HL7 FHIR® IG: Payer Coverage Decision Exchange, R1 - US Realm

DESCRIPTION

This U.S. implementation guide defines a standardized way for a 'new' payer to access the clinical and financial information held by a previous payer that is necessary to ensure that a member who is switching coverage is able to enjoy continuity of care with their new payer.

Payers have rules that govern when certain therapies will be covered. Certain test results might be needed, certain assessments must be completed, providers with particular credentials must make a diagnosis, prior authorization requests must be submitted, alternative 'first line' therapies must first be found to be ineffective, etc. When a member switches coverage to a new payer, they risk starting at "ground zero" and needing to repeat all of these processes in order to receive coverage from therapies that were already authorized by their prior payer. This implementation guide defines a standardized mechanism and format for the sharing of information from the prior payer to the new payer about 'current' therapies the patient was receiving coverage for from the old payer as well as the clinical and other information that the prior payer used to determine their eligibility for that coverage. This significantly increases the chances that the new payer's requirements for coverage will also be met and the member's therapy will be able to continue without interruption to coverage.

The implementation guide also supports sharing of other relevant information that will allow the new payer to best provide appropriate coverage. For example, knowledge of past amputations, gender reassignment, adverse reactions or other clinical events may influence future coverage decisions, as well as payer services such as mammogram reminders.

ALTERNATIVE NAMES

HL7 FHIR® IG: Payer Coverage Decision Exchange, R1 - US Realm may also go by the following names or acronyms:

BENEFITS

• Supports sharing of other relevant information that will allow the new payer to best provide appropriate coverage. For example, knowledge of past amputations, gender reassignment, adverse reactions or other clinical events may influence future coverage decisions, as well as payer services such as mammogram reminders
• Defines a standardized mechanism and format for the sharing of information from the prior payer to the new payer about 'current' therapies the patient was receiving coverage for from the old payer as well as the clinical and other information that the prior payer used to determine their eligibility for that coverage.

IMPLEMENTATIONS/CASE STUDIES

• Mettle Solutions
• Mitre

DEVELOPMENT BACKGROUND

This implementation guide leverages Task to allow one payer to solicit a Coverage Transition FHIR document from a prior payer. It provides guidance on both the structure and interactions around the exchange of and monitoring of the Task as well as the contents of the FHIR document. The profiles and terminology it leverages are U.S.-specific, however, the architectural approach could be applicable outside the U.S.

RELATED DOCUMENTS

HL7 FHIR® IG: Payer Coverage Decision Exchange, R1 - US Realm

STU DOCUMENTS

HL7 FHIR® Implementation Guide: Payer Coverage Decision Exchange, R1 - US Realm http://hl7.org/fhir/us/davinci-pcde/STU1/index.html

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TOPIC

• Financial Management

BALLOT TYPE

• STU

STATUS DATE

2020-12-23

RESPONSIBLE WORK GROUP

PRODUCT TYPE

• Implementation Guide

STAKEHOLDER

• Payors

FAMILY

• FHIR

CURRENT STATE

• Active

REALM

• US Realm