Uploaded image for project: 'FHIR Specification Feedback'
  1. FHIR Specification Feedback
  2. FHIR-45852

Misapplication of convening provider requirement

XMLWordPrintableJSON

    • Icon: Change Request Change Request
    • Resolution: Persuasive with Modification
    • Icon: Highest Highest
    • US Da Vinci Patient Cost Transparency (PCT) (FHIR)
    • 2.0.0-ballot
    • Financial Mgmt
    • STU
    • Formal Specification
    • Hide

      Apply changes listed in:

      Make a change to the GFE coordination Workflow page https://hl7.org/fhir/us/davinci-pct/2024May/gfe_coordination_overview.html:

      This section of the Implementation Guide focuses on enabling providers and facilities to coordinate cost and planned service(s) or item(s) information for a patient’s period of care for which multi-provider Good Faith Estimates (GFE) are required, either to provide to the patient or, optionally, to submit to a payer (for patients using insurance).

      Remove the following paragraph:

      Good Faith Estimate (GFE) Bundle including Good Faith Estimate resource profiles (Claim resources of type predetermination) along with supporting data (such as Patient, Coverage, etc.) to a payer. The payer can then use this information to generate an Advanced Explanation of Benefit (AEOB) Bundle including Advanced Explanation of Benefits resource profiles (ExplanationOfBenefit resources of type predetermination) along with supporting data that the patient, and optionally the provider (GFE submitter on claim resources), can retrieve to get an estimation of costs for expected services as known at a specific point in time.

       

      Change the following sentence from:

      GFE Coordination Requestor provides the GFE Bundle to the patient directly, or proceeds to the GFE Submission and AEOB Workflow and submits the GFE Collection Bundle to the Payer.

      to:

      GFE Coordination Requestor provides the GFE Bundle to the patient directly, or optionally for insured patients, proceeds to the GFE Submission and AEOB Workflow and submits the GFE Collection Bundle to the Payer.

      Note: This IG does not require GFE coordination to take place in order for providers to submit GFEs to payers, nor does it require the output of the GFE coordination be submitted to a payer.

       

      Show
      Apply changes listed in: https://jira.hl7.org/browse/FHIR-45854 https://jira.hl7.org/browse/FHIR-45853 https://jira.hl7.org/browse/FHIR-45912 Make a change to the GFE coordination Workflow page https://hl7.org/fhir/us/davinci-pct/2024May/gfe_coordination_overview.html: This section of the Implementation Guide focuses on enabling providers and facilities to coordinate cost and planned service(s) or item(s) information for a patient’s period of care for which multi-provider Good Faith Estimates (GFE) are required, either to provide to the patient or , optionally, to submit to a payer (for patients using insurance). Remove the following paragraph: Good Faith Estimate (GFE) Bundle including  Good Faith Estimate resource profiles  (Claim resources of type predetermination) along with supporting data (such as Patient, Coverage, etc.) to a payer. The payer can then use this information to generate an Advanced Explanation of Benefit (AEOB) Bundle including  Advanced Explanation of Benefits resource profiles  (ExplanationOfBenefit resources of type predetermination) along with supporting data that the patient, and optionally the provider (GFE submitter on claim resources), can retrieve to get an estimation of costs for expected services as known at a specific point in time.   Change the following sentence from: GFE Coordination Requestor provides the GFE Bundle to the patient directly, or proceeds to the  GFE Submission and AEOB Workflow  and submits the  GFE Collection Bundle  to the Payer. to: GFE Coordination Requestor provides the GFE Bundle to the patient directly, or optionally for insured patients,  proceeds to the GFE Submission and AEOB Workflow  and submits the  GFE Collection Bundle  to the Payer. Note: This IG does not require GFE coordination to take place in order for providers to submit GFEs to payers, nor does it require the output of the GFE coordination be submitted to a payer.  
    • Clarification
    • Non-substantive

      Throughout the IG, there are repeated references to the "convening provider" in the AEOB use case. I want to reiterate my continued and strong disagreement with the use of this term in the AEOB context. The No Surprises Act explicitly articulates the need for a definition of a convening provider in the self-pay/uninsured use case. However, it is inappropriate to apply this legislative term to a technical solution in the absence of legislation or regulation requiring its use. 

            Unassigned Unassigned
            apreisler Andrea Preisler
            Andrea Preisler
            Watchers:
            1 Start watching this issue

              Created:
              Updated:
              Resolved: