HL7® FHIR® is a registered trademark owned by Health Level Seven International®

Oncology Clinical Pathways: Prior Authorization

June 24, 2020

| 1 |

Oncology Clinical Pathways and Prior Authorization

| 2 |

Draft Clinical Pathway

© 2020 THE MITRE CORPORATION. ALL RIGHTS RESERVED. FOR INTERNAL USE ONLY.

MITRE: Chartered to Serve the Public Interest

©2020 The MITRE Corporation. All rights reserved

© 2020 THE MITRE CORPORATION. ALL RIGHTS RESERVED. FOR INTERNAL USE ONLY.

MITRE Manages Federally-Funded Research &

Development Centers (FFRDCs)

©2020 The MITRE Corporation. All rights reserved

Community:A new HL7 FHIR Accelerator

A community and platform accelerating interoperable datamodeling and implementation

around FHIR and mCODE, leading to step-change improvements in

cancer care and research

http://hl7.org/CodeX

CodeX Use-Case-Based Projects

EHR Endpoints for Cancer Clinical Trials (ICAREdata)1

Integrated Trial Matching for Cancer Patients and Providers

2

Cancer Registry Reporting3

Oncology Clinical Pathways

4Radiation Therapy Treatment Data for Cancer

5

Oncology Clinical Pathways: Prior Authorization Support6

Alternative Payment Model Data Reporting for Cancer7

Drug Value Based Agreements for Cancer

8

mCODE++ Extraction0

In Discovery

Active Community Development

Active CommunityPlanning

| 7 |

CANCER

Providers Research

Payers

Government

/ RegulatoryVendors

Patients

Standard:minimal Common Oncology Data Elements

▪Small, stable set of critical data elements

▪Driven by oncology experts

▪Standardized for collection

and sharing, using FHIR

▪Better cancer care and research

http://hl7.org/fhir/us/mcode/https://mcodeinitiative.org/

mCODE Release 1 :

TM

TM

HL7 Implementation Guide

8

| 9 |

Oncology Clinical Pathways: Prior Authorization Support

Run Pathway App Receive and Accept

Treatment RecommendationReceive Pathway Accept or

Decline Message plus cancer

data

X12N Interface

X12N Interface

ASC X12N 278/275

mCODE++ Extraction

(as needed)

mCODE++: leveraging mCODE with possible extensions

Retrieve

FHIR

Map

mCODE++

mCODE++

mCODE++

© 2020 THE MITRE CORPORATION. ALL RIGHTS RESERVED. FOR INTERNAL USE ONLY.

Prior Authorization (PA) – Healthcare System Costs• Key driver of high US healthcare system administrative costs: lack of

adoption of electronic, automated approaches to transactions

• Save up to $10 billion annually by adopting fully electronic administrative transactions

• Least automated activities are PA and claims attachments

• Greatest per transaction savings opportunity is PA - $2.11 (partially to fully electronic) or

$12.11 (manual to fully electronic) per transaction

Adoption of Fully Electronic Administrative Transactions, 2019

CAQH. 2019 CAQH Index. Available at: https://www.caqh.org/sites/default/files/explorations/index/report/2019-caqh-index.pdf?token=SP6YxT4u (Accessed on April 2,

2020)

Leveraging the mCODE™ standard (minimal Common Oncology Data Elements), CodeX will expand around this core to encompass additional use cases, accelerating opportunities to create a learning health system

based on interoperable data and improved patient care.

Learn more www.hl7.org/codex/

| 11 |