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  1. FHIR Specification Feedback
  2. FHIR-36568

Use cases missing specialty providers

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    • Icon: Change Request Change Request
    • Resolution: Not Persuasive with Modification
    • Icon: Highest Highest
    • US Da Vinci CRD (FHIR)
    • 1.1.0-ballot [deprecated]
    • Financial Mgmt
    • STU
    • Use Cases and Overview
    • 2.2 Example CRD "success" Scenarios
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      The workflow won't be any different for different providers.  In all cases, as an order is being written or appointment is being being booked CRD will be called and it will provide information about whether the service is covered at all, whether prior authorization is needed, or any other guidance it has.

      If the workflow is "query to see what benefits exist, then order accordingly", CRD won't help with that as querying for plan benefits is out of scope.

      However, we will update the specification to explicitly call out its utility for specialty providers and ensure that at least one of the use-cases shows specialty practice use. Will make this a 'sad path' scenario where the result from the payer is "this service is not a benefit and will not be covered, and patient opts to not receive care".

      Will do this as part of the change made in FHIR-36576

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      The workflow won't be any different for different providers.  In all cases, as an order is being written or appointment is being being booked CRD will be called and it will provide information about whether the service is covered at all, whether prior authorization is needed, or any other guidance it has. If the workflow is "query to see what benefits exist, then order accordingly", CRD won't help with that as querying for plan benefits is out of scope. However, we will update the specification to explicitly call out its utility for specialty providers and ensure that at least one of the use-cases shows specialty practice use. Will make this a 'sad path' scenario where the result from the payer is "this service is not a benefit and will not be covered, and patient opts to not receive care". Will do this as part of the change made in FHIR-36576
    • Bob Dieterle / Chris Cioffi : 12-0-0
    • Clarification
    • Non-substantive

    Description

      The use cases are all happy path and physician based. Other specialty providers, such as dietitians, need to determine if there is benefits first, and then what the coverage requirements are for their services. Use cases need to be added to address possible alternative flows for specialty providers.

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            Unassigned Unassigned
            bgradl Becky Gradl
            Becky Gradl
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