Da Vinci Risk Based Contract Member Identification FHIR IG Proposal

Risk Based Contract Member Identification

Owning Workgroup

Financial Management

Committee Approval Date:

FM Presentation and Approval - 10/29/2019

FMG Presentation and Approval - 10/30/2019

Publishing Lead

Nagesh (Dragon) Bashyam (nagesh.bashyam@drajer.com)

Contributing or Reviewing Work Groups

Attachments (Now PIE!)

FHIR Development Project Insight ID

1517

Scope of coverage

The implementation guide will enable Payers and Providers to exchange Member Attribution Lists which are a necessity for Risk Based Contracts. The IG builds on US Core 3.1.0 and Bulk Data IG to enable the Member Attribution list data exchange. The IG only deals with the representation of the Member Attribution List using FHIR resources and its exchange using FHIR mechanisms. It does not deal with the algorithms and processes used to create the Member Attribution List.

Content location

https://github.com/hl7/davinci-atr

Proposed IG realm and code

us/DaVinci-ATR

Maintenance Plan

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

Short Description

Enable Payers and Providers to exchange a roster of patients for inclusion in a risk based contract

Long Description

The implementation guide will define the mechanisms, resources, profiles and extensions required to exchange Member Attribution Lists. The Member Attribution Lists enable providers and payer organization to validate enrollment in Value-Based Care (VBC) programs and support reporting requirements and payment reconciliation.

This project scope is only to represent and exchange the member attribution list and does not deal with algorithms or other processes that are used to determine if a member should be on the list or should be removed from the list. The project does not also deal with exchanging any data because of which the patient is put on the list. The resources that will be used to represent the Member Attribution List are Group, Patient, PractitionerRole, Practitioner, Organization and Coverage. The project will reuse US core profiles where one exists and will use the Bulk Data protocols for exchanging the list.

In the initial version of the IG, the only use case is to exchange the full attribution list and in subsequent versions incremental lists and notifications of changes in the list would be addressed.

Involved parties

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

Expected implementations

Da Vinci participants -

1) Cambia Healthcare Solutions

2) MultiCare

3) Providence

Content sources

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

Example Scenarios

A payer may provide a roster of patients to a provider for a specific risk based contract.

A Provider organization may submit a roster of patients to a payer to confirm patient enrollment

IG Relationships

This project build on US Core 3.1.0 (based on R4) and the Bulk Data implementation guide for defining rosters and exchanging roster information.

Timelines

Connectathon in December and/or January.

Submit for STU Ballot for 2020 Jan Ballot cycle