HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm

DESCRIPTION

This implementation guide defines a FHIR interface to a health insurer’s insurance plans, their associated networks, and the organizations and providers that participate in these networks. Publication of this data through a standard FHIR-based API will enable third parties to develop applications through which consumers and providers can query the participants in a payer’s network that may provide services that address their health care needs. Although there are multiple types and sources of providers’ directories, including provider organizations (i.e., a hospital listing all its physicians), government (i.e., listing of providers in Medicare), payers (i.e., a health plan’s provider network), and third-party entities (such as vendors that maintain provider directories), the focus of this implementation guide is on Payer Provider Directories.

 

See the standard at http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1.2

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ALTERNATIVE NAMES

HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm may also go by the following names or acronyms:

BENEFITS

• Enables consumer-directed exchange of clinical information to meet the requirements of the CMS Interoperability Rule
• Enables third parties to develop applications through which consumers and providers can query the participants in a payer’s network that may provide services that address their health care needs
• Provides a standard for adoption by payers, providers and third party applications for the exchange of payer information. 
• Enables access by providers, members, and other payers to payer information regarding current and prior healthcare services received by the patient/member to more effectively manage the patient's care.
• Enables standardization of the method of exchange (push, pull, triggers, subscription, etc.) or the formal representation (e.g. Bundles, Profiles and Vocabulary) for specific elements of payer information of interest to providers, members, and other payers.

 

IMPLEMENTATIONS/CASE STUDIES

• MITRE
• Edifecs
• Humana

 

This IG addresses two actors: Health Plan API Actor: A payer publishing a directory of its provider networks through a FHIR endpoint. Application Actor: A third party using the API published by a payer to provide useful views of the payer's provider networks for end users.

DEVELOPMENT BACKGROUND

This project will address many of the payer exchange requirements covered in March 2019 CMS NPRM.

The Implementation Guide has been developed with the support of the HL7 Da Vinci project.

RELATED DOCUMENTS

HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm

STU DOCUMENTS

	HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 STU1.1 - US Realm See the standard at http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1.1.	Expiration Apr 2026
	HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 STU1.2 - US Realm See the standard at http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1.2.	Expiration Apr 2026
	HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm http://hl7.org/fhir/us/davinci-pdex-plan-net/STU1/index.html	Expiration Apr 2024

TOPIC

• Financial Management

BALLOT TYPE

• STU

STATUS DATE

2020-12-20

RESPONSIBLE WORK GROUP

PRODUCT TYPE

• Implementation Guide

STAKEHOLDERS

• Clinical and Public Health Laboratories
• Clinical Decision Support Systems Vendors
• Health Care IT Vendors
• Healthcare Institutions
• Immunization Registries
• Lab Vendors
• Medical Imaging Service Providers
• Payors
• Quality Reporting Agencies
• Regulatory Agency

FAMILY

• FHIR

CURRENT STATE

• Active

REALM

• US Realm