Patient Cost Transparency Implementation Guide
0.1.0 - STU 1 Ballot

Patient Cost Transparency Implementation Guide, published by HL7 International - Financial Management Work Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/davinci-pct/ and changes regularly. See the Directory of published versions

Formal Specification

This section of the implementation guide (IG) defines the specific conformance requirements for systems wishing to conform to this Patient Cost Transparency (PCT) IG. The bulk of it focuses on the GFE $submit operation and an AEOB query, though it also provides guidance on privacy, security, and other implementation requirements.

Context

Pre-reading

Before reading this formal specification, implementers should first familiarize themselves with two other key portions of the specification:

  • The Use Case page provides context for what this formal specification is trying to accomplish and will give a sense of both the business context and general process flow enabled by the formal specification below.

  • The Technical Background and Underlying Technologies page provides information about the underlying specifications and indicates what portions of them should be read and understood to have the necessary foundation to understand the constraints and usage guidance described here.

Conventions

This implementation guide uses specific terminology to flag statements that have relevance for the evaluation of conformance with the guide:

  • SHALL indicates requirements that must be met to be conformant with the specification.

  • SHOULD indicates behaviors that are strongly recommended (and which may result in interoperability issues or sub-optimal behavior if not adhered to), but which do not, for this version of the specification, affect the determination of specification conformance.

  • MAY describes optional behaviors that are free to consider but where there is no recommendation for or against adoption.

Systems

This implementation guide sets expectations for at least two types of systems:

  • Payer systems adjudicate GFEs that have been submitted by a healthcare provider. These systems determine if a provider is in or out of network, verifies patient eligibility, applies contracted amounts (the provider’s network status needs to be confirmed), and applies member cost sharing amounts.

  • Payer Intermediary The payer intermediary can assist a payer and respond to PCT queries in order to perform functionality such as x12 transformations.

System Actors

  • Client systems are typically billing management systems, revenue cycle management systems, or other client systems responsible for requesting AEOBs.

  • Member The health plan member / patient who is, or was, a member of a health plan.

  • Provider The practitioner or clinician, or their representative, that initiates a data access request to retrieve member data from a health plan.

  • Third-Party Application Health Plan Members / Patients have a right under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to direct the information held by a covered entity, such as a hospital or Health Plan to a third party of their choosing.

There are different terms used for an individual or patient in the Health Plan industry. Terms such as subscriber or member may be used. A subscriber and a member are not necessarily equivalent. For example, the subscriber may be the primary family member on a plan that covers the entire family. Therefore, the term Member will be used throughout this guide to identify the individual subject of the “member health history”.

Profiles

This specification makes significant use of FHIR profiles and terminology artifacts to describe the content to be shared as part of AEOB requests and responses.

The full set of profiles defined in this IG can be found by following the links on the Artifacts page.

Integration with other Implementation Guides

  • Implementations of the PCT implementation guide SHALL support the US Core R4 IG profiles for USCoreOrganizationProfile, USCorePatientProfile, and USCorePractitionerProfile. They SHOULD support any other profiles relevant to the types of AEOBs they process.
  • Clients and Servers supporting this implementation guide SHOULD comply with the Security and Privacy page in the Da Vinci HRex IG.
  • Clients and Servers supporting this implementation guide SHOULD comply with some value sets that are referenced in this IG that are also used by the CARIN for Blue Button® IG.

Note: At this time the use of the CARIN for Blue Button® IG value sets are under review. It is possible and probable similar or equivalent value sets will be used instead.

Detailed Requirements

Summary

FHIR uses a pair of resources called Claim and EOB for multiple purposes - they are used for actual claim submission, but they are also used for managing prior authorizations and pre-determinations. These are distinguished by the Claim.use code. All references to Claim and EOB in this IG are using it for the Advanced Explanation of Benefits (AEOB) purpose.

