Overview: Da Vinci ATR List

There are currently no standards in use for establishing and exchanging member lists between payers and providers. Opala uses HL7 FHIR to specify standards for exchanging Member Attribution Lists (MAL). The MAL can be used by providers and payers to implement use cases for, for example, Value-Based Contracts (VBC), Quality Reporting, Da Vinci Payer Data Exchange (PDex), and Da Vinci Clinical Data Exchange (CDex).

The MAL typically contains the following information:

• Plan/Contract information This is the basis for the Member Attribution list
• Patient Information
• Attributed Individual Provider Information
• Attributed Organization Information
• Member and Subscriber Coverage Information

Member Attribution List Workflows and Definitions

Using FHIR based APIs, providers and payers can exchange Member Attribution Lists which can enable existing business processes and systems to meet the business' needs. Providers need to access MALs for business needs, such as:

• Closing care gaps for members that count in financial reconciliation.
• Managing patients and meeting quality metrics, and managing costs by closing care gaps.
• Tracking care costs of attributed patients; managing utilization; monitoring referrals and specialist care.
• Performing end-of-year reconciliation for patients based on plans/contracts.
• Tracking monthly membership to identify trends and confirm accountable care PMPM payments.
• Determining project membership for the upcoming year based on prospective lists at the end/start of the year.
• Keeping historical data of patients for continuity of care as members fall-off or are added-to the list.
• Reporting performance on specific targets and measures.

The creation of a Member Attribution List typically starts with a need to identify the patients for a specific purpose such as value-based contracts or quality reporting. Once the patients are identified, other FHIR APIs and Da Vinci specifications can be used to retrieve clinical, financial, or other relevant information as needed.

The following definitions are used to document the various workflows encountered during Member Attribution List exchange.

Attribution: Results of an algorithmic process that assigns patients to providers, payers, or groups. Also, the assignment process where patients are assigned to a group manually. A Patient could declare to be part of a group by providing or selecting their PCP information or ACO information.

For example, when patients belong to a HMO plan there is an Attribution List created with all the patients who are on the HMO plan.

Member Attribution List: A list of patients who are attributed to payers, providers, medical homes, or groups. The Attribution list contains the patient information along with information such as Attributed Provider, Health Plan information, Validity Period for the list, Risk Information, etc.

Attributed Provider: The provider responsible for the health of the patient per the contract and who will receive the payments and credits based on performance.

Producer: The entity creating the attribution list. The producer owns the master copy of the list and allows for changes to be made to the list. The producer can receive an initial list from a consumer, but owns the list after that and publishes the list from that point on.

Consumer: The entity consuming the attribution list. The consumer may contribute to the creation of the list by the producer. The consumer can receive an initial list from producer and can request changes after that point in time.

Attribution List Data: Data contained within the attribution list.

Identifiers

The following identifiers are used for Member Attribution Lists:

Member Identifier: A unique identifier for a member within a payer's plan.

Payer Identifier: A unique identifier for an organization that provides insurance plans and enters into contracts with health care providers.

Contract Identifier: A unique identifier assigned by the payer to the agreement with a specific health care provider.

Plan Identifier: A unique identifier for an insurance plan that a payer provides. Members belong to specific plans.

The combination of Member Identifier, Payer Identifier, Contract Identifier, and Plan Identifier is always unique.

Attribution List Data Mapped to FHIR Constructs

This image maps the Member Attribution List data to FHIR resources.

Image from Da Vinci Member Attribution (ATR) List — 3.3.2 Data Model

Developers should familiarize themselves with the FHIR resources used in the above data model.

Dependencies

The Da Vinci ATR List implementation guide relies on the following other specifications:

• FHIR R4 . The current official version of FHIR as of the time the ATR implementation guide (0.1.0 - STU1 Ballot) was published. See the background page for key pieces of this specification implementers should be familiar with.
• US Core STU3 . The version of US Core based on FHIR R4.
• Bulk Data IG . The Bulk Data Implementation Guide leveraged as part of the ATR implementation guide (0.1.0 - STU1 Ballot).
• SMART on FHIR Backend Services Authorization . Security protocols to be used for exchaning the MAL.

The ATR implementation guide (0.1.0 - STU1 Ballot) defines additional constraints and usage expectations above and beyond the information found in these base specifications.