×

To enhance security, Multi-Factor Authentication (MFA) is mandatory for all HL7 users. More information

 
Return to Search

FHIR Implementation Guide for Coverage Requirements Discovery

Return to Search

Basics

FHIR Implementation Guide for Coverage Requirements Discovery

1428
Ballot - STU to Normative


FHIR Implementation Guide

Implementation Guide

Details

1. Providers need to easily discover which payer covered services or devices have

- Specific documentation requirements,

- Rules for determining need for specific treatments/services

- Requirement for Prior Authorization (PA) or other approvals

- Specific guidance.

2. With a FHIR based API, providers can discover in real-time specific payer requirements that may affect the ability to have certain services or devices covered by the responsible payer.

3. The discovery may be based on

- Plan identification only (e.g. no need for PHI)

- Member identification (PHI) in the event the specific plan is not known at the time of request or required to respond to the request

- Or a combination

4. Response may be

- The answer to the discovery request

- A list of services, templates, documents, rules (that have potential to inform or create CDS artifacts)

- URI may be included to allow retrieval of specific items (e.g. template) (that have potential to inform or create CDS artifacts)

This project will create a FHIR implementation guide (IG) to define the API(s) to allow the above workflows to determine payer coverage requirements at point of service. The IG will specify both a PHI based solution and a non-PHI based solution that may be used for payers that do not need PHI to determine the specific coverage requirements. The IG will specify the required resources, extensions, profiles, value sets and operations.


To give providers real-time access to payer approval requirements, documentation, and rules at point of service to reduce provider burden and support treatment planning.



Submit for STU Ballot(First Ballot Cycle) - Target: 2018 Sept Ballot Complete STU Reconciliation - Target: 2018 Nov Request STU Publication - Target: 2018 Dec STU Period - 12 months - Target: 2019 Jan - 2020 Jan Submit for additional STU rounds as appropriate based on feedback - Target: 2019 Sept - 2020 Jan Submit for Normative Ballot - Target: Based on FHIR normative schedule for incorporated artifacts Complete Normative Reconciliation - Target: TBD Submit Publication Request - Target: TBD


HL7 Da Vinci Project Confluence page(s)

This is an externally funded Da Vinic project How much content for this project is already developed? 0% Was the content externally developed (Y/N)?

FHIR STU 4.0 Final Ballot, Reconciliation and Publication

Regulatory Agency, Payors,Medical Imaging Service; Healthcare Institutions (hospitals, long term care, home care, mental health),Pharmaceutical; EHR, PHR; Equipment; Health Care IT; Clinical Decision Support Systems; Lab

1) Cerner 2) Epic 3) Allscripts 4) CMS 3) United 4) Humana 5) Anthem

Creation of Implementation Guide regarding Coverage Requirements Discovery to be completed for balloting in the September 2018 cycle

Coverage Requirements Discovery, CRD, Payer requirements

N/A

Yes

N/A

No

2026 March: TSC approved an STU Publication Request for HL7 FHIR® Implementation Guide: Coverage Requirements Discovery, Edition 2.2 - US Realm 2025 June: TSC approved the STU Publication of HL7 FHIR® Implementation Guide: Da Vinci - Coverage Requirements Discovery (CRD) Edition 2.1 - US Realm for 2 years 2024 November: TSC Approved Unballoted STU Update Publication Request for HL7 FHIR Implementation Guide: Da Vinci - Coverage Requirements Discovery Edition 2.1, US Realm 2023 October: TSC approved STU Publication Request for HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Edition 2 - US Realm for 2 years 2022 November: TSC approved STU Extension Request for Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v1.0.0: STU 1) for one year 2021 December: TSC approved Out of Cycle Ballot Request for HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Release 2 - US Realm 2020 Dec: TSC Approved STU Publication Request for HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Release 1 - US Realm for 2 years The work group is using the Confluence PSS for this project. External vocabularies: SNOMED, CPT, HCPCS/CPT II, RxNorm, LOINC
Organization & Realm

Realm Specific - Enter "U.S." or name of HL7 Affiliate below

U.S.
People

Robert Dieterle, Lenel James



Financial Management Work Group


Status & Dates

Active

STU - Test Period/Accepting Comments

06/04/2018

05/01/2028

2028 May WGM/Ballot

05/15/2028

2028 May WGM/Ballot

2025 Sep Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 36 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Edition 3 - US Realm 2022 May Ballot Cycle Info: STU Ballot results: Met basic vote requirements. 35 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Release 2 - US Realm 2022 Jan Ballot Cycle Info: STU Ballot Results: Postponed Document Name: HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Release 1 - US Realm 2019 May Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 26 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Release 1 - US Realm 2018 Oct Ballot Cycle Info: STU Ballot results: Met basic vote requirements. 35 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Coverage Requirements Discovery, Release 1 - US Realm
Approvals

07/16/2018


Received


All Received




System Info



View Ballot Items (with NIBs)



04/09/2026

Anne Wizauer
Return to Search