The primary interaction supported by this implementation guide is submitting an AEOB request and receiving an AEOB response. To perform this, a GFE Bundle resource is constructed by the client (e.g., Billing Management Software) system. The response is an AEOB Bundle.

The GFE Bundle will be sent as the sole payload of a $gfe-submit operation. The response will be an AEOB Bundle which will contain a Bundle.identifier. The Bundle.identifier is important because the response will happen in an asynchronous fashion.

The AEOB(s) will often not be complete and the calling client (or other interested systems - e.g., patient or submitting provider system) will need to periodically poll the payer server in order to determine if the AEOB(s) are complete. Below are the outcomes that SHOULD be used to determine if the AEOB(s) are complete.

The AEOB bundle will contain one of these outcomes queued | complete | error | partial .

The client (or other interested systems - e.g., patient or submitting provider system) can now query the endpoint outcome status using the polling mechanism.

Once all the AEOB(s) have an outcome equal to complete, the client (or other interested systems - e.g., patient or submitting provider system) can perform a FHIR query to receive the completed AEOB bundle.

Note: Although technically possible, conveying the AEOB to the patient via FHIR API is optional and the workflow is contingent upon the payer opting to expose the API to the patient.

GFE and AEOB Bundle Graphics

The below illustrates what is contained in the GFE and AEOB bundles. For full details see the PCT FHIR Artifacts. Of note is the Bundle.identifier which is used in the AEOB query. Note: For brevity not all bundle data elements are shown below.

GFE Bundles

AEOB Bundle

Note: The AEOB bundle SHALL contain one or more AEOBs. Each AEOB SHALL contain a reference to the original GFE bundle.

AEOB Request

The $gfe-submit operation is executed by POSTing a GFE FHIR Bundle to the $gfe-submit endpoint. The Bundle SHALL be encoded in JSON. The GFE FHIR Bundle will include one or more claim resources. The GFE profiles used for the claim resources can be found here. Additional Bundle entries SHALL be populated with any resources referenced by the GFE resource (and any resources referenced by those resources, fully traversing all references, and complying with all identified profiles). Note that even if a given resource instance is referenced multiple times, it SHALL only appear in the Bundle once. E.g., if the same Practitioner information is referenced in multiple places, only one Practitioner instance should be created - referenced from multiple places as appropriate.

Bundle.entry.fullUrl values SHALL be:
• the URL at which the resource is available from the Billing Management System if exposed via the client’s REST interface;
or
• the form “urn:uuid:[some guid]”

All GUIDs used SHALL be unique, including across independent GFE submissions - with the exception that the same resource instance being referenced in distinct AEOB request Bundles can have the same GUID.

In addition to these core elements, any “supporting information” resources needed to process the AEOB request must also be included in the Bundle. Relevant resources referenced by those “supporting information” resources SHALL also be included. Any such resource that has a US Core profile SHALL comply with the relevant US Core profiles. All “supporting information” resources included in the Bundle SHALL be pointed to by the GFE resource using the GFE.supportingInfo.valueReference element.

To attach PDFs, CDAs, JPGs, a DocumentReference instance should be used. The GFE.supportingInfo.sequence for each entry SHALL be unique within the GFE.

All resources SHALL comply with their respective profiles. FHIR elements not marked as ‘must support’ MAY be included in resources within the Bundle, but client systems should have no expectation of such elements being processed by the payer unless prior arrangements have been made. Systems that do not process such elements SHALL ignore unsupported elements unless they are ‘modifier’ elements, in which case the system MAY treat the presence of the element as an error. This IG treats everything that happens beyond the defined operations endpoint receiving the FHIR bundle as a black box. This black box includes any business associate(s), clearinghouse(s), payers, contracted review entities, and other intermediaries that may be involved in the AEOB request and response. It is up to that black box to ensure that any other requirements are met and to perform all processing within the allowed timeframe.

