1. 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

2. 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

3. 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

4. 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

5. MEMBER DIRECTED APPLICATION
CMS NPRM Member Access for Covered Payers
MEMBER DIRECTED APPLICATION 1 1 1
Blue Button 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

6. 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)

7. 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
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