Da Vinci - Member Attribution (ATR) List
2.1.0-preview - STU 2.0.0
Da Vinci - Member Attribution (ATR) List
2.1.0-preview - STU 2.0.0
Da Vinci - Member Attribution (ATR) List, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.0-preview built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-atr/ and changes regularly. See the Directory of published versions
This section of the implementation guide defines the specific conformance requirements for systems wishing to conform to this Member Attribution List implementation guide. The bulk of it focuses on the implementation of the Bulk Data IG to meet Member Attribution List use-cases. It also describes the use of SMART on FHIR Backend Services Authorization and provides guidance on privacy, security and other implementation requirements.
Before reading this formal specification, implementers should first familiarize themselves with two other key portions of the specification:
The Use Cases & Overview 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 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.
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.
This implementation guide sets expectations for two types of systems:
Producer systems are typically Payer systems but could theoretically be any system responsible for producing a Member Attribution List. These systems typically act as servers.
Consumer systems are typically Provider systems that act on behalf of provider organizations who retrieve the Member Attribution List from Producer. These systems typically act as clients.
The requirements and expectations described here are not intended to be exhaustive. Producers and Consumers could potentially support additional resources and extensions, etc. The purpose of this implementation guide is to establish a baseline of expected behavior and data elements that communication partners can rely on and then build from. Future versions of this specification will evolve based on implementer feedback.
Producers and Consumers asserting conformance to this implementation guide have to implement the requirements outlined in Producer Capability Statement and Consumer Capability Statement respectively. The following definition of MUST SUPPORT is to be used in the implementation of the requirements.
This specification makes significant use of FHIR profiles, search parameter definitions and terminology artifacts to describe the content to be shared as part of Member Attribution List interactions. The implementation guide is based on FHIR R4 and profiles are listed for each interaction.
The full set of profiles defined in this implementation guide can be found by following the links on the FHIR Artifacts page.
This implementation guide also leverages the US Core set of profiles defined by HL7 for sharing non-veterinary EMR individual health data in the U.S. Where US Core profiles exist, this Guide either leverages them directly or uses them as a base for any additional constraints needed to support the Member Attribution List use cases. If no constraints are needed, this IG doesn’t define any profiles.
Where US Core profiles do not yet exist (e.g. for Coverage, Group), profiles have been created that try to align with existing US Core profiles in terms of elements exposed and terminologies used.
The Bulk Data Export async pattern is used by this IG for the implementation of the davinci-data-export operation. The actual Bulk Data export operation is not directly used in this IG.
Producer systems SHALL support the $davinci-data-export operation for Member Attribution List implementation.
Producer systems SHALL support the exportType of hl7.fhir.us.davinci-atr for implementing the Member Attribution List IG.
Producer systems SHALL export only the patients contained in the identified group if a list of member references are supplied as part of the $davinci-data-export operation.
When member references are not supplied, the Producer systems SHALL export data for all members contained in the Member Attribution List.
Producer systems SHALL support the reading and searching of Group resources per the capability statement expectations outlined below.
Producer systems SHALL support Group,Patient,Coverage as resource types for the [base]/Group/[id]/$davinci-data-export?_type parameter for the exportType of hl7.fhir.us.davinci-atr.
Producer systems SHOULD support RelatedPerson, Practitioner, PractitionerRole, Organization, Location resource types for the [base]/Group/[id]/$davinci-data-export?_type parameter for the exportType of hl7.fhir.us.davinci-atr.
Producer systems SHALL reject requests that do not contain the minimum resource types of Group,Patient,Coverage as resource types for the [base]/Group/[id]/$davinci-data-export?_type parameter for the exportType of hl7.fhir.us.davinci-atr.
The resource list includes
The Patient who is the member.
The Coverage which resulted in the Patient being a member of the Group
The Organization to which the Patient is attributed to as part of the Member Attribution List.
The Practitioner or PractitionerRole that the patient is attributed to as part of the Member Attribution List
The RelatedPerson who may be the Subscriber of the Coverage.
The Group itself contains the list of members and their relationship to the other members.
Producer systems SHALL support the Bulk Data Kick-off Request for the $davinci-data-export as defined in the Bulk Data IG export operation specification.
Producer systems MAY support the Bulk Data Delete Request for the $davinci-data-export as defined in the Bulk Data IG export operation specification.
Producer systems SHALL support the Bulk Data Status Request for the $davinci-data-export as defined in the Bulk Data IG export operation specification.
Producer systems SHALL set the requireAccessToken to true within the Bulk Data Status Request response body as defined in the Bulk Data IG export operation specification.
