CMS NPRM for Payer Data Exchange – to Member 1) Must implement and maintain an open API that permits third-party applications to retrieve, with the approval and at the direction of an individual MA enrollee, data specified below through the use of common technologies and without special effort from the enrollee. a) Accessible content – all plans i) Standardized data concerning adjudicated claims, including claims … ii) Standardized encounter data, … iii) Provider directory data on the MA organization’s network of contracted providers, including names, addresses, phone numbers, and specialties, … and iv) Clinical data, including laboratory results, if the MA organization manages any such data … b) Accessible content – for plans that offer an MA-PD plans i) Standardized data concerning adjudicated claims for covered Part D drugs … ii) Pharmacy directory data …, and Formulary data that includes covered Part D drugs, and any tiered formulary structure or utilization management procedure which pertains to those drugs. Notes: a) applies to other plans covered by the CMS NPRM – see specific language for each b) applies in part to some other covered plans – see specific language for each

Use Case Focus Areas Quality Improvement Member Access Clinical Data Exchange Data Exchange for Quality Measures Clinical Data Exchange Payer Data Exchange Payer Data Exchange Gaps in Care & Information Payer Data Exchange: Formulary Payer Data Exchange: Directory Clinical Data Exchange Process Improvement Payer Coverage Decision Exchange Patient Cost Transparency Alerts / Notifications Coverage / Burden Reduction Coverage Requirements Discovery Risk Based Contract Member Identification Chronic Illness Documentation for Risk Adjustment Patient Data Exchange Documentation Templates and Rules Documentation Templates and Rules Prior-Authorization Support Performing Laboratory Reporting May ballot STU and for comment In early September ballot (July) as STU September ballot as STU Currently targeted for early or regular January 2020 ballot Use cases in discovery (some may be balloted in January 2020) Use Case Status 2

2019 2020 Ballots and Connectathons EARLY SEPTEMBER BALLOT (June 21 – July 21) STU Health Record Exchange (HRex) STU Payer Data Exchange (PDex) STU PDex Formulary STU Clinical Data Exchange (CDex) MAY BALLOT (Mar 29 – Apr 29) STU Data Exchange for Quality Measures (DEQM) STU Coverage Requirements Discovery (CRD) Comment Documentation Templates & Rules (DTR) Proposed Early January ballot (Oct 15 – Nov 15) STU PDex Payer Directory STU Alerts / Notifications ONC Annual Meeting Da Vinci Meeting & Connectathon HL7 Connectathon 2019 2020 MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Da Vinci Connectathon & Working Session JANUARY BALLOT (Dec 27 – Jan 26) STU Gaps in Care STU STU Patient Cost Transparency STU RBC Member ID and Bulk Data SEPTEMBER BALLOT (Aug 9 - Sept 9) STU Documentation Templates and Rules (DTR) STU Payer Coverage Decision Exchange STU Prior Authorization Support (Prior Auth) HL7 Connectathon HL7 Connectathon

Information Exchanges Supported by Da Vinci IGs [10] Provider Data [12] Alerts/Notifications Quality Measures and Gaps [1] Data Exchange for Quality Measures [2] Gaps in Care and Information Member Directed Exchange (CMS NPRM) [3] Payer Data Exchange [4] Payer Data Exchange: Directory [5] Payer Data Exchange: Formulary [6] Payer Coverage Decisions (Treatment) Coverage/Documentation Requirements [7] Coverage Requirements Discovery [8] Documentation Templates and Rule [9] Prior-Authorization Support Patient Data Exchange [10] Clinical Data Exchange (Provider Data) [11] Payer Data Exchange (Payer Data) [12] Alerts/Notification Patient Cost Transparency (in discovery) Provider Provider [9] Prior-Authorization [12] Alerts/Notifications [2] Gaps in Care [7] Coverage Requirements [8] Documentation Rules [11] Payer Data [1] Quality Data [10] Provider Data [3] USCDI [6] Continuity of Treatment Payer Payer [2] Aggregated Quality Measure Reporting [3] USCDI [4] Directory [5] Formulary [3] USCDI [4] Directory [5] Formulary Patient Member authorization Consumer Application

MEMBER DIRECTED APPLICATION CMS NPRM Member Access for Covered Payers MEMBER DIRECTED APPLICATION 1 1 1 Blue Button 2.0 -- CARIN 2 2 2 USCDI -- Da Vinci PDex 3 3 3 Directory: Da Vinci Payer Network 4 4 4 Formulary: Da Vinci Formulary PAYER 1 PAYER 2 Member Direction Will Supports bulk data exchange for USCDI and Directory

Attested Provider Data Validated Healthcare Directory Do it once, do it right Use it as often as necessary Attested Provider Data Provider attests once Information is validated in one place Information is shared based information type, need and use agreements Examples of “local” workflow environments Social Security Administration DoD/VA CMS HIEs HISPs Provider Organization Commercial Payers EHR Not an exhaustive list Attested Information Primary Source Initial Validation Primary Source Primary Sources Core Data Healthcare Directory Healthcare Directory Healthcare Directory Recurring Validation Local Workflow Environment Use Case X Local Workflow Environment Use Case Y Exchange Processes HcDir HcDir FHIR FHIR HcDir Validated National Data Set (VNDS)

Third Party Application CMS NPRM Payer Provider Directory Payer RESTful GET Provider Directory Healthcare Directory Third Party Application Synchronous FHIR API Asynchronous Bulk Data Pharmacy Directory This Photo by Unknown Author is licensed under CC BY