201901 Coverage Requirements Discovery

Track Name

Coverage Requirements Discovery (CRD)

Submitting WG/Project/Implementer Group

The Da Vinci Project

Justification

The goal of the CRD Implementation Guide is to allow healthcare payers to be able to query payers to determine:

• Specific documentation requirements
• Rules for determining need for specific treatments/services
• Requirement for Prior Authorization (PA) or other approvals
• Specific guidance

This track will be testing the ability of a participants to to use the CRD Implementation Guide. Implementation experience will be used to drive change to the STU1 ballot. This test will help demonstrate:

• Profiles of FHIR resources along with the operation allow the necessary information for discovery of coverage discovery
• Profiles of FHIR resources allow the communication of the location of coverage requirement documentation back to providers.

Proposed Track Lead

Andy Gregorowicz - The MITRE Corporation - andrewg@mitre.org

Expected participants

Epic, CMS (via The MITRE Corporation), Mettle Solutions

Roles

Healthcare Provider

In this role, a provider wishes to discover the documentation requirements for home oxygen therapy. It is expected that the provider will be able to:

• Invoke the CRD via CDS Hooks
  • Populate the hook request with the necessary demographic, payer and requested service information or have a FHIR server that will respond to queries for the information
• Handle the response of the CRD CDS Hooks Cards
  • Display to the provider the links to the documentation requirements and allow the provider to follow the links

It is expected, but not necessary, that the Provider end will be implemented as a SMART on FHIR app. The app would pull demographic and payer information from the local EHR and then provide a user interface to allow the provider to select the desired service. The SMART on FHIR app would then invoke the CRD CDS Hooks and display the response.

Healthcare Payer

In this role, the payer examines the request for documentation and responds appropriately. This could be viewed as the server part of the transaction. It is expected that participants in this role will:

• Provide a FHIR server that implements the CDS Hooks specified in the CRD IG
• Provide sample documentation responses for incoming queries

Scenarios

medication-prescribe Scenario

This scenario uses the CRD resource profiles in the medication-prescribe CDS Hook as described in the CRD IG.

For both of these scenarios, the Healthcare Provider system should create a patient resource that is 40 years old. The MedicationRequest resource should have a medicationCodeableConcept of RxNorm - 860195. See the full example for details.

medication-prescribe Scenario

Step 1 - Hook Request

Action: Healthcare Provider executes medication-prescribe CDS Hook, sending the request to the Healthcare Payer which includes a CRD MedicationRequest resource

Precondition: Healthcare Provider hosts a FHIR server that provides the Patient, Encounter referenced in the hook context as well as the Coverage referenced by MedicationRequest.insurance

Success Criteria: Healthcare Payer receives a valid CDS Hook medication-prescribe request

Bonus point: Healthcare Provider supplies OAuth token

Step 2 - Fetch Relevant Data

Action: Healthcare Payer issues FHIR GET requests to retrieve relevant Patient, Encounter, Coverage and other related resources

Precondition: none

Success Criteria: Healthcare Payer obtains all information necessary to resolve the CDS Hook request made in Step 1

Bonus point: Healthcare Payer uses the OAuth token supplied in Step 1 and the Healthcare Provider requires OAuth for all requests

Step 3 - Return Cards

Action: Healthcare Payer returns CDS Hooks Cards with documentation requirements

Precondition: none

Success Criteria: Healthcare Provider system displays the cards

Bonus point: Healthcare Payer requests form completion and the Provider displays the form to complete

medication-prescribe prefetch Scenario

Step 1 - Hook Request

Action: Healthcare Provider executes medication-prescribe CDS Hook, sending the request to the Healthcare Payer which includes a CRD MedicationRequest resource and prefetches related resources

Precondition: Healthcare Payer has a prefetch template that requests the Patient, Encounter referenced in the hook context as well as the Coverage referenced by MedicationRequest.insurance

Success Criteria: Healthcare Payer receives a valid CDS Hook medication-prescribe request with all information needed to satisfy the request

Bonus point: Healthcare Provider supplies OAuth token

Step 2 - Return Cards

Action: Healthcare Payer returns CDS Hooks Cards with documentation requirements

Precondition: none

Success Criteria: Healthcare Provider system displays the cards

Bonus point: Healthcare Payer requests form completion and the Provider displays the form to complete

order-review Scenario

This scenario follows the constraints on the order-review CDS Hook as described in the CRD IG.

Mrs. Smith is an 75 year-old on Medicare FFS with long standing COPD who has had slowly and progressively worsening shortness of breath with activity. In the office her room air saturation after a 5 minute walk is 84%. She has additional evaluation that reveals no new findings. Dr. Good (Healthcare Provider) wants to initiate home oxygen therapy for Mrs. Smith.

Using an application, Dr. Good performs a CRD query against the Healthcare Payer and is informed that specific testing and documentation is required to substantiate the need for home oxygen therapy.

Dr. Good retrieves the documentation templates from the Healthcare Payer.

Step 1 - Hook Request

Action: Healthcare Provider executes order-review CDS Hook, sending the request to the Healthcare Payer which includes a CRD DeviceRequest resource and prefetches related resources

Precondition: Healthcare Payer has a prefetch template that requests the Patient, Encounter referenced in the hook context as well as the Coverage referenced by MedicationRequest.insurance

Success Criteria: Healthcare Payer receives a valid CDS Hook order-review request with all information needed to satisfy the request

Bonus point: Healthcare Provider supplies OAuth token

Step 2 - Fetch Relevant Data

Action: Healthcare Payer issues FHIR GET requests to retrieve relevant Patient, Encounter, MedicationRequest, Coverage and other related resources

Precondition: none

Success Criteria: Healthcare Payer obtains all information necessary to resolve the CDS Hook request made in Step 1

Bonus point: Healthcare Payer uses the OAuth token supplied in Step 1 and the Healthcare Provider requires OAuth for all requests

Step 3 - Return Cards

Action: Healthcare Payer returns CDS Hooks Cards with documentation requirements

Precondition: none

Success Criteria: Healthcare Provider system displays the cards

Bonus point: Healthcare Payer requests form completion and the Provider displays the form to complete