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Payer Data Exchange (PDex) (Da Vinci Pjt; PSS in Confluence)

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Basics

Payer Data Exchange (PDex) (Da Vinci Pjt; PSS in Confluence)

1489
Ballot - STU to Normative


FHIR Implementation Guide

Implementation Guide

Details

This project has been updated many times, each update is a unique PSS in Confluence, those links are in the Project Document Repository.

Below is the initial project description from the Confluence PSS for Payer Data Exchange (PDex) (Update 3). View the PSS on Confluence for the entire description.

This project will define exchange methods (e.g. push, pull, triggers, subscription, bulk), use of other interoperability 'standards' (e.g. CDS Hooks and SMART on FHIR) and specific use of FHIR resources to effectively exchange payer information regarding current, previous, or potential future care, including the provenance of the data, of one or more specific patients/members with authorized individuals and organizations including providers responsible for evaluating/specifying/ordering/delivering care for the patient. The scope includes exchange of member specific or general program related data such as network information (e.g. provider directory) and drug benefits (formulary).


Updated to include exchanges with members, other payers and third parties

Providers, members, interested individuals, and other payers need access to payer information including current and prior healthcare services received by the patient/member and plan information to more effectively manage the patients care and make informed healthcare decisions. Currently, no other FHIR implementation guides exists to standardize 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, interested individuals, and other payers. This implementation guide will provide a standard for adoption by payers, providers, and third party applications for the exchange of payer information. This project will address many of the payer exchange requirements covered in May 1, 2020 CMS Final Rule on Interoperability.



Ballot for Comment - Target: 2019 May Ballot Submit for STU Ballot(First Ballot Cycle) - Target: 2019 Sep Ballot Complete STU Reconciliation - Target: 2020 Jan WGM Request STU Publication - Target: 2020 Jan WGM STU Period - Target: 2020 Jan Submit for STU 2 Ballot (First Ballot Cycle) - Target: 2020 Sep Ballot Complete STU 2 Reconciliation - Target: 2021 Jan WGM Request STU 2 Publication - Target: 2021 Jan WGM STU Period - Target: 2021 Jan -2022 Jan Submit for Normative Ballot - Target: 2022 May Ballot Complete Normative Reconciliation - Target: 2022 Sep WGM Submit Publication Request - Target: 2022 Oct Project End Date (all objectives have been met) - Target: 2022 Dec


PSS for Payer Data Exchange (PDex) (Update 3) https://confluence.hl7.org/pages/viewpage.action?pageId=94639340 PSS for Payer Data Exchange (PDex) (Update 2) https://confluence.hl7

How much content for this project is already developed? 10% Was the content externally developed ? : Y (Da Vinci) Is this a hosted (externally funded) project? (not asking for amount just if funded)? Yes

HealthRecord Exchange Framework

Clinical and Public Health Laboratories, Immunization Registries, Quality Reporting Agencies, Regulatory Agency, Payors, Other (specify in Misc. Notes below),Medical Imaging Service; Healthcare Institutions (hospitals, long term care, home care, mental health),Health Care IT; Clinical Decision Support Systems; Lab

1) Humana 2) Cerner

On March 4 2019, CMS issued a Notice of Proposed Rule Making (NPRM) requiring that that covered payers (Medicare Advantage, Medicaid, CHIP and FFE Qualified Health Plans) make specific data available to their members. In addition, payers must make clinical data available to another health plan and/or third party application at the members request. In addition to the clinical data, the payer must also make the provider network directory information available to the member via the API. On May 1, 2020, CMS and ONC issued their final rules and selected FHIR R4 as the release for certification. This PSS has been updated to reflect the final rule requirements for FHIR R4

Payer Data exchange, PDex, Da Vinci


Yes

N/A

No

2026 June: TSC denied an Unballoted STU Update Publication Request for HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex), Release 2.2.0 - US Realm; project advised to go back to ballot due to changes being too large for an unballote update. 2025 June: TSC approved an STU Publication Request for HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex), Edition 2.1 - US Realm for 2 years 2025 February: TSC approved Unballoted STU Update Publication Request for DaVinci Payer Data Exchange (PDex) US Drug Formulary 2024 June: TSC approved STU Extension Request for DaVinci Payer Data Exchange (PDex) US Drug Formulary 2.0.1 - STU 2 for 2 years 2023 September: TSC approved STU Extension Request for DaVinci Payer Data Exchange US Drug Formulary for 2 years 2022 November: TSC approved STU Extension Request for HL7 FHIR Implementation Guide: Payer Data Exchange (PDex), Release 1 - US Realm for one year 2022 August: TSC Approved STU Publication Request for HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Drug Formulary, Release 2 - US Realm 2022 March: Corey Spears updated the PSS on Confluence by creating an 'Update 3' version. PMO added links to all the PSSs associated with this project to Project Insight and all Confluence PSS's in the Project Document Repository section. PMO archived the prior versions of the Confluence PSSs 2021 December: TSC approved Out of Cycle Ballot Request for HL7 FHIR Implementation Guide: ePayer Data Exchange (ePDx), Release 2 - US Realm 2021 Sept: TSC approved unballoted STU update for DaVinci Payer Data Exchange US Drug Formulary 2020 Dec: TSC approved STU Publication Request for HL7 FHIR Implementation Guide: Payer Data Exchange (PDex), Release 1 - US Realm for 2 years. 2019 January: TSC approved STU Publication Request for Da Vinci Formulary Implementation Guide 2019 September: TSC approved Out of Cycle Ballot Request for HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm Other Stakeholders: Federal Healthcare Agencies (e.g. CMS), Providers (e.g. Physicians)
Organization & Realm

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

U.S.
People

Mark Scrimshire, Tony Benson, Corey Spears



Financial Management Work Group

Payer/Provider Info Exchange Work Group; Pharmacy Work Group

Status & Dates

Active

STU - Test Period/Accepting Comments

04/16/2019

09/01/2027

2027 Sept WGM/Ballot

05/15/2027

2027 May WGM/Ballot

2024 Sept Ballot Cycle Info: STU Ballot results: Met basic vote requirements. 12 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex), Release 2 - US Realm 2024 Sept Ballot Cycle Info: STU Ballot Results: Postponed Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm 2022 May Ballot Cycle Info: STU Ballot Results: Did not meet basic vote requirements. 39 Negatives to reconcile Document Name: * HL7 FHIR Implementation Guide: Payer Data Exchange (PDex), Release 2 - US Realm (See Jira Ballot Dashboard) 2022 Jan Ballot Cycle Info: STU Ballot results: Met basic vote requirements. 17 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Drug Formulary, Release 2 - US Realm (See Jira Ballot Dashboard) 2022 Jan Ballot Cycle Info: STU Ballot Results: Postponed Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm 2022 Jan Ballot Cycle Info: STU Ballot Results: Postponed Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex), Release 1 - US Realm 2022 May Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 39 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 2 - US Realm 2020 Sept Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 38 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm 2020 Sept Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 37 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm 2019 Sept Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 42 Negatives to reconcile Document Name: * HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Drug Formulary, Release 1 - US Realm 2019 Sept Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 60 Negatives to reconcile Document Name: * HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex), Release 1 - US Realm 2019 Sept Ballot Cycle Info: STU Ballot results: Postponed Document Name: HL7 FHIR® Implementation Guide: Payer Data Exchange (PDex) Payer Network, Release 1 - US Realm 2019 Out of Cycle Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 42 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex) Drug Formulary, Release 1 - US Realm 2019 Out of Cycle Ballot Cycle Info: STU Ballot results: Did not meet basic vote requirements. 60 Negatives to reconcile Document Name: HL7 FHIR Implementation Guide: Payer Data Exchange (PDex), Release 1 - US Realm 2019 May Ballot Cycle Info: COMMENT ONLY Ballot results: Postponed Document Name: HL7 FHIR Implementation Guide: ePayer Data Exchange (ePDx), Release 1 - US Realm
Approvals

05/08/2019


Received


All Received




System Info



View Ballot Items (with NIBs)



08/20/2026

Anne Wizauer
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