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Background

There are two parallel paths pursued by the CARIN Alliance and the Da Vinci Project related to providing health plan data to various stakeholders. 

The CARIN Alliance focused on replicating the CMS Blue Button 2.0 solution directed at providing beneficiaries access to claims information for Medicare Fee For Service (FFS) in the form of a FHIR based ExplanationOfBenefits (EOB). The CARIN Alliance Consumer Directed Payer Data Exchange (CARIN BB) solution was intended to provide the same information based on commercial payer databases, at a least for Medicare Advantage products. The CMS Interoperability Final Rule expanded the scope of a Blue Button 2.0 equivalent to include not just Medicare Advantage but also Medicaid HMO, CHIP HMO and QHP's in the federal marketplace.

The Da Vinci Payer Data Exchange (PDex) solution started with the goal of providing payer sourced information to providers in the form of FHIR resources consistent with US Core profiles for FHIR Release 4 (R4). The CMS Interoperability Final Rule directs covered payers (as noted above) to make encounter information and clinical data available to members through an API defined by the ONC 21 st Century Cures Act Final Rule for, at a minimum, information defined in USCDI release 1.1. Since PDex was already focused on making the same information available through a compliant API, Da Vinci expanded the scope of PDex to include not only payer to provider exchange at the request of the provider but also payer to third party application exchange at the request of the member.

In addition, the CMS Interoperability Final Rule requires a covered plan, at the members’ request, to make their information (as defined by USCDI release 1.1, at a minimum) available to any other plan as directed by the member. This ability must exist for up to 5 years after the member leaves the plan. Da Vinci expanded the scope of the PDex Implementation Guide to support this exchange. 

At this point we have two solutions that provide an overlapping but different set of information for the members of a health plan. The first is the CARIN BB which is focused on providing claims information, including the adjudication information, in the form of a FHIR EOB.  The second solution is to provide all payer information related to the clinical condition and care of the patient using US Core profiles on FHIR R4 resources. In the latter case, information coming from claims is represented as USCDI V1.1 information and includes, at a minimum: encounters, providers, organizations, locations, dates of service, diagnoses (conditions), procedures and observations. This information would also include clinical information from sources other than claims maintained by the payer, such as:

1)       laboratory results received via HL7 V2 transactions,

2)       clinical data from HL7 consolidated CDAs,

3)       information derived from HL7 V2 ADT transactions,

4)       information received or extracted from immunization registries,

5)       information related to medication administration from pharmacy benefit managers in pharmacy networks,

6)       FHIR transactions, and any other source of clinical information related to the member.