Producer systems SHALL require Consumer systems to provide valid access token to access the Member Attribution List files.
Producer systems SHALL support the Bulk Data File Request for the $davinci-data-export as defined in the Bulk Data IG export operation specification.
When the Consumer systems do not have appropriate authorization to the data requested, the Producer systems SHALL return OperationOutcome with appropriate error message.
When the Consumer systems do not have appropriate access token to access the data requested, the Producer systems SHALL return OperationOutcome with appropriate error message.
This section outlines how the SMART on FHIR Backend Services Authorization will be used by this implementation guide.
Producer systems SHALL advertise conformance to SMART Backend Services by hosting a Well-Known Uniform Resource Identifiers (URIs) as defined in the SMART on FHIR Backend Services Authorization specification.
Producer systems SHALL include token_endpoint, scopes_supported, token_endpoint_auth_methods_supported and token_endpoint_auth_signing_alg_values_supported as defined in the SMART on FHIR Backend Services Authorization specification.
Consumer systems SHALL share their JWKS with the Producer systems using URLs as defined in the SMART on FHIR Backend Services Authorization specification.
Consumer systems SHALL obtain the access token as defined in the SMART on FHIR Backend Services Authorization specification.
Producer systems SHALL support ```system/*.read`` scopes for Member Attribution List exchange.
Producer systems supporting the creation and reconciliation of a Member Attribution List by Consumer systems SHOULD also support the system/*.write scope for Member Attribution List exchange.
During Consumer registration, the Producer system MAY collect the NPI and Tax Identification Numbers applicable for a specific contract along with the specific contract information. This information MAY be used by the Producer to create the necessary Member Attribution List and provide an API that will allow the Consumer to retrieve the Member Attribution List. Producers MAY follow other OAuth best practices for Consumer registration.
When the Consumer is trying to discover the specific Group resource that represents the Member Attribution List for a specific use case, the Producer SHALL verify that the Consumer credentials provided allow the Consumer to access the requested specific Group Resource.
NOTE: This verification is for a specific Group instance and not just the Group Resource type which is controlled by the scopes.
This section lists the capability statements for Producer and Consumer systems.
The Producer specific requirements for REST interactions, operations, profiles and search parameters to be supported are outlined in the Producer Capability Statement.
The Consumer specific requirements for REST interactions, operations, profiles and search parameters to be supported are outlined in the Consumer Capability Statement.
The section outlines specific requirements that need to be followed in creating the Member Attribution List.
Producers SHALL create one Member Attribution List represented by an instance of Group Resource. There will be exactly one Group Resource instance per Contract between a Payer and a Provider.
Producers SHALL ensure the combination of Member Identifier, Payer Identifier, Contract Identifier and Plan Identifier are unique.
Producers SHALL include the Contract Identifier within the Group.identifier element during the creation of the Member Attribution List.
Producers SHALL make available the Group resource for Consumers for at least the duration of the contract in compliance with applicable regulations and policies.
Producers SHALL create new versions of Group resource instances as data in the Group (Members, Attributed periods, coverage references, attributed providers) change. Producers may or may not retain older versions of the Group based on their instance version scheme. In some instances Producers may choose a version scheme based on agreements with Consumers. When queried by the Consumers, Producers SHALL return the latest version of the Group resource instance unless a specific version is queried.
Producers SHALL represent the validity period of the contract in the Group.contractValidityPeriod extension.
Producers SHALL include the Plan Identifier in Coverage.class data element during the creation of the Member Attribution List.
Producers SHALL include the Coverage that is associated with the member in the Member Attribution List as part of the Group.member.anyReference data element.
Producers SHALL include settlement entity names, ACO identifiers in Group.identifier during the creation of the Member Attribution List. This is helpful for Consumers to discover the Group using a single settlement entity name and/or an ACO identifier.
Producers SHALL include the provider NPI and/or TIN in Group.identifier field during the creation of the Member Attribution List. These identifiers are used by Consumers to discover the Group Resource using their own NPI and/or TIN.
When Member Identifiers are present, Producers SHALL include the Member Identifier in the Coverage.identifier.
Producers SHALL include the attribution period in the Group.member.period data element. This indicates the period over which the member is attributed to the provider.
When members get attributed to different providers during the same contract for different providers, Producers SHALL include the member multiple times in the Member Attribution List, once for each provider with whom the member is attributed including their attribution period.
When members are not attributed to a provider or an organization, Producers MAY attribute the member to the Settlement Entity organization which is responsible for the contract. Producers SHALL include the attribution period in the Group.member.period element.
