Stream: implementers
Topic: Requirements for a Payer
Mohammad Wahid (May 27 2020 at 03:02):
Hello,
I'm totally new to FHIR and would greatly appreciate a quick response on the following queries:
- How can I find what is a must have by 01/01/2021 for a payer (i.e. what data should be available for query (claims), etc)
- Rxnorm to NDC bulk conversion process.
Much appreciated!
Lloyd McKenzie (May 27 2020 at 03:21):
Based on question #2, I'm going to assume you're U.S.-based. (The answer to #1 would vary significantly based on where you are.)
- In the U.S., claims are generally mandated to be submitted via X12 and NCPDP. There are new regulations coming into force about payers being able to share data with other payers and in some cases with providers. The Da Vinci project is working on a number of implementation guides aiming to help payers meet those requirements in a standardized way. You can find information about Da Vinci and its various IGs here: https://confluence.hl7.org/display/DVP
- @Scott Robertson @Rob Hausam ?
Scott Rossignol (May 27 2020 at 12:11):
You're likely looking for a distilled version of the CMS Interoperability rule. I haven't seen one specifically for Payors. You can read the rule and pull out pertinent requirements from just the Executive Summary though; it seems daunting but it's not too bad. The rule and a lot of supporting detail is here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index
If I had to summarize the requirements for a payor for next year they would be: Patient Access API (claims, USCDI data), Provider Directory API ( provider and pharmacy data)
These APIs should use FHIR R4 standards.
Scott Rossignol (May 27 2020 at 12:15):
I would review the ONC Interoperability rule as well, but I wouldn't worry about the requirements there as they pertain almost solely to EHR vendors and the users of EHR software. If the organization you're working with does use an EHR then I would push the EHR vendor to provide you a roadmap of their development efforts to meet these requirements. If they have a payor module then they're likely obligated to support many of these requirements.
The second video here also provides an overview you might find useful. https://www.redoxengine.com/blog/videos-from-our-interoperability-virtual-conference/
Nathan Hall (May 27 2020 at 12:45):
Rxnorm to NDC isn't a one-size answer. There can be many ndcs mapped to an RXNORM.
From the FHIR standpoint, we generally use a ConceptMap Resource. Here's an example that does SNOMED to ICD-10 but it's the same idea. https://www.hl7.org/fhir/conceptmap-103.json.html
Depending on your workload, rxnav (part of NIH) can handle some, but if you hit it too much it will rate limit you.
https://rxnav.nlm.nih.gov/RxNormAPIs.html#uLink=RxNorm_REST_getNDCs
Last updated: Apr 12 2022 at 19:14 UTC
