1. HITSP Capabilities Public Review Webinar HITSP Communicate Referral Authorization Capability Public Review Administration and Finance Domain Technical Committee October 1, 2009 1

2. HITSP Capabilities Public Review Webinar HITSP Communicate Referral Authorization Capability Requirements and Design Public Comment  Introduction  Schedule  Review of Capabilities  Technical Approach  Public Comment 2

3. HITSP Capabilities Public Review Webinar HITSP Communicate Referral Authorization Capability Requirements and Design Public Comment  Introduction  Schedule  Review of Capabilities  Technical Approach  Public Comment 3

4. HITSP Capabilities Public Review Webinar Introduction  The purpose of this Webinar is to provide a high-level overview of a HITSP proposed solution for exchanging prior-authorization information between a Pay Benefits Manager and a Provider or Pharmacy  Today we will be discussing the requirements section of the document. The capability and all associated HITSP constructs will be released for the traditional 4 week public comment period in early November 4

5. HITSP Capabilities Public Review Webinar Introduction – Co-Chairs and Staff Staff/Co-ChairContact Information Don Bechteldonald.bechtel@siemens.com Durwin Daydayd@bcbsil.com Manick Rajendranmanicktiger@gmail.com 5

6. Providing specifications that integrate diverse standards to meet clinical and business needs for sharing information: 1.Develop specifications that address broad stakeholder perspectives 2.Support testing and validation of specifications 3.Catalyze efforts of standards organizations to realize changes to address gaps and overlaps Enabling Interoperability between healthcare stakeholders Healthcare Information Technology Standards Program (HITSP) Specifying Standards needed to enhance care quality and contain costs 6HITSP Capabilities Public Review Webinar

7. Base or Composite Standards Constructs (single purpose or reusable) Interoperability Specification (construct) Type 1: Base or Composite Standards HITSP Interoperability Specifications A complete IS set provides a framework that defines □ A hierarchy of constructs □ The role of each construct □ The relationship of one construct to another in the context of specific business and/or clinical requirements Interoperability Specification (Complete Set) 7HITSP Capabilities Public Review Webinar

8. Capabilities and Service Collaborations HITSP Capabilities Public Review Webinar8 Keys to Simpler Definition and Implementation of HITSP Specifications

9. Service Collaboration (SC) □ Defines a standards-based secure infrastructure needed for interoperable information exchanges □ Includes a secure transport mechanism with topology and other options □ Uses HITSP Constructs to specify the secure infrastructure □ Does not specify the content of the information exchange but may include information to support the exchange (e.g., authorization information) HITSP Capabilities Public Review Webinar9

10.  Patient Identification  Email address/ distribution list Topology  System-to-System  Portable Media  System-to-HIE  HIE-to-HIE Service Collaboration Standards-based Secure Infrastructure Needed for Interoperable Information Exchanges 10HITSP Capabilities Public Review Webinar  Delivery notification  Patient consent Management

11. Service Collaborations □ SC108 - Access Control □ SC109 - Security Audit □ SC110 - Patient Identification Management □ SC111 - Knowledge and Vocabulary □ SC112 - Healthcare Document Management □ SC113 - Query for Existing Data □ SC114 - Administrative Transport to Health Plan □ SC115 - HL7 Messaging □ SC116 - Emergency Message Distribution Element 11HITSP Capabilities Public Review Webinar

12. HITSP Capability □ Enables systems to address a business need for interoperable information exchange □ Bridges between business, policy and implementation views: – Defines a set of information exchanges at a level relevant to policy and business decisions – Supports stakeholder requirements and business processes – Defines information content and secure infrastructure – Specifies use of HITSP constructs sufficiently for implementation – Includes constraints and identifies specific network topologies 12HITSP Capabilities Public Review Webinar

13. What is an example of a capability?  Requirement: An organization wants to exchange a prescription with an ambulatory organization  The diagram on the right shows how Capability 117 was assembled to support this requirement CAP117 – Communicate Ambulatory and Long Term Care Prescription System Roles Medication Order Prescriber Medication Order Filler Health Plan Health Information Exchange (HIE) I want to exchange a prescription with an Ambulatory or Long-Term Care (LTC) Organization 13HITSP Capabilities Public Review Webinar

14. Existing HITSP Capabilities – Clinical Operations Clinical Operations Communicate Ambulatory and Long Term Care Prescription - CAP117 Communicate Hospital Prescription - CAP118 Communicate Clinical Referral Request - CAP121 Retrieve Genomic Decision Support - CAP125 Communicate Lab Results Message - CAP126 Communicate Lab Results Document - CAP127 Communicate Imaging Information - CAP128 Retrieve and Populate Form - CAP135 Communicate Encounter Information Message - CAP137 14HITSP Capabilities Public Review Webinar

15. Existing HITSP Capabilities – Public Health and Emergency Response; Administration and Finance Administration and Finance Communicate Benefits and Eligibility - CAP140 Communicate Referral Authorization - CAP141 Public Health and Emergency Response Communicate Quality Measure Data - CAP129 Communicate Quality Measure Specification - CAP130 Update Immunization Registry - CAP131 Retrieve Immunization Registry Information - CAP132 Communicate Immunization Summary - CAP133 Communicate Emergency Alert - CAP136 Communicate Resource Utilization - CAP139 15HITSP Capabilities Public Review Webinar

16. Existing HITSP Capabilities - Security, Privacy, and Infrastructure Security, Privacy, and Infrastructure Communicate Structured Document - CAP119 Communicate Unstructured Document - CAP120 Retrieve Medical Knowledge - CAP122 Retrieve Existing Data - CAP123 Establish Secure Web Access - CAP124 Retrieve Pseudonym - CAP138 Retrieve Communications Recipient - CAP142 Manage Consumer Preference and Consents - CAP143 16HITSP Capabilities Public Review Webinar

17.  Patient Identification  Email address/ distribution list Topology  System-to-System  Portable Media  System-to-HIE  HIE-to-HIE  Patient consent Management Marrying Content Definition with Secure Infrastructure for a set of Interoperable information exchanges  Delivery notification Capability Service Collaboration Defining Content  Component Service Collaboration 17HITSP Capabilities Public Review Webinar

18. HITSP Communicate Referral Authorization Capability Requirements and Design Public Comment  Introduction  Schedule  Review of Capabilities  Technical Approach  Public Comment 18

19. HITSP Capabilities Public Review Webinar Schedule  Requirements for Prior-Authorization introduced to the Public via Webinar October 1 st  Comment feedback on the Requirements for this work item closes October 8 th – The process for submitting comments is included on slide 46 of this presentation  The Capability with all supporting constructs will be released for a 4 week Public Comment period in early November 19

20. HITSP Capabilities Public Review Webinar HITSP Communicate Referral Authorization Capability Requirements and Design Public Comment  Introduction  Schedule  Review of Capabilities  Technical Approach  Public Comment 20

21. HITSP Capabilities Public Review Webinar Definition of Capabilities  Capabilities provide the ability for two or more systems to address a business need for interoperable information exchange  The objective is to provide the bridge between the business, policy and implementation disciplines by: – Defining a set of information exchanges at a level relevant to policy and business decisions – Supporting stakeholder requirements and business processes by including information content, infrastructure, Security, Privacy – Specifying the use of HITSP constructs sufficiently for implementation – Including constraints and operating on specific network topologies (contexts)  Capabilities have topology and other options (e.g., point-to-point, portable media, system-to-HIE, HIE-to-HIE) 21

22. HITSP Capabilities Public Review Webinar What is a capability?  Capabilities are specified using HITSP Constructs  As part of the HITSP Tiger Team effort addressing ARRA, Capabilities are meant to clearly state what types of data HITSP can and cannot “exchange”  During the ARRA Tiger Team effort, no new standards were selected, and no new constructs were specified to build capabilities Requirements Capability System Roles HITSP Constructs Orchestration of HITSP Constructs and System Roles 22

23. HITSP Capabilities Public Review Webinar HITSP Communicate Referral Authorization Capability Requirements and Design Public Comment  Introduction  Schedule  Review of Capabilities  Technical Approach  Public Comment 23

24. HITSP Capabilities Public Review Webinar Technical Approach of Capability 141  High level review of the purpose of this capability  Review of the requirements that have been defined 24

25. Purpose of Capability 141 □ Addresses interoperability requirements that support electronic inquiry and response for authorizing a health plan member to be referred for service by another provider or to receive a type of service or medication under the patient’s health insurance benefits. □ The Capability supports: – Transmittal of a patient and insurance identification information – Identification of the type of service or medication requested for benefit coverage – Communication of authorization number from the Payer System □ It provides clinicians and pharmacists with information about each patient’s medical insurance coverage and benefits. It may include information on referral or authorization permission HITSP Capabilities Public Review Webinar25

26. Why The Capability Was Developed □ Capability 141 was developed to enable: – Consumers and Providers to request prior-authorization for medical related encounters and medications – Payors to respond to such requests – Payors to provide: Non-patient specific guidelines for prior-authorization Patient specific guidelines for prior-authorization HITSP Capabilities Public Review Webinar26

27. Capability 141 Information Exchanges Information Exchange Identifier Exchange Action Exchange ContentConstraints Initiating Interface Responding Interface ARequest & Response HITSP/SC114 – Administrative Transport to Health Plan, and HITSP/EC68A – Health Plan Request None1, 32, 4 BRequest & Response HITSP/SC114 – Administrative Transport to Health Plan, and HITSP/EC68B – Health Plan Response None2, 41, 3 CRequest & Response HITSP/SC114 – Administrative Transport to Health Plan, and HITSP/EC79A – Health Plan Request None1, 32, 4 DRequest & Response HITSP/SC114 – Administrative Transport to Health Plan, and HITSP/EC79B – Health Plan Response None2, 41, 3 HITSP Capabilities Public Review Webinar27

28. Service Collaborations Included in Capability 114 Manage Consent Directives Access Control Secured Communic ation Channel Security Audit Entity Identity Assertion Document Integrity Non- Repudiatio n of Origin De- identificati on Integrated NA Option HITSP Capabilities Public Review Webinar  Uses HITSP/Service Collaboration 114  SC 114 contains the Security, Privacy, and Infrastructure functionality depicted in the table below  Also includes HITSP/T85 – Administrative Transport to Health Plan  T85 uses CAQH Phase II CORE #270 Connectivity Rule v2.0.0, which addresses the message envelope metadata and envelope standards, submitter authentication standards, and communications-level errors, and acknowledgements 28

29. INFORMATION EXCHANGE OPTIONS TopologyAvailable or NotOption Point-to-PointAvailableDirect Point-to-Point*NAe-mail Portable MediaNAPortable Media System-to-HIEAvailableSystem-to-HIE HIE-to-HIENAHIE-to-HIE HITSP Capabilities Public Review Webinar *NOTE: As the gaps are evaluated email will be reconsidered 29

30. Capability 141 Requirements □ Detailed definition of the requirements, recommended solutions and identified gaps in the solutions may be found in Section 6 of the document □ The following slides provide a high-level overview of the requirements HITSP Capabilities Public Review Webinar30

31. Consumer Requirements Functional RequirementsIERData Requirements Analysis A. The ability for consumers to participate in prior- authorization processes and information exchange i. Consumers may need the ability to receive certain standardized payer or provider information related to prior- authorization within their PHR or similar systems. Examples include provider lists or eligibility coverage information for various services and frequency limitations Gap Provider List Eligibility Information Formulary and Benefits Information ASC X12 does not currently support consumers as receiver ASC X12 270/271 does not support consumer as receiver Formulary and benefits information – Gap, not currently designed to interact with a consumer HITSP Capabilities Public Review Webinar31

32. Consumer Requirements Functional RequirementsIERData Requirements Analysis A. The ability for consumers to participate in prior-authorization processes and information exchange ii. Consumers may need the ability to use their PHR or similar systems to communicate prior-authorization information to provider and/or payer systems. Examples include supplying medical history or prior coverage information Gap A, B Gap Prior -Auth Information Medical History Prior coverage information There are no current standards available today that include the consumer business actor function ASC X12 278 transaction may need additional functionality to support all medical history Prior coverage is NOT part of prior-authorization. We are wondering if this really means Prior Coverage, which would be supported today by 278 HITSP Capabilities Public Review Webinar32

