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| − | = | + | =Coverage Requirements Discovery= |
<!-- Resource names should meet the following characteristics: | <!-- Resource names should meet the following characteristics: | ||
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<!-- The name of the committee that is proposed to have responsibility for developing and maintaining the IG. --> | <!-- The name of the committee that is proposed to have responsibility for developing and maintaining the IG. --> | ||
| − | [[ | + | [[Financial Management]] |
==Committee Approval Date:== | ==Committee Approval Date:== | ||
| − | <i>Please enter the date that the committee approved this IGproposal</i> | + | <i><b>TODO</b>Please enter the date that the committee approved this IGproposal</i> |
==Contributing or Reviewing Work Groups== | ==Contributing or Reviewing Work Groups== | ||
<!-- Additional work groups that may have an interest in contributing to, or reviewing the content of the IG (optional) --> | <!-- Additional work groups that may have an interest in contributing to, or reviewing the content of the IG (optional) --> | ||
| − | * | + | * [[Attachments]] |
| − | |||
| − | |||
==FHIR Development Project Insight ID== | ==FHIR Development Project Insight ID== | ||
| + | 1428 | ||
<!-- Please specify the id of your work group’s PSS for doing FHIR work that covers the development and maintenance of this IG. (If submitted but not yet approved, just write “pending”.) The link to the PSS template can be found here: http://gforge.hl7.org/gf/download/docmanfileversion/6832/9398/HL7FHIR_DSTUballotPSS-20120529.doc --> | <!-- Please specify the id of your work group’s PSS for doing FHIR work that covers the development and maintenance of this IG. (If submitted but not yet approved, just write “pending”.) The link to the PSS template can be found here: http://gforge.hl7.org/gf/download/docmanfileversion/6832/9398/HL7FHIR_DSTUballotPSS-20120529.doc --> | ||
==Scope of coverage== | ==Scope of coverage== | ||
| + | The IG is specific to the US Human financial claims process across all healthcare disciplines, though the primary focus is inpatient and outpatient primary care. The content is developed by a mix of payor and EHR representatives. | ||
<!-- Define the full scope of coverage for the IG. The scope must be clearly delineated such that it does not overlap with any other existing or expected HL7 Int'l-maintained IG. The scope will be used to govern "what is the set of potential applications to consider when evaluating what elements are 'core' – i.e. in the 80%" | <!-- Define the full scope of coverage for the IG. The scope must be clearly delineated such that it does not overlap with any other existing or expected HL7 Int'l-maintained IG. The scope will be used to govern "what is the set of potential applications to consider when evaluating what elements are 'core' – i.e. in the 80%" | ||
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==IG Purpose== | ==IG Purpose== | ||
| + | One of the challenges in the US Healthcare environment is that clinicians are often unaware of the expectations of payor organizations around the delivery of care, requirements for pre-authorizations and other processes. The result is that payment can be delayed, changes must be made to therapy after initiation and/or additional overhead costs are incurred. Defining a standardized mechanism by which care delivery organizations and providers can query payors to find relevant guidance prior to care delivery will increase efficient delivery of care and corresponding payment. | ||
<!-- Why is this IG necessary? --> | <!-- Why is this IG necessary? --> | ||
==Content location== | ==Content location== | ||
| + | https://github.com/HL7/davinci-crd | ||
<!-- What is the path within the HL7 github repository (i.e. https://github.com/HL7/xxx) or what is the Simplifier project name? --> | <!-- What is the path within the HL7 github repository (i.e. https://github.com/HL7/xxx) or what is the Simplifier project name? --> | ||
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==Proposed IG realm and code== | ==Proposed IG realm and code== | ||
| + | uv/davinci-crd | ||
<!-- What is the realm code (2-character country code or 'uv') and IG code to use for the path when the IG is published under http://hl7.org/fhir? E.g. us/ccda --> | <!-- What is the realm code (2-character country code or 'uv') and IG code to use for the path when the IG is published under http://hl7.org/fhir? E.g. us/ccda --> | ||
==Maintenance Plan== | ==Maintenance Plan== | ||
| + | This specification will be maintained by the FM work group once the Da Vinci project has completed initial development | ||
<!-- What commitment does the WG have to maintaining this IG as the FHIR core specification continues to evolve - particularly if the initial project sponsors are no longer providing resources --> | <!-- What commitment does the WG have to maintaining this IG as the FHIR core specification continues to evolve - particularly if the initial project sponsors are no longer providing resources --> | ||
==Short Description== | ==Short Description== | ||
| + | Provides a mechanism for healthcare providers to discover guidelines, pre-authorization requirements and other expectations from payor organizations related to a proposed medication, procedure or other service associated with a patient's insurance coverage. Supports both patient-specific and patient-independent information retrieval. | ||
<!-- 1-2 sentences describing the purpose/scope of the IG for inclusion in the registry --> | <!-- 1-2 sentences describing the purpose/scope of the IG for inclusion in the registry --> | ||
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==Long Description== | ==Long Description== | ||
| + | |||
| + | This implementation guide allows practitioners and provider organizations to query payor organizations for any payor-specific expectations related to a proposed course of treatment. Search parameters include drug codes, procedure codes and other service descriptions as well as information about the type of coverage or specific insurance involved. It might also include patient identify information and support provider query of additional patient healthcare information relevant to determining what the payor expectations are. The response to the operation might include guidelines for care, pre-authorization requirements, necessary first line treatments and/or other instructions and recommendations for care delivery related to the proposed course of treatment (and if specified), for the specified patient. | ||
<!-- 1 paragraph describing the purpose/scope of the IG in more detail for inclusion in the version history --> | <!-- 1 paragraph describing the purpose/scope of the IG in more detail for inclusion in the version history --> | ||
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==Involved parties== | ==Involved parties== | ||
| − | + | This implementation guide has been developed by U.S. EHR and Payor organizations as part of the Da Vinci project | |
<!-- 1 paragraph describing who is sponsoring or involved in creating the IG for inclusion in the version history --> | <!-- 1 paragraph describing who is sponsoring or involved in creating the IG for inclusion in the version history --> | ||
==Expected implementations== | ==Expected implementations== | ||
| − | + | In addition to a pilot reference implementation and testing at the Sept. 2018 and Jan. 2019 WGMs, several EHR and Payor organizations are expected to implement this implementation guide prior to the end of 2019 | |
<!--Key resources are justified by CCDA, for resources not deemed "key", what interest is there by implementers in using this particular resource. Provide named implementations if possible - ideally provide multiple independent implementations. --> | <!--Key resources are justified by CCDA, for resources not deemed "key", what interest is there by implementers in using this particular resource. Provide named implementations if possible - ideally provide multiple independent implementations. --> | ||
==Content sources== | ==Content sources== | ||
| − | + | Requirements are drawn from payor organizations as part of Da Vinci discussions. Some insights around pre-authorization data elements come from X12 | |
<!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult | <!-- List all of the specifications (beyond those in the "standard" (FHIR_Design_Requirements_Sources) list of source specifications) that you’re planning to consult | ||
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==Example Scenarios== | ==Example Scenarios== | ||
| − | + | * EHR performs coverage requirements discovery specifying an insurance plan type and a proposed medication. Payor returns a protocol indicating an alternate first-line medication and indicates that pre-authorization is required, providing a questionnaire that must be completed as part of the pre-authorization process | |
| + | * Clinician performs coverage requirements discovery for a proposed physio therapy. Payor organization queries the patient record to identify details about the patient's health conditions and recent procedures and identifies that no pre-determination or additional guidance is required. | ||
| + | * Hospital submits a patient's insurance information at the time of emergency admission. Insurer identifies the associated patient's insurance plan and notifies the hospital that any costs exceeding a base amount must receive prior clearance by the insurer | ||
<!-- Provide a listing of the types of scenarios to be represented in the examples produced for this IG. They should demonstrate the full scope of the IG and allow exercising of the IG's capabilities (all profiles, different types of applications, etc.) --> | <!-- Provide a listing of the types of scenarios to be represented in the examples produced for this IG. They should demonstrate the full scope of the IG and allow exercising of the IG's capabilities (all profiles, different types of applications, etc.) --> | ||
==IG Relationships== | ==IG Relationships== | ||
| − | + | This implementation guide will be "aligned" with US Core and will eventually be derived from US Core once that IG has been updated to align with FHIR R4. | |
<!-- Are there any IGs this resource depends on or that depend on this IG? --> | <!-- Are there any IGs this resource depends on or that depend on this IG? --> | ||