Producers SHALL include the contract validity period in Group.extension (membershipValidityPeriod) data element.
Producers SHALL set Group.member.inactive = true when the member is no longer attributed.
Producers SHALL set Group.member.extension.ext-changeType = dropped when the member is no longer attributed.
Producers SHALL set Group.member.extension.ext-changeType = new` when a member is added to the Member Attribution List for the first time.
Producers SHOULD set Group.member.extension.ext-changeType = changed` when a member’s information has changed.
Producers SHOULD set Group.member.extension.ext-changeType = nochange` when a member’s information has not changed from the previous version of the Member Attribution List.
Producers SHOULD exchange Provider NPI and TIN only as needed and when the NPIs and TINs belong to providers associated with the receiving organization.
Consumers SHOULD NOT be sharing the NPI and TIN information amongst providers unless required for transactions related to Payment, Treatment and Operations (PTO).
This interaction outlines the APIs for a Consumer (for example, Provider organization) to discover the Group Resource in a Producer’s system ( for example, Payer organization).This Group resource represents the Member Attribution List that has been created by the Producer based on a contract between the Producer and the Consumer. For example, Multicare a Provider Organization would like to identify the Member Attribution List that a Payer organization (e.g Cambia Health Systems) has created based on a contract between Cambia and Multicare.
Precondition:
In order to discover the appropriate Group Resource (Member Attribution List) the Consumer is expected to know its own NPI and/or Tax Identification Number or Contract Identifier or Settlement Entity Identifiers. Producers and Consumers may exchange this information during the contract establishment. Similarly Producers may provide the name of the Group resource representing the Member Attribution List that can be retrieved by the Consumer. Note: Producers and Consumers MAY have a predetermined cadence on exchanging Member Attribution Lists and this API could be invoked based on the cadence.
API: Discover Group using NPI or TIN
GET <Server Base URL>/Group?identifier=http://hl7.org/fhir/sid/us-npi|<Example NPI>&_summary=true
GET <Server Base URL>/Group?identifier=urn:oid:2.16.840.1.113883.4.4|<Example TIN>&_summary=true
API: Discover Group using Identifiers (Contract Identifier or Settlement Entity Identifier)
GET <Server Base URL>/Group?identifier=http://example.org|<Identifier Value>&_summary=true
API: Discover Group using Name
GET <Server Base URL>/Group?name=myorg&_summary=true
Expected Result:
Consumer receives one or more Group Resources from the above API call(s). Each Group Resource represents a specific Member Attribution List between the Producer and the Consumer. To narrow down the specific Member Attribution List for a specific contract the Consumer has to examine the Group.identifier and Group.contractValidityPeriod element and compare the contract information. An example resource retrieved by the above discovery APIs can be found at Group Example.
This interaction outlines the APIs for a Consumer (Provider) organization to request the full Member Attribution List that is applicable to their specific organization for a specific contract. Note: The request has to be accepted by the Payer and eventually a Member Attribution List would be made available. This is an asynchronous request following Bulk Data IG specifications.
For example, Multicare would like to request the Member Attribution List details from Cambia Health Systems for a specific contract.
Precondition:
Provider Organization knows the specific Group Resource for the specific contract that represents the Member Attribution List from executing the discovery of group resource API outlined previously.
API:
GET or POST <Server Base URL>/Group/[Group id]/$davinci-data-export?resourceTypes=GRoup,Patient,Practitioner,PractitionerRole,Organization,Location,Coverage,RelatedPerson&exportType=hl7.fhir.us.davinci-atr
OR
GET or POST <Server Base URL>/Group/[Group id]/$davinci-data-export?resourceTypes=GRoup,Patient,Practitioner,Organization,Coverage&exportType=hl7.fhir.us.davinci-atr
NOTE: Any other combination of resourceTypes are not valid for the exportType of hl7.fhir.us.davinci-atr.
Expected Results: Request is accepted by the Producer and a Content Location is received as part of the Response. Detailed examples for Bulk Data Request can be found in the Bulk Data IG.
This interaction outlines the APIs for a Consumer (Provider) organization to poll the Content Location received as part of Member Attribution List Export Request outlined previously. This polling is required to determine completion status of the export request. This would be repeated until the request is complete or cancelled following the Bulk Data IG specifications.
For example, Multicare would poll the content location received from Cambia as part of the Member Attribution List Export Request.
Preconditions:
API
GET <Content Location from Member Attribution List Export Request>
Expected Results:
AThis interaction outlines the APIs for a Consumer (Provider) organization to retrieve each of the files that represent the Member Attribution List.
For example, Multicare retrieves each of the NDJSON files representing the Member Attribution List.
Precondition:
Consumer has the URLs to retrieve the files representing the Member Attribution List from a successfully completed Member Attribution List Export Request. These URLs are obtained by executing the Member Attribution List Export Request Polling interaction until the request is completed.
API:
GET <File URL for each Resource identified in Member Attribution List Export Request completion response>
Expected Results:
Member Attribution List are typically created by the Producer and published for use by the Consumer. However as described in the Use Cases section the Consumer could create a Member Attribution List in the Producer’s system. In order to accomplish this the following API’s are expected to be used by the Consumer.
The following are the Member Attribution List Reconciliation APIs and their purpose
Scenario 1 : A Consumer wants to add a specific patient to the Attribution List.
The Consumer determines the patient’s memberId and the NPI of the attributed provider and uses the member-add operation on the specific Group instance to add the member.
Scenario 2 : A Consumer wants to remove a specific patient and their attributions from the Attribution List.
The Consumer determines the patient’s memberId and uses the member-remove operation on the specific Group instance to remove the member.
Scenario 3 : A Consumer wants to update the attribution associated with a specific patient
Step 1: The Consumer determines the patient’s memberId and uses the member-remove operation on the specific Group instance to remove the member.
Step 2: Once the attributions are removed in Step 1, The Consumer determines the patient’s memberId and the NPI of the attributed provider and uses the member-add operation on the specific Group instance to add the member.
Scenario 4 : A Consumer wants to confirm that the Attribution List is final
The Consumer uses the confirm-attribution-list operation on the specific Group instance to indicate to the Producer that the list is final and no more changes will be requested by the Consumer.
Scenario 5 : A Consumer wants to determine the status of attribution for a specific member
The Consumer determines the patient’s memberId and uses the attribution-status operation on the specific Group instance to retrieve the attribution status of the patient.
This interaction outlines the APIs for a Consumer (for example, Provider organization) to add a member to the Member Attribution List.
Precondition:
In order to add a member to the Member Attribution List, the Consumer should have successfully discovered the Member Attribution List. The Consumer knows the MemberId and the AttributedProvider NPI or the references to the Member and the Attributed Provider in the Producer system. The Member Attribution List status has to be “draft” for the reconciliation API of member-add to be allowed.
API: Add a member to the Member Attribution List
The following combinations of parameters SHALL be supported by the server implementing the operation.
patientReference + providerReference + attributionPeriod: Adds the member, attributed provider and the attribution period to the Attribution List.
POST [Base FHIR URL]/Group/[id]/$member-add
The body will contain the parameters resources with combinations specified above.
Expected Results:
This interaction outlines the APIs for a Consumer (for example, Provider organization) to remove a member from the Member Attribution List. The semantics of the member-remove operation based on the Member Attribution List status is outlined at Member Remove semantics.
Precondition:
To remove a member from the Member Attribution List, the Consumer should have successfully discovered the Member Attribution List. The Consumer knows the MemberId and the Attributed Provider’s NPI or the references to the Member and the Attributed Provider in the Producer system. The Member Attribution List status has to be “draft” for the reconciliation API to be allowed.
API: Remove a member from the Member Attribution List
The following combinations of parameters SHALL be supported by the server implementing the operation.
patientReference + providerReference + coverageReference: Removes the attribution for the combination of Member and Provider and Coverage resources
POST [Base FHIR URL]/Group/[id]/$member-remove
The body will contain the parameters resources with combinations specified above.
Expected Results:
This interaction outlines the APIs for a Consumer to indicate to the Producer that the Consumer has finished the reconciliation process and has no pending changes.
Precondition:
The Consumer and the Producer are already exchanging a specific Member Attribution List in draft form.
API: Confirm Attribution List
The operation does not require any parameters.
The Producer SHALL return a status of 201 Accepted when the API is invoked.
The Producers SHOULD change the Member Attribution List status to final from draft.
Prior to changing the Member Attribution List status to final, the Producer MAY make changes to the Member Attribution List based on internal business processes and information.
POST [Base FHIR URL]/Group/[id]/$confirm-attribution-list
There are no parameters for the operation.
Expected Results:
The requirements and mechanisms to use Subscriptions for notifications is outlined in Subscriptions Requirements.
IG © 2019+ HL7 International / Financial Management. Package hl7.fhir.us.davinci-atr#2.1.0-preview based on FHIR 4.0.1. Generated 2024-12-04
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