Presented by Beth Spears

December 6, 2017

FHIR Application for Payers

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DISCLAIMER

10000+ customers 3500+ employees

Global footprint Based in Palo Alto,

California, and present in 30+ countries

20 years of innovation

Founded in 1997, has fueled digital ever since

© Copyright 2000-2017 TIBCO Software Inc.

Visual analytics

Embedded Analytics

Streaming analytics

Data and systems

APIs People and processes

© Copyright 2000-2017 TIBCO Software Inc.

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Need for health/medical records in support of Prior Authorizations, Claims, Risk Adjustment and more

• Currently request via email, phone, fax, US mail, physical retrieval.

• HIPAA has not yet mandated an electronic transaction

Payer FHIR Application

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• Manual – human initiates the request via a user interface or other mechanism

• Automatic – data within the EDI file triggers the request automatically, i.e. ICD10 code in claim

Payer Request for Additional Information via FHIR

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Demo scenario 1 – Manual Trigger

• Human selects Provider from which to receive data (EPIC/Cerner)

• Human enters Patient ID in the specific data request form (Patient OR Medication)

• Retrieved data is displayed on screen and entered into a database.

**TIBCO BusinessWorks integration suite**

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8© Copyright 2000-2017 TIBCO Software Inc.

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Demo scenario 2 - Automatic• Based off ICD10 code in ANSI 837 Claim (ABK:E08.00/024)

• FHIR request executed automatically retrieving programmatic data that is needed (patient & medication)

• Data is put into a database and can be viewed in Spotfire.

• A risk score is assigned to patient based on diagnosis

• Risk Scores are viewed in Spotfire

• Business Process Management (BPM) assigns retrieved data to applicable staff, i.e. Adult Diabetes specialist or Child Diabetes specialist

© Copyright 2000-2017 TIBCO Software Inc.

© Copyright 2000-2017 TIBCO Software Inc.

Visual analytics

Embedded Analytics

Streaming analytics

Data and systems

APIs People and processes

© Copyright 2000-2017 TIBCO Software Inc.

© Copyright 2000-2017 TIBCO Software Inc.