The payers will need to adjust to receiving clinical codes.  The EHRs will not provide translations.  The encoding process happens at a completely different point in the business cycle and the full translation often involves human decision-making.  To provide the needed decision support, payers will have to map SNOMED, LOINC and other clinical codes to billing codes - or more likely to "ranges of possible billing codes" and will need to deal with clinical data as it is, not as they might wish it to be.  We understand this involves adding extra capabilities to payer systems they have not previously had.  This expectation is called out explicitly here: http://build.fhir.org/ig/HL7/davinci-crd/background.html#impact-on-payer-processes. However, we should call out the same impact in the DTR specification.  We will raise a tracker item to do that.