HL7 FHIR® Implementation Guide: Risk Adjustment, Release 1 - US Realm

DESCRIPTION

The Da Vinci Fast Healthcare Interoperability Resource (FHIR) Risk Adjustment Implementation Guide describes exchanging risk adjustment coding gaps between payers and providers. Risk adjusted premium calculations are important to government managed care. To better inform providers of opportunities to address risk adjusted conditions, better enable payers to communicate risk adjustment information, and enhance government sponsors’ ability to allocate funding accurately, payers and providers need a standard protocol to share and receive clinical data related to risk adjustment and a standard methodology to communicate risk based coding, documentation and submission status of chronic conditions. The STU1 of this implementation guide focuses on the standard exchange format of risk adjustment coding gaps from payers to providers, it offers potential for reducing administrative burden experienced by providers by standardizing the reporting they receive from all payers.

 

See the specification at http://hl7.org/fhir/us/davinci-ra/STU1

ALTERNATIVE NAMES

HL7 FHIR® Implementation Guide: Risk Adjustment, Release 1 - US Realm may also go by the following names or acronyms:

BENEFITS

• Improve the accuracy and completeness of risk adjustment.
• Facilitates communication of risk adjustment coding gaps and efficient partnerships between payers and providers to align incentives
• Reduces the administrative burden associated with the current processes by creating a standard for sharing risk adjustment information
• Minimizes health information gaps and improves documentation of risk adjusted conditions, leading to more appropriate and equitable financial revenues.

IMPLEMENTATIONS/CASE STUDIES

• Da Vinci; Da Vinci risk adjustment Reference Implementation

DEVELOPMENT BACKGROUND

This implementation guide is supported by the Da Vinci initiative which is a private effort to accelerate the adoption of Health Level Seven International Fast Healthcare Interoperability Resources (HL7® FHIR®) as the standard to support and integrate value-based care (VBC) data exchange across communities. Like all Da Vinci Implementation Guides, it follows the HL7 Da Vinci Guiding Principles for exchange of patient health information. As an HL7 FHIR Implementation Guide, changes to this specification are managed by the sponsoring Clinical Quality Information (CQI) Work Group and are incorporated as part of the standard balloting process.

RELATED DOCUMENTS

HL7 FHIR® Implementation Guide: Risk Adjustment, Release 1 - US Realm

STU DOCUMENTS

HL7 FHIR® Implementation Guide: Risk Adjustment, Release 1 - US Realm See the standard at http://hl7.org/fhir/us/davinci-ra/STU1.

(Submit Feedback on STU)

TOPICS

• Clinical Quality
• Financial Management

BALLOT TYPE

• STU

STATUS DATE

2022-06-16

RESPONSIBLE WORK GROUP

PRODUCT TYPE

• Implementation Guide

STAKEHOLDERS

• Clinical Decision Support Systems Vendors
• EHR, PHR Vendors
• Emergency Services Providers
• Health Care IT Vendors
• Healthcare Institutions
• Payors
• Quality Reporting Agencies

FAMILY

• FHIR

CURRENT STATE

• Active