Da Vinci Payer Coverage Decision FHIR IG Proposal

PutProposedIGNameHere

Payer Coverage Decision Exchange

Owning work group name

Financial Management

Committee Approval Date:

Approved by FM on 7/2/2019

Publishing Lead

Paul Knapp pknapp@pknapp.com

Contributing or Reviewing Work Groups

Attachments

FHIR Development Project Insight ID

1515

Scope of coverage

This IG will provide a FHIR standard for exchanging, at member request, current treatments/support,conditions, guidelines (commercial), and supporting documentation for a payer member with a new payer when the member moves from one covered payer to another. This is to support the "treatment portability" described in the CMS Interoperability NPRM from March 3, 2019. The plan is to use the CarePlan resource as the basis for associating the information with regard to current therapy.

Content location

https://github.com/HL7/davinci-pcovex

Proposed IG realm and code

US/DaVinci-PCD

Maintenance Plan

Da Vinci project intends to provide ongoing support of this implementation guide

Short Description

Payer coverage decision exchange will promote continuity of treatment when a member moves from one covered payer to another without increasing provider burden or cost to the member. This IG enables member-authorized sharing of treatment, conditions, authorizations, relevant guidelines and supporting documentation from an original payer to a new payer when a patient changes coverage plans.

Long Description

The Payer Coverage Decision (PCD) Exchange FHIR IG will support the secure Member-authorized exchange of information between a current and prior payer regarding ongoing problems/treatments 1) The exchange will use OAuth2.0 and FHIR APIs for information sharing 2) Information to exchange will include the "careplan" for any current conditions/treatments 3) Relevant conditions 4) Relevant guidelines (reference to commercially available guidelines) 5) Any relevant prior-authorizations, with any remaining scope/duration (e.g. number of authorized session left) 6) relevant past or current medical history used to support coverage of the current treatment 7) other information as appropriate

Involved parties

This implementation guide has been developed by U.S. Payer organizations as part of the Da Vinci project.

Expected implementations

Da Vinci payer members in response to the details in the CMS final rule

Content sources

Requirements are drawn from payer organizations as part of the Da Vinci initiative.

Example Scenarios

1. General: An Authenticated Member at their old Health Plan will be able to use an OAuth2.0 authorization to permit their New Health Plan to access the old Health Plan's FHIR API to access the member's payer coverage decisions using a superset of profiles defined in this guide, US Core and Da Vinci Health Record Exchange (HRex) Profiles. 2. Specific: A member that is currently receiving home oxygen therapy will be able to exchange supporting documentation form the prior payer to the new payer to avoid, where possible, discontinuation of the current treatment, payment out of pocket, and/or need for a provider to submit documentation that is currently available to the previous plan.

2. Specific: A member that is currently receiving step therapy for diabetes will be able to exchange supporting decisions, prior treatment, guidelines and documentation form the prior payer to the new payer to avoid, where possible, a need to restart treatment that has deemed ineffective and/or need for a provider to submit documentation that is currently available to the previous plan.

IG Relationships

This project will reference, where possible the "standards" defined by the Health Record exchange (HRex) Framework Implementation Guide which in turn will utilize prior work from US Core and R4. In addition, this guide will refer to the Payer Data Exchange (PDex) Implementation Guide since it uses the same member directed exchange methods and clinical content standards for the Payer to Payer exchange described in PDex.

Timelines

Submit for STU Ballot for 2019 Sep Ballot cycle

When IG Proposal Is Complete

When you have completed your proposal, please send an email to FMGcontact@HL7.org