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  1. FHIR Specification Feedback
  2. FHIR-40884

Should selecting primary coverage be SHALL?

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    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Medium Medium
    • US Da Vinci CRD (FHIR)
    • 1.0.0 [deprecated]
    • Financial Mgmt
    • Supported Hooks
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      Will change "For requests on information related to prior auth, in order to reduce complexity CRD clients SHOULD only invoke the hook on the payer service associated with their best guess of which coverage will be primary."

      to

      "To avoid confusion for providers, where a patient has multiple active coverages that could be relevant to the current order/appointment/etc., CRD clients SHALL select from those coverages which is most likely to be primary and only solicit coverage information for that one payer.  If they invoke CRD on other payers, CRD clients SHALL ensure that card types that return coverage information are disabled for those 'likely secondary' payers."

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      Will change "For requests on information related to prior auth, in order to reduce complexity CRD clients  SHOULD only invoke the hook on the payer service associated with their best guess of which coverage will be primary." to "To avoid confusion for providers, where a patient has multiple active coverages that could be relevant to the current order/appointment/etc., CRD clients SHALL select from those coverages which is most likely to be primary and only solicit coverage information for that one payer.  If they invoke CRD on other payers, CRD clients SHALL ensure that card types that return coverage information are disabled for those 'likely secondary' payers."
    • Bob Dieterle / Mark Scrimshire : 4-0-1
    • Correction
    • Non-compatible
    • Yes

    Description

      The specification currently says "For requests on information related to prior auth, in order to reduce complexity CRD clients SHOULD only invoke the hook on the payer service associated with their best guess of which coverage will be primary."

      Discussion on calls has raised questions about whether we should tighten this to SHALL.

      SHOULD means there's the possibility of getting responses back seeking DTR use from multiple payers (which means DTR would need to deal with that).  It also creates challenges for payers in terms of understanding whether they're primary or secondary.

      On the other hand, SHOULD means that EHRs don't have to worry about embedding logic or external calls to figure out primary coverage in order-entry systems that typically don't have any knowledge of coverage.

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            lloyd Lloyd McKenzie
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              Created:
              Updated:
              Resolved: