The new statements provided are rather dense and awkwardly worded.
3.3 users "The human users of CRD will all be on the CRD Client side, as CRD Services must be fully automated with no human intervention. The humans who benefit from the decision support provided by payer services will be many and varied. They will include clinicians who might adjust therapies or even make decisions about whether to pursue a therapy at all based on information from a payer (e.g. projected patient expense, whether a therapy is covered, whether there is a contraindication detected based on information known to the payer but previously unknown to the clinician). However, they will also include non-clinical staff - those making appointments, those managing dispatching of referrals to available providers, and those handling back-end collection of documentation that was inappropriate/inefficient for the clinician to gather at the time of the encounter. As such, CRD encompasses a broad spectrum of decision support that isn't exclusively 'clinical'."
It would be clearer and much more concise to state something like: "CRD Services is intended as a fully automated process to provide decision support about a patient's coverage for a treatment or procedure. There are many human users requesting and receiving information using this service. Clinicians may need to determine issues such as projected patient expense, whether the patient's insurance benefits cover the therapy, or if the payer has information about any potential contraindication. Non-clinical staff who may also request and process such information include those making appointments, those processing referrals, and those handling documentation to support clinician decision-making."
AND section 3.5.1 "Information passed to the CRD service will typically contain clinical terminologies, might not contain billing terminologies, and will certainly not include billing modifier codes or similar information typically included in prior authorization requests. CRD services will need to support these clinical terminologies or map them to internally used billing terminologies when determining decision support results - such as whether a therapy is covered or requires prior authorization. In some cases, mappings may not be fully deterministic and may impact the ability respond with useful decision support. Services will also need to consider that the mapping they perform between clinical terminologies and billing codes may be different than the bill coding process performed by the client system when claims are eventually submitted. This may mean that assertions about coverage or prior authorization requirements will need to be expressed conditionally. E.g. "Provided this service is billed as X, Y or Z, then prior authorization is not needed"."
I'm not sure how to reword this one but it seems circuitous and not direct in the statement. Specifically, CRD service will typically contain.... then CRD Services will need to support these clinical terminologies - but you already states the service uses the clinical terminology. I think you are referencing 2 types of services but the statement is unclear. I think you are trying to say 'implementation services need to map...." if so, please be direct in your wording.