Validation Results for DaVinciPayerDataExchange

This STU 2.2 specification has undergone ballot and connectathon testing. It is expected to continue to evolve, possibly significantly, as part of that process. Feedback is welcome and may be submitted through the FHIR JIRA tracker indicating US Da Vinci PDex as the specification. If balloting on this IG, please submit your comments via the tracker and reference them in your ballot submission implementation guide.

This guide can be reviewed offline. Go to the Downloads section. Click on the link to download the full Implementation Guide as a zip file. Expand the zip file and use a web browser to launch the index.html file in the directory created by the zip extract process. External hyperlinks in the guide will not be available unless you have an active internet connection.

Financial Management is the Sponsoring Work Group for this Implementation Guide.

The Payer Data Exchange (PDex) Implementation Guide (IG) is provided for Payers/Health Plans to enable them to create a Health History for a Member using clinical resources (based on US Core 3.1.1 and 6.1.0 Profiles based on FHIR R4) which can be understood by providers and, if they choose to, committed to their Electronic Medical Records (EMR) System.

The PDex work group has made changes to the original version of the IG following the publication of the final CMS Interoperability and Patient Access Rule (CMS-9115_ and in STU 2.1 the IG has been expanded to meet the requirements of the CMS Prior Authorization Rule (CMS-0057).

This IG uses the same Member Health History payload for member-authorized exchange of information with other Health Plans, with Providers and with Third-Party Applications. It describes the interaction patterns that, when followed, allow the various parties involved in managing healthcare and payer data to more easily integrate and exchange data securely and effectively.

This IG covers the exchange of:

• Claims-based information (without financials)
• Clinical Information (such as Lab Results, Allergies and Conditions)
• Prior Authorization information

This IG covers the exchange of this information using US Core and Da Vinci Health Record Exchange (HRex) Profiles. This superset of clinical profiles forms the Health History for a Health Plan Member.

This IG covers the exchange of the Health History for a member in the following scenarios:

• Provider requested exchange using SMART-on-FHIR Bulk exchange
• Health Plan Exchange using SMART-on-FHIR
• Member-authorized Health Plan to Health Plan exchange
• Member-authorized Health Plan to Third-Party Application exchange

The latter two scenarios are provided to meet the requirements identified in the CMS Interoperability and Patient Access Final Rule.

There are items in this guide that are subject to update. This includes:

• Value Sets
• Vocabularies (X12, NUBC etc.)
• Examples

The Vocabulary, Value Sets and codings used to express data in this IG are subject to review and will be reconciled with X12.

See the Table of Contents for more information.