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Da Vinci Payer Coverage Decision FHIR IG Proposal

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PutProposedIGNameHere

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. Member-authorized sharing of treatment, conditions, authorizations, relevant guidelines and supporting documentation.

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

IG Relationships

Timelines

When IG Proposal Is Complete

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

FMG Notes