==Timelines== | ==Timelines== | ||
| − | + | The intention is to perform initial balloting of the IG in the Sept. 20 | |
<!-- Indicate the target date for having the IGcomplete from a committee perspective and ready for vetting and voting --> | <!-- Indicate the target date for having the IGcomplete from a committee perspective and ready for vetting and voting --> | ||
Revision as of 22:20, 1 July 2018
This page documents a Pending FHIR IG Proposal
Contents
- 1 Coverage Requirements Discovery
- 1.1 Owning work group name
- 1.2 Committee Approval Date:
- 1.3 Contributing or Reviewing Work Groups
- 1.4 FHIR Development Project Insight ID
- 1.5 Scope of coverage
- 1.6 IG Purpose
- 1.7 Content location
- 1.8 Proposed IG realm and code
- 1.9 Maintenance Plan
- 1.10 Short Description
- 1.11 Long Description
- 1.12 Involved parties
- 1.13 Expected implementations
- 1.14 Content sources
- 1.15 Example Scenarios
- 1.16 IG Relationships
- 1.17 Timelines
- 1.18 When IG Proposal Is Complete
- 1.19 FMG Notes
Coverage Requirements Discovery
Owning work group name
Committee Approval Date:
TODOPlease enter the date that the committee approved this IGproposal
Contributing or Reviewing Work Groups
FHIR Development Project Insight ID
1428
Scope of coverage
The IG is specific to the US Human financial claims process across all healthcare disciplines, though the primary focus is inpatient and outpatient primary care. The content is developed by a mix of payor and EHR representatives.
IG Purpose
One of the challenges in the US Healthcare environment is that clinicians are often unaware of the expectations of payor organizations around the delivery of care, requirements for pre-authorizations and other processes. The result is that payment can be delayed, changes must be made to therapy after initiation and/or additional overhead costs are incurred. Defining a standardized mechanism by which care delivery organizations and providers can query payors to find relevant guidance prior to care delivery will increase efficient delivery of care and corresponding payment.
Content location
https://github.com/HL7/davinci-crd
Proposed IG realm and code
uv/davinci-crd
Maintenance Plan
This specification will be maintained by the FM work group once the Da Vinci project has completed initial development
Short Description
Provides a mechanism for healthcare providers to discover guidelines, pre-authorization requirements and other expectations from payor organizations related to a proposed medication, procedure or other service associated with a patient's insurance coverage. Supports both patient-specific and patient-independent information retrieval.
Long Description
This implementation guide allows practitioners and provider organizations to query payor organizations for any payor-specific expectations related to a proposed course of treatment. Search parameters include drug codes, procedure codes and other service descriptions as well as information about the type of coverage or specific insurance involved. It might also include patient identify information and support provider query of additional patient healthcare information relevant to determining what the payor expectations are. The response to the operation might include guidelines for care, pre-authorization requirements, necessary first line treatments and/or other instructions and recommendations for care delivery related to the proposed course of treatment (and if specified), for the specified patient.
Involved parties
This implementation guide has been developed by U.S. EHR and Payor organizations as part of the Da Vinci project
Expected implementations
In addition to a pilot reference implementation and testing at the Sept. 2018 and Jan. 2019 WGMs, several EHR and Payor organizations are expected to implement this implementation guide prior to the end of 2019
Content sources
Requirements are drawn from payor organizations as part of Da Vinci discussions. Some insights around pre-authorization data elements come from X12
Example Scenarios
- EHR performs coverage requirements discovery specifying an insurance plan type and a proposed medication. Payor returns a protocol indicating an alternate first-line medication and indicates that pre-authorization is required, providing a questionnaire that must be completed as part of the pre-authorization process
- Clinician performs coverage requirements discovery for a proposed physio therapy. Payor organization queries the patient record to identify details about the patient's health conditions and recent procedures and identifies that no pre-determination or additional guidance is required.
- Hospital submits a patient's insurance information at the time of emergency admission. Insurer identifies the associated patient's insurance plan and notifies the hospital that any costs exceeding a base amount must receive prior clearance by the insurer
IG Relationships
This implementation guide will be "aligned" with US Core and will eventually be derived from US Core once that IG has been updated to align with FHIR R4.
Timelines
The intention is to perform initial balloting of the IG in the Sept. 20
When IG Proposal Is Complete
When you have completed your proposal, please send an email to FMGcontact@HL7.org
