Da Vinci Payer Data Exchange
2.1.0 - STU2 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 2.1.0 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

Provider Access API

Previous Page - Handling Data Provenance

Provider Access API bulk data guidance in this version of the IG is draft only. It has not appeared in ballot and has not been fully tested. It is included to support the requirements of the CMS prior Authorization Rule (CMS-0057). The bulk data transfer is based upon published guidance in the Da Vinci Member Attribution (ATR) IG.

Provider Access API

In December 2022, CMS released the Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule CMS-0057-P. This rule was finalized in February 2024.
One of the requirements of the rule is for Impacted Payers to implement a Provider Access API. This is an API that conforms to the HL7 FHIR Bulk Data API specification. The purpose of the Provider Access API is to enable Providers to query a Payer API for information about the members of the health plan where they have a current, or upcoming treatment relationship. The API will enable a provider to ask a Payer “What do you know about my Patients?”

The Payer Data Exchange Implementation Guide supports the Provider Access API by utilizing the $Davinci-data-export-operation operation in the Da Vinci Member Attribution Implementation Guide.

How does Provider Access Work?

The diagram below illustrates how health plans may construct and maintain their Member Attribution lists for Organizations, Locations and Providers. It also illustrates how a Provider Representative, such as an EMR, can query the health plan for the PDexProviderGroup resources they are permitted to see and then use the Group/{id} endpoint for those records to request Member clinical, prior authorization and non-financial claims and encounter data.

In-Network ProviderIn-Network ProviderProvider Representative | EMRProvider Representative | EMRMember | PatientMember | PatientPayerPayerAttribution ProcessAttribution ProcessPayer FHIR StorePayer FHIR StoreClaimsClaimsMember Attribution Creation and MaintenanceAttribution rules and dataPayer providesAttribution processing rulesand any Additional Data SourcesHistorical Claims dataClaims data provides evidence of atreatment relationship betweenMember and ProviderOpt-in/Opt-out decisionDefault is for Member to beOpted-in to data sharingAppointmentBook HookCDS Hooks (as defined inDa Vinci CRD IG)Hooks provide a potential indicator ofan impending treatment relationshipEncounterStart HookPDexProviderGroupPDexProviderGroup Group resource atOrganization + Location + Providerlevel of granularityProvider Bulk Access APIAuthorizes RepresentativeProvider/Provider Organization authorizesEMR/Provider Representative to retrieveAttribution data on their behalfRequest SMART Bulk Access CredentialPayer issues Bulk Access CredentialSEARCH /GroupBundle responsePDexProviderGroup resources returned.Group records returned will be bounded by theaccess permission of the Provider Representative/Group/{id}/$davinci-data-exportBulk request can request a subset of Members,a subset of resources and/or a date period.$DaVinci-data-export notifies Reuestor that transaction is completedFHIR Store compiles bundles in response torequest, notifies requestor and requestor retrievesBulk NDJson bundle(s). Content comprises:- US Core Clinical data,- PDex Prior Authorizations- CARIN EOBs (Non-Financial profiled claims and encounter data)

Attribution List driven

The Provider Access API is centered around Attribution lists that enable a Provider/Provider Organization or Facility to retrieve data for health plan members that are assigned to that Provider. The data retrieval uses a FHIR Bulk data export operation to retrieve the requested data.

Members SHALL have the ability to opt-out of data sharing with providers.

The Health Plan is responsible for managing Attribution Lists. Attribution Lists SHOULD be discrete lists at the Organization + Facility + Provider level. This level of granularity is needed to account for Providers working across different organizations, or at different facilities that may use different EMRs. A health plan MAY adopt their own methodology for managing and maintaining provider attribution lists. Health plans are encouraged, for transparency purposes, to share their methodology for managing Member Attribution.

Health plans:

  • MAY use claims data as a source to identify existing treatment relationships.
  • MAY utilize their own rules for determining the attribution of members to Providers.
  • SHOULD use the Coverage Requirements Discovery IG’s AppointmentBook and OrderSelect CDS Hooks as a means to determine impending treatment relationships.

Attribution lists SHALL be searchable via a secure RESTful API. Access to the Group resource to READ attribution lists should be scoped to the appropriate Organization, Facility, Provider or their authorized representative that is acting on the behalf of the Provider.

The Da Vinci Data Export Operation in the Member Attribution IG supports the Bulk FHIR API specification. The operation uses the Group resource. For the PDex Provider Access API the following capabilities SHOULD be supported:

  • Search for Group.
  • Get Group record.
  • Request all information for members in the Group.
  • Request information for a subset of members in the Group.
  • Request a limited set of information for a subset of members in the Group.

This combination of requests should cover all provider data requests, such as:

  • Send all data for this set of patients that are new to my practice.
  • Send new data since I last requested for this set of patients.
  • Send just the lab results for this set of patients since this date.

Access SHALL be controlled using client credentials that are compliant with SMART-On-FHIR. Access SHOULD be restricted to Providers with a contractual relationship with a Payer.

Attribution List

The Payer SHALL be responsible for managing and maintaining the attribution list that assigns Members to Providers. The payer SHALL take account of members that have chosen to opt out of sharing data with providers. Those opted-out members SHALL be omitted from the Provider Attribution list. The Payer MAY choose to maintain a separate Group resource for a Provider that identities the Opted-out Members that would otherwise have been Attributed to the Provider. If a Payer maintains an Opted-out Group resource it is the Payers responsibility to ensure that a Provider is unable to download data about those opted-out members using a bulk export operation. The Da Vinci Attribution (ATR)IG provides transactions to manage the Group resource through Add, change and delete member actions.

The PDexProviderGroup profile SHALL be used to record the members attributed to a Provider, Provider Group or Organization. PDexProviderGroup is based on the ATRGroup Profile from theDa Vinci Member Attribution (ATR) 2.0.0 IG.

The profile adds an extension at the root level. This is used to optionally record the number of potentially attributed members that instead used their right to opt-out of sharing data with providers. By recording this quantity it can help providers reconcile their attribution lists with those managed by the Payer, The extension is:

  • MembersOptedOut

The Profile adds three extensions to the member element. These are used to track the data retrieved for a member by the provider. These extensions are:

These extensions SHALL be updated by the Da Vinci Data Export PDex Use Case Operation.

Da Vinci Data Export Operation - PDex Provider Use Case

Provider Representative:

  • SHALL be issued with OAuth2.0/SMART-On-FHIR client credentials that enable access to /Group/{id}. Where {id} is the PDexProviderGroup(s) attributed to the Organization, Facility and Provider they are representing.
  • SHALL be permitted to SEARCH /Group. The search function and the bundle contents returned SHALL be restricted to the {ids} that are associated with the Provider Representative’s account.
  • MAY be associated with more than one attribution group list.
  • SHALL be permitted to GET /Group/{id} for any Attribution Group list they are associated with.
  • SHALL be permitted to call $davinci-data-export operation for any /Group/{id} they are associated with.

The $davinci-data-export operation enables a Provider Representative to perform granular requests for data.

Data can be constrained by:

  • Patient subset
  • Date range
  • Resource Type
  • Resource filter (valid search parameters for a resource)

Data available via the API includes:

  • Clinical resources (US Core and PDex)
  • Prior Authorizations and supporting structured documentation
  • Non-Financial claims and encounters (CARIN Blue Button)

The Data Export operation SHALL check the consent status for each member at the time of execution. This is necessary to identify members that may have changed their opt-out status for sharing with providers.

Da Vinci Data Export Parameter Handling

patient

If the patient parameter is not provided data SHALL be retrieved for all members in the Group. If the patient parameter is provided the operation SHALL ignore references to patients that are invalid, or not a member of the group.

exportType

This is an optional parameter in the Da Vinci Data Export Operation. The exportType parameter SHALL have one of the following values:

  • hl7.fhir.us.davinci-pdex#provider-delta
  • hl7.fhir.us.davinci-pdex#provider-download
  • hl7.fhir.us.davinci-pdex#provider-snapshot

The hl7.fhir.us.davinci-pdex#provider-delta option SHALL be used when the provider is retrieving new, or updated data that will be stored as part of the patient record.

The hl7.fhir.us.davinci-pdex#provider-download option SHALL be used when the provider is retrieving data that will be stored as part of the patient record.

The hl7.fhir.us.davinci-pdex#provider-snapshot value SHOULD be used when a provider wants to download data for viewing.

From the Data Provider’s perspective the hl7.fhir.us.davinci-pdex#provider-download exportType parameter will require the Data Provider/Payer to track the latest download date/time for the Patients that the provider requests data for. These values SHALL be updated in an extension associated with the Patient for which a download was requested.

_since

Resources in the Patient Access and Provider Access API can extend back to January 1, 2016. The _since parameter SHOULD be used for resource requests when the full history is not required. It is expected that providers MAY first request data for members without limiting the request using the _since parameter. Subsequent requests MAY then use _since to limit data to information that is new.

_until

The _until parameter MAY be used less frequently. It is most likely to be used with the
hl7.fhir.us.davinci-pdex#provider-snapshot exportType to retrieve member data for a specific period.

_type

The _type parameter MAY be used to restrict the resources retrieved by the Provider. This enables providers to only retrieve the resource types they are interested in seeing. If this parameter is not used all available resources SHALL be returned by the Payer, subject to the constraints applied by other input parameters.

When _type is used the export operation SHALL record the content of the _type parameter in the lastResources element for each Member for which data is retrieved. The lastTransmitted SHALL be recorded with either the Date/Time of the Export Transaction or the value of the _until parameter, if it is earlier.

_typeFilter

The _typeFilter parameter MAY be used to further restrict the resources retrieved by the Provider. For example, to only retrieve Observations of a certain type. The _typeFilter, if used, SHALL comprise one, or more, valid FHIR search queries for the respective resource being filtered.

When _typeFilter is used the export operation SHALL record the content of the _typeFilter parameter in the lastFilters element for each Member for which data is retrieved. The lastTransmitted SHALL be recorded with either the Date/Time of the Export Transaction or the value of the _until parameter, if it is earlier.

Access and Refresh Tokens

Implementers SHOULD implement OAuth 2.0 access management in accordance with the SMART Backend Services Authorization Profile. When SMART Backend Services Authorization is used, Bulk Data Status Request and Bulk Data Output File Requests with requiresAccessToken=true SHALL be protected the same way the Bulk Data Kick-off Request, including an access token with scopes that cover all resources being exported. A server MAY additionally restrict Bulk Data Status Request and Bulk Data Output File Requests by limiting them to the client that originated the export. Health plans SHALL limit the data returned to only those FHIR resources for which the client is authorized.

Clients SHALL require OAuth client credentials to enable secure access to read and search the Group resources and perform Bulk export operations. Access Tokens SHALL be required to access the Group resources and and the Bulk export operation. Access and Refresh Tokens SHOULD be issued to support the client requesting and subsequently retrieving the bulk data response to their request.

Registering of a client application or service to perform the bulk Payer-to-Payer Exchange should be registered in accordance with the approach defined in the SMART App Launch IG. That IG also encourages the use of the OAuth2.0 Dynamic Client Registration Protocol (DCRP). An alternative approach that is closely aligned with the DCRP protocol is to use the B2B protocols detailed in the HL7 Security for Scalable Registration, Authentication, and Authorization IG.

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