Payer Coverage Decision Exchange (Da Vinci project; PSS in Confluence)

Description

This PSS will use FHIR to exchange specific coverage/treatment decisions to another payer to allow for continued coverage of specific treatments without needing to repeat the review and authorization process that creates a burden for the provider, patient, and the payer. The decisions may be based on commercial guidelines that can be uniquely referenced or based on specific payer rules (may be difficult to define in a structured, rules based, resource or be limited by the proprietary nature of the payer's evaluation process). In addition, the need exists to exchange the supporting documentation that was used to validate the necessity for coverage of specific treatments.

This PSS builds on existing or in process implementation guides for the automation of requests to a payer for coverage information (Coverage Requirements Discovery - CRD), access to payer information (Payer Data Exchange - PDex) and the Health Record Exchange Library/Framework (HRex).

This project will define patient driven/authorized exchange methods to meet the anticipated requirements for coverage portability.

This project will reference, where possible, the 'standards' defined by the Health Record exchange (HRex) Library/Framework Implementation Guide which in turn will utilize prior work from Argonaut, US Core and QI Core effort for FHIR DSTU2, STU3, and R4 where appropriate.

The ultimate goal is to support the portability of coverage by exchanging information between payers to define decision making and supporting documentation with regard to treatment for chronic illnesses without the need to burden the provider and/or patient or risk a discontinuity of care.

The project team plans to work with existing FHIR artifacts where possible. If changes are necessary, the project team will work with the responsible Work Group to review and implement (via tracker items or new PSS) any necessary enhancements to base FHIR resources, extensions, and/or profiles.

Misc Notes
2025 April: TSC approved STU Extension Request for Da Vinci - Payer Coverage Decision Exchange (PCDE) for 9 months 2022 November: TSC approved STU Extension Request for Da Vinci Payer Coverage Decision Exchange (PCDE) FHIR IG (v1.0.0: STU 1) for two years 2020 Dec: TSC approved STU Publication Request for HL7 FHIR Implementation Guide: Payer Coverage Decision Exchange, Release 1 - US Realm for 2 years. External Vocabularies: HCPCS, SNOMED, CPT, ICD, RxNorm, LOINC For FHIR IGs and FHIR Profiles, what product version(s) will the profiles apply to? R4, STU3, DSTU2 Other Stakeholders and Providers: Federal Healthcare Agencies (e.g. CMS), Providers (e.g. Physicians)