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Hyperledger Project
Healthcare Working Group (HCWG) Payer Subgroup Meeting
August 14, 2018

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Meeting Notes

Prior Auth Process

PA Process flow

VA problem is a problem that needs to be solved. Veterans choice program - split, outsource care to a payor network - too big of a problem, talk about a whitepaper

Pre Authorization as a use case

  • Soft Prior Auth
  • Hard Prior Auth
  • Patient has identity in a digital wallet
    • Does person have auth for specialist consultation?
    • Patient initiates medical encounter
      • Depending on insurance either
        • Goes to primary physician
        • Goes to specialist
      • Provider uses trust certificate to identify your payor
      • Some kind of ID card, digital certificate, chip reader
    • Exam, Dr wants to send you to a specialist for further tests
    • Nurse uses your certificate to send to the payor to see if they need Prior Auth
      • If no - order test
      • If yes - place order form for prior auth
        • Auth process
          • Internal channel processes
            • Collaboration between physician, medical records, contractors,
            • External info required
      • Query against EHR in a zero knowledge proof
      • Publish criteria for approval, submit all info up front for prior auth, immediate auth unless marginal result
    • Build out private channel in Payor network
      • Business
      • Medical
      • Forms submitted
        • Goes onto ledger
        • Approve, reject, qualify request
    • Data model that needs to go to the ledger, needs a consensus mechanism, endorsed, put a block on the ledger
      • Valid patient
      • Valid provider
      • Payor notified Prior auth request made
        • Get transaction from the ledger and process it
groups/healthcare/np16.txt · Last modified: 2018/08/16 17:42 by Jennifer DeVivo