33. Provider Requirements Functional RequirementsIERData Requirements Analysis B. The ability for providers to access standardized prior-authorization information and to incorporate and/or use the information within an EHR or related system i. The ability to receive non patient-specific prior-authorization information such as eligibility and reimbursement guidelines. Providers may receive more detailed information than the consumer for treatment, payment, and operations A, B (Gap ) C, D (Partial Gap) X12 does not support this function. Gap solution: Ask X12 to change 278 to allow health plan to send attachment of administrative guidelines. Alternative: Ask HL7 to develop a discrete CDA dataset for this purpose T79 Pharmacy to Health Plan Authorization uses the NCPDP Telecommunication Standard for real-time PA requests, PA billings, PA inquiries for pharmacies. Gap solution: NCPDP Formulary and Benefit standard exchange might be enhanced HITSP Capabilities Public Review Webinar33

34. Provider Requirements Functional RequirementsIERData Requirements Analysis B. The ability for providers to access standardized prior-authorization information and to incorporate and/or use the information within an EHR or related system ii. The ability to query for patient- specific prior- authorization criteria. The ability to review such information without actually submitting a prior- authorization request may reduce workflow disruption and help providers aid consumers in evaluating their treatment options A, B (Partial Gap) C, D T68 provides ASC X12 270/271 for eligibility/benefit inquiries. The eligibility transaction today cannot provide information about the P.A. criteria. It also does not provide alternative treatments. T79 Pharmacy to Health Plan Authorization uses the NCPDP Telecommunication Standard for real-time PA requests, PA billings, PA inquiries for pharmacies HITSP Capabilities Public Review Webinar34

35. Provider Requirements Functional RequirementsIERData Requirements Analysis B. The ability for providers to access standardized prior-authorization information and to incorporate and/or use the information within an EHR or related system iii. The ability to electronically submit patient- specific prior- authorization requests and related information to payers A, B C, D CAP141 refers to T68 for provider obtaining prior authorization from the Payer. (no changes needed) CAP141 refers to T79 for prescriber obtaining prior authorization from the PBM. (no changes needed) HITSP Capabilities Public Review Webinar35

36. Provider Requirements Functional RequirementsIERData Requirements Analysis B. The ability for providers to access standardized prior-authorization information and to incorporate and/or use the information within an EHR or related system iv. The ability to request a modification or extension of a previously approved prior- authorization A, B C, D CAP141 refers to T68 for provider obtaining prior authorization from the Payer. (no changes needed) CAP141 refers to T79 for prescriber obtaining prior authorization from the PBM. (no changes needed) HITSP Capabilities Public Review Webinar36

37. Provider Requirements Functional RequirementsIERData Requirements Analysis B. The ability for providers to access standardized prior-authorization information and to incorporate and/or use the information within an EHR or related system v. Providers may need the ability to communicate prior-authorization information to another provider A, B C, D Supported by CAP141 with T68 transaction Supported by CAP141 with T79 transaction Need to determine the business need for a pharmacy- to-pharmacy exchange of PA information HITSP Capabilities Public Review Webinar37

38. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems i. The ability to broadly disseminate certain types of non patient- specific information such as a list of eligible providers or different therapies. Medications may need prior- authorization and what types of accompanying information are typically needed for approval A, B (Partial Gap) A, B (Gap) C, D Provider List Procedures or therapies non patient- specific eligibility request by a consumer or provider Medications P- A T68 (ASC X12 274) supports a list of providers within a health plan There is an X12 gap for showing alternate therapies, treatment No standards available that include the consumer business actor function T79 depends on HITSP/TP46-Medication Formulary and Benefits Information to provide formulary and benefit information HITSP Capabilities Public Review Webinar38

39. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems ii. The ability to communicate patient-specific prior-authorization or eligibility information in response to consumer and/or provider queries B, A (Partial Gap) D, C (Partial Gap) Eligibility Information CAP141 refers to T68 for provider obtaining prior authorization from the Payer. The gap is support of the consumer CAP141 refers to T79 for prescriber obtaining prior authorization from the PBM. The gap is support of the consumer HITSP Capabilities Public Review Webinar39

40. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems iii. The ability to electronically receive prior- authorization request submissions from providers and/or consumers and to process these requests within payers or third party intermediary systems B, A (Partial Gap) D, C (Partial Gap) Prior- Authorization Information CAP141 refers to T68 for provider obtaining prior authorization from the Payer. The gap is support of the consumer CAP141 refers to T79 for prescriber obtaining prior authorization from the PBM. The gap is support of the consumer HITSP Capabilities Public Review Webinar40

41. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems iv. The ability to communicate a request for additional information such as clinical justification or treatment history in order to make a prior-authorization decision B, A (Partial Gap) D, C (Partial Gap) Diagnosis Medical History Medication History CAP141 refers to T68 for provider which supports this function CAP141 refers to T79 for prescriber which supports this function HITSP Capabilities Public Review Webinar41

42. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems v. The ability to electronically communicate patient-specific prior-authorization decisions, co- payment, and co- insurance information to provider and/or consumer systems B, A (Partial Gap) D, C (Partial Gap) CAP141 refers to T68 for provider obtaining prior authorization from the Payer. Co-payments and co- insurance information related to an approved P.A. request would not supported in X12 278 CAP141 refers to T79 for prescriber obtaining prior authorization from the PBM. The gap is support of the consumer. Can provide co- payment or co-insurance information at the patient level HITSP Capabilities Public Review Webinar42

43. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems vi. Particularly in the event of a rejection, a payer may need the ability to communicate an explanation for a prior-authorization decision as well as to communicate information on alternative treatment options or an Advanced Beneficiary Notification (ABN) B, A (Partial Gap) D, C T68 content would be an explanation of benefits or reason for denial. The gap is being able to communicate alternate treatment options for medical benefits T79 for Pharmacy to Health Plan Authorization supports this HITSP Capabilities Public Review Webinar43

44. Payor Requirements Functional RequirementsIERData Requirements Analysis C. The ability for payors to electronically communicate standardized prior-authorization information to provider and/or consumer systems vii. A payor may need the ability to communicate co- payment, co- insurance or other information related to patient responsibility for expenses B, A D, C T68 supports this exchange. The Gap is for consumer T79 - NCPDP Formulary and Benefit Standard supports the exchange of benefit information including PA information HITSP Capabilities Public Review Webinar44

45. HITSP Capabilities Public Review Webinar HITSP Communicate Referral Authorization Capability Requirements and Design Public Comment  Introduction  Schedule  Review of Capabilities  Technical Approach  Public Comment 45

46. HITSP Capabilities Public Review Webinar Comment Tracking System  HITSP.org link: http://www.hitsp.org/public_review.aspxhttp://www.hitsp.org/public_review.aspx Using the HITSP Comment Tracking System Using the HITSP Comment Tracking System The HITSP Comment Tracking System allows registered authors to provide comments on documents that are undergoing public review or implementation testing. A unique user ID and password is required for each comment submitter Please note that the Comment Tracking System closes at 5 PM Pacific Daylight Time on the final day of public review, October 8 th Current HITSP members: Submit comments by following the link above and entering your current user ID and password New Users: Contact Hzander@ansi.org for a user name and password to access the CTSHzander@ansi.org Add Comment Register a NEW comment in the tracking systemAdd Comment View (My) Comments View the status or disposition of a comment previously submittedView (My) Comments Please contact Hannah Zander (HZander@ansi.org) with any questions or problems with entering commentsHZander@ansi.org 46

47. HITSP Capabilities Public Review Webinar Questions and Comments  Comments regarding the Requirements outlined to meet the needs of Communicate Referral Authorization are welcome during this portion of the Webinar  Comments regarding the complete Capabilities documents can be addressed via Comment Tracking System (see previous slide for instructions) 47