Interoperability: Provider network directories/Standards

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QHP Provider Formulary APIs

Process

  • Plans are already required to submit URLs for provider network and/or formulary lists or applications.
    • These URLs are submitted to HIOS (Health Insurance Oversight System) via the CMS Enterprise Portal at https://portal.cms.gov/.
    • Consumers or applications can retrieve these URLs by using the Plan Finder API (https://finder.healthcare.gov/#services/version_3_0). Issuing a "getIFPPlanBenefits" request returns the URL in a "ProviderURL" tag.
    • However there is no consistency in the format of the data that resides in these URLs.



Schema and Guidelines

  • Guidelines for 'Public Discoverability'
    1. Organizations must post their plans.json, providers.json, and drugs.json files on their websites, accessible to the public.
    2. The path to the URLs will be submitted via HIOS to CMS.
    3. JSON URLs listed must be provided over HTTPS secure protocol to ensure the integrity of the data.


  • Health Plans - plans.json
    • plans.json contains a list of health plans and their corresponding network of providers and formularies.
    • Includes: Main schema, Network sub-type, Formulary sub-type, Cost sharing sub-type
[
   {
      "plan_id_type":"HIOS-PLAN-ID",
      "plan_id":"12345XX9876543",
      "marketing_name":"Sample Gold Health Plan",
      "summary_url":"http://url/to/summary/benefits/coverage",
      "marketing_url":"http://url/to/health/plan/information",
      "plan_contact":"email@address.com",
      "network":[
         {
            "network_tier":"PREFERRED"
         },
         {
            "network_tier":"NON-PREFERRED"
         }
      ],
      "formulary":[
         {
            "drug_tier":"GENERIC",
            "mail_order":true,
            "cost_sharing":[
               {
                  "pharmacy_type":"1-MONTH-IN-RETAIL",
                  "copay_amount":20.0,
                  "copay_opt":"AFTER-DEDUCTIBLE",
                  "coinsurance_rate":0.10,
                  "coinsurance_opt":"BEFORE-DEDUCTIBLE"
               },
               {
                  "pharmacy_type":"1-MONTH-IN-MAIL",
                  "copay_amount":0.0,
                  "copay_opt":"NO-CHARGE",
                  "coinsurance_rate":0.20,
                  "coinsurance_opt":null
               }
            ]
         },
         {
            "drug_tier":"BRAND",
            "mail_order":true,
            "cost_sharing":[
               {
                  "pharmacy_type":"1-MONTH-IN-RETAIL",
                  "copay_amount":15.0,
                  "copay_opt":null,
                  "coinsurance_rate":0.0,
                  "coinsurance_opt":null
               },
               {
                  "pharmacy_type":"1-MONTH-IN-MAIL",
                  "copay_amount":20.0,
                  "copay_opt":"AFTER-DEDUCTIBLE",
                  "coinsurance_rate":0.10,
                  "coinsurance_opt":"BEFORE-DEDUCTIBLE"
               }
            ]
         }
      ],
      "last_updated_on":"2015-03-17"
   }
]


  • Providers - providers.json
    • providers.json contains a list of providers and the plans that cover their services.
    • Main schema, Plans sub-type
[
   {
      "npi":"1234567890123456",
      "type":"INDIVIDUAL",
      "name":{
         "first":"Sarah",
         "middle":"Maya",
         "last":"Ngyuen",
         "suffix":"Jr."
      },
      "address":{
         "address":"123 Main Street",
         "address_2":"Suite 120",
         "city":"Little Rock",
         "state":"AR",
         "zip":"72201"
      },
      "phone":"2025551212",
      "specialty":"Ophthalmology",
      "accepting":true,
      "plans":[
         {
            "plan_id_type":"HIOS-PLAN-ID",
            "plan_id":"12345XX9876543",
            "network_tier":"PREFERRED"
         },
         {
            "plan_id_type":"HIOS-PLAN-ID",
            "plan_id":"12345XX9876543",
            "network_tier":"NON-PREFERRED"
         }
      ]
   },
   {
      "npi":"1234567890123949",
      "type":"FACILITY",
      "facility_name":"Main Street Hospital",
      "facility_type":"Hospital",
      "address":{
         "address":"123 Main Street",
         "address_2":"Suite 120",
         "city":"Little Rock",
         "state":"AR",
         "zip":"72201"
      },
      "phone":"2025551212",
      "plans":[
         {
            "plan_id_type":"HIOS-PLAN-ID",
            "plan_id":"12345XX9876543",
            "network_tier":"PREFERRED"
         },
         {
            "plan_id_type":"HIOS-PLAN-ID",
            "plan_id":"12345XX9876543",
            "network_tier":"NON-PREFERRED"
         }
      ]
   }
]



Potential Improvements

The link below has suggestions of potential improvements to the proposed schema, in response to PRA notice:

 Interoperability: Provider network directories/PRA Comments




Proposed Medical Insurance Extension for Schema.org

Medical insurance in the United States is unique in many ways, making it difficult to model alongside other forms of insurance or non-US medical plans. Under the proposed extensions mechanism , the extension "USA Medical Insurance" (http://usamedicalinsurance.schema.org) could be used for domain-specific schema.


Thing > Intangible > MedicalInsuranceNetwork
The new type MedicalInsuranceNetwork models a single network offered by a single insurance organization.
Property
  • insuranceOrganization
  • networkId
  • includedMedicalProvider


Thing > Intangible > MedicalNetworkProvider
The new type MedicalNetworkProvider models the dates a specific provider was a member of the network.
Property
  • includedMedicalProvider
  • startDate
  • endDate
  • medicalProviderId


Example
ACME Insurance has a network of PPO providers. Massachusetts General Hospital, Charlestown Healthcare Center, and Dr. Cazador.
{
   "@context":"http://usa-medical-insurance.schema.org/",
   "@type":"MedicalInsuranceNetwork",
   "name":"ACMEPPOProviders",
   "networkId":"ACMENET0001",
   "insuranceOrganization":{
      "@type":"InsuranceAgency",
      "name":"ACMEInsurance",
      "sameAs":"http://acmemedicalinsurance.com"
   },
   "includedMedicalProvider":[
      {
         "@type":"MedicalNetworkProvider",
         "medicalProviderId":"MGH-Boston-MA",
         "startDate":"2014-01-01",
         "includedMedicalProvider":{
            "@type":"Hospital",
            "name":"MassachusettsGeneralHospital",
            "url":"http://www.massgeneral.org"
         }
      },
      {
         "@type":"MedicalNetworkProvider",
         "medicalProviderId":"CHC-Charlestown-MA",
         "startDate":"2014-01-01",
         "includedMedicalProvider":{
            "@type":"Physician",
            "name":"CharlestownHealthcareCenter",
            "url":"http://www.massgeneral.org/charlestown/"
         }
      },
      {
         "@type":"MedicalNetworkProvider",
         "medicalProviderId":"Maria-Cazador",
         "startDate":"2014-01-01",
         "endDate":"2015-01-01",
         "includedMedicalProvider":{
            "@type":"Person",
            "name":"MariaCazador,MD",
            "url":"http://www.massgeneral.org/maria_cazador"
         }
      }
   ]
}



Model provider directory for Medicare Advantage

Model for provider network directory for use by Medicare Advantage plans. Includes instructions for designating primary care physicians, specialists, hospitals, skilled nursing facilities, outpatient mental health, pharmacies. Requires designation of plan name, service area, publication date.



IHE standards related to ONC's HPD requirement for EHRs



  • Specifies the following enumeration of provider speciality field:

A major Grouping i.e., Dermatology, Oncology, Dental, Internal Med. (Issuing Authority: Code System: Code: CodeDisplayName)
Populate with ISO 21298 defined medical specialties.
May also be populated with other specialties specified by jurisdiction or organization



From IHC site


28.3.2.2 Detail Interactions – Entities and Attributes

1. Organizational Provider – An organization that provides or supports healthcare services, such as hospitals, Healthcare Information Exchanges (HIEs), Integrated Delivery Networks (IDNs), and Associations (Table 28.3.2.2-1).

2. Individual Provider – A person who provides healthcare services, such as a physician, nurse, or pharmacist (Table 28.3.2.2-2).



From ONC's site

Additional Considerations

JSON vs. HTML/Schema.org

  • JASON
    • Less verbose than HTML
    • Easier for humans to interpret than XML or HTML


  • Schema.org tags embedded within HTML
    • Keeps machine readable and human readable in one place. So easier to maintain.
    • Ideal for indexing by search engines, both due to browser readability and Google's use of Schema.org


Extensibility

A schema can be made extensible.

  • A good example is the "Common Core" schema, based on the DCAT standard and used by data.gov. Here the Catalog Fields can be extended. The "describedBy"/"@context" fields references either the default JSON/JSON-LD Schema file or an extended one.


Time stamps

Since the provider network data changes often and there's a requirement for monthly updates, the schema should have date and time stamps.

  • These time stamps should be associated either with an entire file or with individual data elements.
  • This approach also helps facilitate a "push" data flow, where those who change the data proactively provide the updates and those who receive the data only act on exceptions, such as when a file hasn't been updated.