AEOB response

Just like the AEOB request, additional Bundle entries must be present for all resources referenced by the AEOB Response or descendent references. When converting additional Bundle entries, the conversion process SHALL ensure that only one resource is created for a given combination of content. E.g., if the same Practitioner information is referenced in multiple places, only one Practitioner instance should be created - referenced from multiple places as appropriate. When echoing back resources that are the same as were present in the AEOB request, the system SHALL ensure that the same fullUrl and resource identifiers are used in the response as appeared in the request.

It is possible that the incoming Bundle cannot be processed due to validation errors or other non-business-errors. In these instances, the receiving system SHALL return OperationOutcome instances that detail why the Bundle could not be processed and no AEOB Response will be returned.

The project is seeking feedback on what errors should be returned in the OperationOutcome.

These errors are NOT the errors that are detected by the system processing the request and that can be conveyed in a AEOB Response via the error capability. The resulting AEOB Bundle is returned in the HTTP body of the POST response.

AEOB Query

This is done by performing GET [base]/Bundle?identifier=1234

Note: 1234 is the Bundle.identifier.

Polling

In this approach, the Client regularly queries the Server to see if the status of the AEOB bundle has changed.

This is done by performing the AEOB query several times. The details are described below.

Clients SHALL perform this operation in an automated/background manner no more than every 5 minutes for the first 30 minutes and no more frequently than once every hour after that. They SHOULD perform this query at least once every 12 hours. Clients SHALL support manual invocation of the query by users. There are no constraints on frequency of manual queries.

The project is seeking feedback on whether these maximum frequency requirements are acceptable.

Note: The returned AEOB bundle SHALL include the current results for all submitted items and/or services.

AEOB Request / Response example

Example bundles can be found here

Privacy & Security Considerations

The profiles in this IG are defined to ensure sufficient information to properly populate the X12 specifications, though they also allow for additional data to be present. As well, the data elements in the X12 specifications are allowed to be omitted - what data is required by the payer to process an AEOB request is context and business-rule-specific. Implementers submitting AEOB requests are not required to use X12. X12 has only been used to inform the FHIR based data elements in this IG.

The sharing of information from provider to payer for determining an AEOB is subject to HIPAA’s “minimum necessary” regulations (specifically 45 CFR 164.514(d)(3) and (d)(4)). Payers are responsible for ensuring that only information necessary to create an AEOB is solicited, and providers are responsible for ensuring that only data that is reasonably relevant to creating an AEOB is transmitted.

Some of the data shared as part of the AEOB process may have associated constraints on the use of that information for other purposes, including subsequent disclosure to other payers, practitioners, policyholders, etc. While HL7 FHIR supports conveying this information via security labels on transmitted resources, this information is not currently mappable (and thus findable) in the X12 837 transactions. Payers who do not view the FHIR version of the transmitted information should be aware of the possibility of these limitations and ensure they have policies that enforce appropriate sharing constraints on data.

In order to access information about an AEOB, the provider system will need to access the payor system. This will require that the provider system authenticates to the payer system or an intermediary. The specifics of how this authentication are covered is handled within the Da Vinci HRex Implementation guide. PCT Servers SHOULD support server-server OAuth and MAY support mutually authenticated TLS. In a future release of this guide, direction will limit the option to server-server OAuth. Every system implementing the PCT guide will need to be aware of and follow the guidance in the FHIR Core Specification on Clinical Safety and the Security and Privacy page in the Da Vinci HRex guide.

Once the system authentication has occurred, the payer will perform any authorization required for the provider to see the current state of the AEOB.

Testing Requirements

It is the intent of this implementation guide to provide specifications for the exchange of patient costs in a way that is conducive to developing test scripts and a reference implementation (RI) that can be used to validate/exercise the IG at Connectathons, during piloting, and production deployment.

It is also the intent of this guide that any test scripts will include testing of:

  1. resources and profiles defined in this guide
  2. artifacts use from referenced IGs and
  3. testing of conformance to the underlying FHIR standards for the associated release (e.g., FHIR R4).