will need to map to J Codes and CPT codes.  
  • EHR will likely not do the map, so will be up to the SMART app or Payer - for this specific order, assuming to be billed as J code.... as PA. 
  • How do we handle the situation where Prior authorization is only required when one of the required codes is used in conjunction with another code.  
    • Confirmed that EHRs likely don't get the J codes.  
    • If two CPT codes are submitted, could the Payers or Smart on FHIR apps to ask: do you have this other code coming or planned?  that way they can predict the need for the PA up front.  
    • Bob - it wasn't envisioned as a conversation.  It's a Request and response.  second trigger not there. 
    • Could use DTR to pull out a questionnaire that would ask... not really planned a response that would be "you need PA" but that could work. use CQL or questionnaire maybe.
    • Dr. Miller and others may want to give input here. 
    • It doesn't need to be a singular workflow.  

Next Agenda

No Burden Reduction meetings next week due to WGM. Pick up on 9/30 or see you this Friday for Supplemental Examples Call.


 Adjournment
Adjourned at 12:00pm

Supporting Documents

Outline Reference

Supporting Document

Minute Approval
Draft list of supplemental examples (from 7/8 call)

Potential Examples:

  1. DME – O2
  2. Specialty Med – CodeX is interested in this topic
  3. Diagnostic Imaging – Head MRI, MRA
  4. Lab – Genetic test –
  5. Referral – Occupational Therapy or prosthetics – Example -
  6. Hospital admission - Pneumonia
  7. Home Health Services - eg.g Wound care
  8. Surgery – Arthroplasty (Total hip/knee replacement)
  9. CRD - Types of information/CARDS returned
  10. DTR - collect data and return it directly to payer - what does request look like, how to return it
    • RI demonstrates sending to PAS and sending to another endpoint
    • Extension on Questionnaire re: where response is supposed to be sent?
      • Not currently addressed in IG - Larry Decellesto add tracker to DTR
      • Sending to payer automatically (to same place request came from) in RI
  11. DTR - scenario where Questionnaire not posted directly, but keep it on file via EHR, or include it with prior auth submission or claim submission
    • IG worded like this, but need explicit instruction with respect to the Questionnaire - how do you ask for it and how do you respond
    • Larry Decelles to add to same tracker noted above
  12. DTR - Task workflow
    • Provider orders MRI, provider requirement is to attach Xray but someone else needs to do that - suspend order, send to someone else to complete (attach Xray) and submit - "to do" item put into a queue and/or assigned
    • Once CARD is received, does it matter who works it?
      • Within EMRs, don't yet have process for external agents/orgs (e.g., payers) to inject tasks
      • Task comes back and isn't assigned to anybody (i.e., no expectation that payer would assign it to someone) - whomever creates order has option to assign to someone else's task list, or leave unassigned and some other process defines who picks it up to complete


Action items

  •  Big Takeaway is needing more examples in the supplemental Guide: checking drug benefits vs. medical benefits and Price Transparency in CRD - Bob and Melanie


Attendees


Present

Name

Affiliation

  •  
Mitre
  •  
George BierOptum
  •  
BCBS AL
  •  
Rush
  •  
Matthew ByrneOptum
  •  
Rush
  •  
Cerner
  •  
Anthem
  •  
Allscripts
  •  
InterSystems
  •  
Allscripts
  •  
Mitre
  •  
Cambia Health
  •  
Cerner
  •  
Enable Care
  •  
Optum
  •  
Aegis
  •  
BCBS FL
  •  
InterSystems
  •  
Anthem
  •  
Mitre
  •  
Allscripts
  •  
Optum
  •  
Jackie HardisonHumana
  •  
Cigna
  •  
Claudia HartmanHighmark Health
  •  
Mark HinghamAnthem
  •  
Optum
  •  
Sheljina Ibrahim KuttyAnthem
  •  
Allscripts
  •  
Point of Care Partners
  •  
Edifecs
  •  
Mitre
  •  
InterSystems
  •  
Anthem
  •  
Tso LukeOptum
  •  
Point of Care Partners
  •  
Optum
  •  
Cognosante
  •  
Optum
  •  
Humana
  •  
Stratametrics
  •  
Casenet
  •  
Allscripts
  •  
Optum
  •  
Optum
  •  
InterSystems
  •  
C SimeoneOptum
  •  
Jeanie SmithBCBS FL
  •  
InterSystems
  •  
Veradigm
  •  
CMS
  •  
Casenet
  •  
Independence Blue Cross
  •  
Anthem
  •  
CentriHealth
  •  
CaseNet
  •  
India DuncanOptum
  •  
Jason Cassidy
  •  
Optum
  •  
Gevity
  •  
Tracy McCutcheonKPMG
  •  
Rashmi MenonKMHP
  •  
Mario JarrinChange healthcare
  •  

  •  
AMA
  •  
Optum
  •  
Megan Smith-HallingsheadRegence
  •  
Regence
  •  
Anthony SmithUNC Health
  •  
Optum
  •  

  •  

  •  
Jennifer Joe
  •  
Texas Health
  •  

  •  
Cigna
  •  
Labcorp
  •  
Cigna
  •  
Matt DyerVyne
  •  

  •  
Barbara Kramer-ZarinsMITRE
  •  
Centene
  •  
Barbara WoodPNC
  •  
Greta HoneycuttCoverMyMeds
  •  
BCBSA
  •  

  •  
MITRE
  •  
Keya ShahCasenet
  •  
Rich Bloch
  •  
Interpro
  •  
Lauri Shock
  •  
Andrew JohnsonNational Decision Support
  •  
MITRE
  •  
Mark FlemingChange Healthcare
  •  
eClinicalWorks
  •  
Prathima
  •  
Rachel Foerster & Associates
  •  
Heather McComasAMA
  •  
Megan RileyMITRE
  •  
Summer DumanRegence
  •  
Michelle BarryAvaility
  •  
Chris Cera
  •  
Michael FasuloRegence
  •  
Mettle
  •  
Lauree Marshall
  •  
Uma Kandasamy
  •  
Mina RasisExpress Scripts
  •  
Harmanpreet Singh
  •  

  •  
AEGIS

PresentNameAffiliation
  •  
Peter MuirESAC
  •  

  •  
Ryanne LaurenceOHSU
  •  

  •  
Mitre
  •  
CMS
  •  
Aim Specialty Health
  •  
Christy DodsonMCG
  •  
Tibco
  •  

  •  
Rajesh Godavarthi
  •  
Santosh
  •  
Tom Hartman
  •  
Tori WillowsWellcare
  •  
Alise WidmerLumeris
  •  
Bart CarlsonAzuba
  •  
David BruinsmaColonial Med
  •  
Deepthi ReddyMettle Solutions
  •  
Danny BrennanMA Health Data
  •  
Patrick Edwards
  •  

  •  
Cambia Health
  •  
CMS
  •  
Pallavi TalekarScope Info Tech
  •  
Rajesh GarlapatiRush
  •  
Susan BellileAvaility
  •  
BCBST
  •  
Ralph Saint-Phard
  •  
Kristi CushmanOHSU
  •  
Briana BarnesScope Info Tech
  •  
Didi DavisSequoia Project
  •  
Sreekanth PuramMettle Solutions
  •  
Duane WalkerBCBSM
  •  
EMDI Team
  •  
David HillMitre
  •  
BCBS AL
  •  
Nandini GangulyEMDI
  •  

  •  
Rajesh GodavarthiMCG Health
  •  
Rim Cothren
  •  
Donna CampbellBCBSIL
  •  
Joanna GaskillLumeris
  •  
Edifecs
  •  
Michael CabralCMS
  •  
Sudhir NairAnthem
  •  
Saul KaravitzMitre
  •  
Dawn PerreaultBCBSM
  •  
Brent WoodmanBCBSM
  •  
Yolanda VillanovaCMS
  •  
Deryl Lam
  •  
Edifecs
  •  
Karen TottCMS
  •  
MITRE
  •  
Dacarba
  •  
Carradora
  •  
Rachel Goldstein
  •  
Ric LightHumana
  •  
eClinicalWorks
  •  
Healow
  •  
Wanda Govan-JenkinsHHS
  •  
Cindy MonarchBCBSM
  •  
Edward Yurcisin
  •  
Humana
  •  
Hibah QudsiMitre
  •  
Nancy SpectorAMA
  •  
Patrick Leblanc
  •  
Anupam ThakurBCBSFL
  •  
MCG
  •  
Chris KlesgesMitre
  •  
BCBSA
  •  
CaseNet
  •  
Epic
  •  
Kat RuizUNC Health
  •  
Laura Bright
  •  
Humana
  •  
Roland Gamache
  •  
Katherine LuskChildrens
  •  
Anthem
  •  

  •  
Chris JohnsonBCBS AL
  •  
Jim AdamsonArkansas Blue Cross
  •  
Carry Denny
  •  
Infor
  •  

  •  
Anna MeisheidCMS
  •  
Celine LefebvreAMA
  •  
Eshaa DhalleClinicalWorks
  •  
BCBSM
  •  
Express Scripts
  •  
Sandhya
  •  
Christopher GraconIndependent Health
  •  
Candice TitusCrisp Health
  •  
Mariana SinghCAQH
  •  
BC Idaho
  •  
Shilesh NairGdit
  •  

  •  

  •  

  •  
UHC
  •  
Tammy BanksProvidence St. Joseph
  •  
Bob HarringtonAllscripts
  •  
Vishnu
  •  
DanielleSutter Health
  •  
MITRE
  •  
Sonya MayOptum
  •  
Molly MalaveyAMA
  •  
Guidewell
  •  
Angela BublikRegence
  •  
eClinicalWorks
  •  
Advocate Health
  •  
Arsal HussainiAccenture
  •  
Allen Saunders
  •  
Steve Ruszkowski
  •  

  •  
Beth Connor
  •  
Thomas KesslerCMS
  •  
Daniel C
  •  

  •  
Thomas Grannan
  •  
Meryl BloomrosenPremier Inc