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  1. FHIR Specification Feedback
  2. FHIR-36299

Mapping CQLs to PA criteria

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    • Icon: Change Request Change Request
    • Resolution: Not Persuasive with Modification
    • Icon: Highest Highest
    • US Da Vinci DTR (FHIR)
    • 1.1.0-ballot [deprecated]
    • Clinical Decision Support
    • CQL [deprecated]
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      We have a separate ticket to change "Payer rules" to "Documentation requirements".

      These sentences note the necessity to take into account data variability in locating necessary documentation (specific coding, representing interventions as procedures vs observations, etc.) 

      Will clarify the intent of this language.

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      We have a separate ticket to change "Payer rules" to "Documentation requirements". These sentences note the necessity to take into account data variability in locating necessary documentation (specific coding, representing interventions as procedures vs observations, etc.)  Will clarify the intent of this language.
    • Bob Dieterle / Howard Strasberg: 13-0-2
    • Clarification
    • Non-substantive

    Description

      IG states "Authors of payer rules should keep this in mind as they create CQL. Due to differences in workflows or information systems, clinical information may be represented in different FHIR resources or with different codes or code systems. Therefore, payer CQL may have to examine different resources or use value sets to find patient information. It is preferable to have more extensive CQL or value sets than require a user to input values that the rules were unable to find."

      This language seems insufficient.  There needs to be a requirement that payers map their CQLs to the prior authorization criteria for specific services.

       

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            apreisler Andrea Preisler
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