There should be some way to limit or scope requests for "medical necessity" data. - PCDE #130

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    • Type: Change Request
    • Resolution: Not Persuasive
    • Priority: Medium
    • US Da Vinci PCDE (FHIR)
    • STU3
    • Financial Mgmt
    • (profiles) [deprecated]
    • 2.4
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      In this specification, the requesting payer can't identify any particular desired information - only that they want the 'summary document'. It's up to the "old" payer to make a determination of what information is relevant/appropriate to be included. The "old" payer is subject to HIPAA and other state and federal recommendations (e.g. "minimum necessary") around what is to be shared, so they have incentive to not share information that is not necessary to continuity of care. The forthcoming regulation may have additional guidance about what information should (and should not) be shared.

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      In this specification, the requesting payer can't identify any particular desired information - only that they want the 'summary document'. It's up to the "old" payer to make a determination of what information is relevant/appropriate to be included. The "old" payer is subject to HIPAA and other state and federal recommendations (e.g. "minimum necessary") around what is to be shared, so they have incentive to not share information that is not necessary to continuity of care. The forthcoming regulation may have additional guidance about what information should (and should not) be shared.
    • Mark Scrimshire / Mary Kay McDaniel: 17-0-2

      Existing Wording: 4. prescriptive on what information is required to substantiate medical necessity for any treatment;

      Comment:

      Absent some sort of rules on what would help a payer make coverage determinations, a payer is essentially free to request any data it wants in the name of "substantiating medical necessity." There should be some way to limit or scope such requests.

      Summary:

      There should be some way to limit or scope requests for "medical necessity" data.

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

              Created:
              Updated:
              Resolved: