There needs to be requirements on the completeness of data exchanged from the old payer. - PCDE #126

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    • Type: Change Request
    • Resolution: Persuasive with Modification
    • Priority: Medium
    • US Da Vinci PCDE (FHIR)
    • STU3
    • Financial Mgmt
    • (profiles) [deprecated]
    • 4.2.2
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      Payers will be both providers and receivers of this information.  It will be in payers interest to provide sufficient information so that when they are receivers they will receive sufficient information.  Community pressure will help ensure appropriate behavior because it's difficult to technically enforce. 

      However, we will also add the following language to the specification:

      Payers SHOULD send all information they have available they believe to be reasonably necessary for the receiving payer to make a determination of medical necessity.  (Future versions of this specification are expected to tighten this requirement to SHALL.)

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      Payers will be both providers and receivers of this information.  It will be in payers interest to provide sufficient information so that when they are receivers they will receive sufficient information.  Community pressure will help ensure appropriate behavior because it's difficult to technically enforce.  However, we will also add the following language to the specification: Payers SHOULD send all information they have available they believe to be reasonably necessary for the receiving payer to make a determination of medical necessity.  (Future versions of this specification are expected to tighten this requirement to SHALL.)
    • Mark Scrimshire / Mary Kay McDaniel: 17-0-2
    • Clarification
    • Non-substantive

      Existing Wording: 4. The new plan incorporates the information in the document into their utilization management/utilization review process for review and approval of the ongoing treatments for the new member.

      Comment: There needs to be requirements on the completeness of data exchanged from the old payer. This sounds like it is going to involve some burdensome manual work for the old payer. If the data is limited to the bare minimum in order to reduce burdens, it could lead to incompleteness of data received.

            Assignee:
            Unassigned
            Reporter:
            Terrence Cunningham
            Watchers:
            3 Start watching this issue

              Created:
              Updated:
              Resolved: