This page is part of the Da Vinci Coverage Requirements Discovery (CRD) FHIR IG (v0.3.0: STU 1 Ballot 2) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

CRD IG Home Page

This specification is currently undergoing ballot and connectathon testing. It is expected to evolve, possibly significantly, as part of that process.

Feedback is welcome and may be submitted through the FHIR change tracker indicating “US Da Vinci CRD” as the specification.

This implementation guide is dependent on other specifications. Please submit any comments you have on these base specifications as follows:

• Feedback on CDS Hooks should be posted to the CDS Hooks GitHub Issue List
• Feedback on the FHIR core specification should be submitted to the FHIR change tracker with "FHIR Core" as the specification.
• Feedback on the US core profiles should be submitted to the FHIR change tracker with "US Core" as the specification.

Individuals interested in participating in the Coverage Requirements Discovery or other HL7 Da Vinci projects can find information about Da Vinci here.

Overview

The process of managing billing for patient insurance is a significant source of complexity and cost in the United States. Insurance coverage accepted by a selected provider may have very different requirements for documentation and determination of necessary or appropriate services, or the necessity for prior authorizations or other approvals. Providers who fail to adhere to payer or coverage expectations may find that costs for a given service are not covered or not completely covered. The outcome of this failure to conform to payer requirements can be increased out of pocket costs for patients, additional visits and changes in ordered therapy, and increased costs for everyone.

The purpose of this implementation guide is to define a workflow where payers can share coverage requirements with clinical systems at the time treatment decisions are being made. This ensures that clinicians and administrative staff have the capability to make informed decisions and can meet the requirements of the patient’s insurance coverage.

The implementation guide supports both Personal Healthcare Information (PHI)-specific and non-PHI mechanisms as required by the needs and privileges of the payer organization. The guide allows payers to share a wide variety of information with providers in a context-sensitive manner. The information that may be shared includes:

• updated coverage information
• alternative preferred/first-line/lower-cost services/products
• documents and rules related to coverage
• forms and templates
• indications of whether prior authorization is required

The implementation guide is designed to allow for initial support of basic capabilities and to subsequently build new features over time.

Content and organization

The implementation guide is organized into the following sections:

• Use Cases and Overview describes the intent of the implementation guide, gives examples of its use and provides a high-level overview of expected process flow
• Technical Background describes the different specifications this implementation guide relies on and indicates what developers should read and understand prior to implementing this specification
• Formal Specification covers the detailed implementation requirements and conformance expectation
• Artifacts introduces and provides links to the FHIR STU3 and R4 profiles, search parameters and other FHIR artifacts used in this implementation guide
• Downloads allows download of this and other specifications as well as other useful files
• Credits identifies the individuals and organizations involved in developing this implementation guide

Dependencies

This implementation guide relies on the following other specifications:

• FHIR R4 - The ‘current’ official version of FHIR as of the time this implementation guide was published. See the background page for key pieces of this specification implementers should be familiar with.
• FHIR STU3 - The prior official version of FHIR, also supported as part of this implementation guide and has differences in the resource structures, data elements and terminologies from the R4 release
• US Core STU2 - Defines profiles on FHIR STU3 that constrain it for use in the U.S. context
• US Core STU3 - draft - The balloted version of US Core based on FHIR R4. This implementation guide will be updated to be based on the final R4 release once it is published.
• CDS Hooks 1.0 - This is the primary standard for exchange used by this implementation guide
• CDS Hooks Registry - The CDS Hooks project maintains a registry of common hooks. This implementation guide leverages several of them.
• SMART on FHIR - Payers can use CRD to allow users to launch SMART apps to help meet coverage requirements

This implementation guide defines additional constraints and usage expectations above and beyond the information found in these base specifications.