Da Vinci Payer Data Exchange
2.1.1 - STU 2.1 United States of America flag

Da Vinci Payer Data Exchange, published by HL7 International / Financial Management. This guide is not an authorized publication; it is the continuous build for version 2.1.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/davinci-epdx/ and changes regularly. See the Directory of published versions

: PDex Provider-Member-Match Operation - XML Representation

Page standards status: Informative

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<OperationDefinition xmlns="http://hl7.org/fhir">
  <id value="ProviderMemberMatch"/>
  <text>
    <status value="generated"/>
    <div xmlns="http://www.w3.org/1999/xhtml"><p class="res-header-id"><b>Generated Narrative: OperationDefinition ProviderMemberMatch</b></p><a name="ProviderMemberMatch"> </a><a name="hcProviderMemberMatch"> </a><p>URL: [base]/Group/$provider-member-match</p><h3>Parameters</h3><table class="grid"><tr><td><b>Use</b></td><td><b>Name</b></td><td><b>Scope</b></td><td><b>Cardinality</b></td><td><b>Type</b></td><td><b>Binding</b></td><td><b>Documentation</b></td></tr><tr><td>IN</td><td>MembersToMatch</td><td/><td>1..*</td><td><a href="http://hl7.org/fhir/R4/parameters.html">Parameters</a></td><td/><td><div><p>Contains one or more members with patient demographics and coverage information to be matched against the payer's member records.</p>
</div></td></tr><tr><td>OUT</td><td>MatchedMembers</td><td/><td>0..1</td><td><a href="http://hl7.org/fhir/R4/group.html">Group</a> (<a href="StructureDefinition-member-provider-treatment-relationship-group.html" title="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/member-provider-treatment-relationship-group">Member-Provider Treatment Relationship Group</a>)</td><td/><td><div><p>A Group resource containing members successfully matched and for whom a treatment relationship has been confirmed. This Group can be used with the $davinci-data-export operation to retrieve bulk data.</p>
</div></td></tr><tr><td>OUT</td><td>NonMatchedMembers</td><td/><td>0..1</td><td><a href="http://hl7.org/fhir/R4/group.html">Group</a> (<a href="StructureDefinition-pdex-member-no-match-group.html" title="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-member-no-match-group">PDex Member No Match Group</a>)</td><td/><td><div><p>A Group resource containing members for whom no match could be found in the payer's member records, or for whom the provider's treatment attestation could not be verified or does not meet the payer's requirements.</p>
</div></td></tr><tr><td>OUT</td><td>ConsentConstrainedMembers</td><td/><td>0..1</td><td><a href="http://hl7.org/fhir/R4/group.html">Group</a> (<a href="StructureDefinition-member-opt-out-group.html" title="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/member-opt-out-group">Member Opt-Out Group</a>)</td><td/><td><div><p>A Group resource containing members who have opted out of data sharing with providers or this specific provider.</p>
</div></td></tr></table><div><p>The Group resources returned by this operation can be used as input to the $davinci-data-export operation to perform bulk member matching and retrieve the associated bulk member health history data.</p>
</div></div>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-wg">
    <valueCode value="fm"/>
  </extension>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status">
    <valueCode value="informative">
      <extension
                 url="http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom">
        <valueCanonical
                        value="http://hl7.org/fhir/us/davinci-pdex/ImplementationGuide/hl7.fhir.us.davinci-pdex"/>
      </extension>
    </valueCode>
  </extension>
  <url
       value="http://hl7.org/fhir/us/davinci-pdex/OperationDefinition/ProviderMemberMatch"/>
  <version value="2.1.1"/>
  <name value="ProviderMemberMatch"/>
  <title value="PDex Provider-Member-Match Operation"/>
  <status value="active"/>
  <kind value="operation"/>
  <experimental value="true"/>
  <date value="2024-12-16T00:00:00Z"/>
  <publisher value="HL7 International / Financial Management"/>
  <contact>
    <name value="HL7 International / Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
    <telecom>
      <system value="email"/>
      <value value="fm@lists.HL7.org"/>
    </telecom>
  </contact>
  <contact>
    <name value="Mark Scrimshire (mark.scrimshire@onyxhealth.io)"/>
    <telecom>
      <system value="email"/>
      <value value="mailto:mark.scrimshire@onyxhealth.io"/>
    </telecom>
  </contact>
  <contact>
    <name value="HL7 International - Financial Management"/>
    <telecom>
      <system value="url"/>
      <value value="http://www.hl7.org/Special/committees/fm"/>
    </telecom>
  </contact>
  <description
               value="Provider-Member-Match Operation enables providers to match patient demographics and coverage information against a payer's member records. The operation returns matched members as a Group resource that can be used with the $davinci-data-export operation for bulk data retrieval. This operation aligns with the Payer-to-Payer Bulk Member Match but is designed for provider-initiated requests.

The matched members returned in the MatchedMembers Group can be used directly with the $davinci-data-export operation on the Group resource to retrieve bulk FHIR data for all matched members. The $davinci-data-export operation will return a manifest file referencing the bulk data files containing the member health information in ndjson format."/>
  <jurisdiction>
    <coding>
      <system value="urn:iso:std:iso:3166"/>
      <code value="US"/>
      <display value="United States of America"/>
    </coding>
  </jurisdiction>
  <code value="provider-member-match"/>
  <comment
           value="The Group resources returned by this operation can be used as input to the $davinci-data-export operation to perform bulk member matching and retrieve the associated bulk member health history data."/>
  <resource value="Group"/>
  <system value="false"/>
  <type value="true"/>
  <instance value="false"/>
  <parameter>
    <name value="MembersToMatch"/>
    <use value="in"/>
    <min value="1"/>
    <max value="*"/>
    <documentation
                   value="Contains one or more members with patient demographics and coverage information to be matched against the payer's member records."/>
    <type value="Parameters"/>
    <part>
      <name value="MemberPatient"/>
      <use value="in"/>
      <min value="1"/>
      <max value="1"/>
      <documentation
                     value="The patient demographics for a member to be matched."/>
      <type value="Patient"/>
      <targetProfile
                     value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-patient-demographics"/>
    </part>
    <part>
      <name value="CoverageToMatch"/>
      <use value="in"/>
      <min value="1"/>
      <max value="1"/>
      <documentation
                     value="The member's existing or previous coverage information to match against."/>
      <type value="Coverage"/>
      <targetProfile
                     value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage"/>
    </part>
    <part>
      <name value="CoverageToLink"/>
      <use value="in"/>
      <min value="0"/>
      <max value="1"/>
      <documentation
                     value="Optional: The member's new coverage information to link to (e.g., during plan transitions)."/>
      <type value="Coverage"/>
      <targetProfile
                     value="http://hl7.org/fhir/us/davinci-hrex/StructureDefinition/hrex-coverage"/>
    </part>
    <part>
      <name value="TreatmentAttestation"/>
      <use value="in"/>
      <min value="1"/>
      <max value="1"/>
      <documentation
                     value="Provider's attestation to an active treatment relationship with the patient. This replaces the general consent with a specific treatment relationship attestation."/>
      <type value="Consent"/>
      <targetProfile
                     value="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/provider-treatment-relationship-consent"/>
    </part>
  </parameter>
  <parameter>
    <name value="MatchedMembers"/>
    <use value="out"/>
    <min value="0"/>
    <max value="1"/>
    <documentation
                   value="A Group resource containing members successfully matched and for whom a treatment relationship has been confirmed. This Group can be used with the $davinci-data-export operation to retrieve bulk data."/>
    <type value="Group"/>
    <targetProfile
                   value="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/member-provider-treatment-relationship-group"/>
  </parameter>
  <parameter>
    <name value="NonMatchedMembers"/>
    <use value="out"/>
    <min value="0"/>
    <max value="1"/>
    <documentation
                   value="A Group resource containing members for whom no match could be found in the payer's member records, or for whom the provider's treatment attestation could not be verified or does not meet the payer's requirements."/>
    <type value="Group"/>
    <targetProfile
                   value="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/pdex-member-no-match-group"/>
  </parameter>
  <parameter>
    <name value="ConsentConstrainedMembers"/>
    <use value="out"/>
    <min value="0"/>
    <max value="1"/>
    <documentation
                   value="A Group resource containing members who have opted out of data sharing with providers or this specific provider."/>
    <type value="Group"/>
    <targetProfile
                   value="http://hl7.org/fhir/us/davinci-pdex/StructureDefinition/member-opt-out-group"/>
  </parameter>
</OperationDefinition>