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Documentation Templates and Rules for Payers
Da Vinci Documentation Templates and Rules (DTR) is a framework under the HL7 FHIR standards that facilitates the exchange of documentation requirements between payers and providers. Utilization Management supports DTR for payers so that you can communicate your documentation requirements to providers in real time, directly to their EHR systems or SMART on FHIR apps. DTR enables the use of standardized templates and rules in the exchange of critical healthcare documentation, ensuring compliance and reducing administrative burden.
Required Editions
Available in: Lightning Experience Available in: Enterprise and Unlimited Editions with Health Cloud |
In the healthcare industry, it’s crucial that accurate and up-to-date clinical information is readily available. As a payer organization handling prior authorization requests, you need documentation such as patient details, lab reports, doctor’s notes, treatment plans, and completed assessments to determine medical necessity for a specific service.
When providers can access your documentation requirements in a matter of seconds, you make sure that prior authorization requests are compliant with your requirements the first time. It also reduces delays in prior authorization reviews, saves costs, and ultimately improves patient outcomes.
DTR for Utilization Management
Documentation Templates and Rules for Utilization Management uses Mulesoft, Omnistudio components, Business Rules Engine, and Discovery Framework to make your documentation requirements easily available to providers. When a provider sends a DTR request, Mulesoft processes the input and sends it to Health Cloud, triggering the Questionnaire API. To learn more about how this integration works, see FHIR Questionnaire API for Health Cloud.
The API invokes the HlsDocTemplatesAndRulesGetQuestionnaireIds integration procedure, which determines the questionnaires required for the specific request, based on the CPT code. Then, the questionnaires are sent to the provider as a response. The provider can automatically retrieve clinical data from their EHR system when they fill the questionnaires, or manually enter responses. Finally, the provider sends the completed questionnaire response back to the payer, along with the prior authorization request for a service.
With Documentation Templates and Rules for payers, you can:
- Validate the DTR request input and capture related metrics on the Service Information Request Detail object
- Identify the questionnaires required for a specific service to determine medical necessity
- Share the questionnaires with providers whose systems support the Questionnaire Package operation
- Author FHIR-aligned questionnaires to be sent to providers, using guided workflows in Discovery Framework Designer
- Get to Know the Data Model
Documentation Templates and Rules uses a FHIR-aligned data model to store records in Health Cloud. It also uses objects from the Coverage Requirement Discovery data model. - Get to Know the Omnistudio Components Related to Documentation Templates and Rules
When you receive a documentation templates and rules (DTR) request, Health Cloud uses pre-built Omnistudio components to process the request, retrieve the required questionnaires, and send a response. - Prepare to Use Documentation Templates and Rules
To use Documentation Templates and Rules for Utilization Management, enable the feature in Setup. - Configure Picklist Values for Service Information Request Fields
Configure the picklist values for the Context Type, Source Type, and Usage Type fields in the Service Information Request object. The context type indicates the source from which the DTR request was initiated, such as a Coverage Requirement Discovery request. The source type specifies the system that captured the DTR request. Finally, the usage type indicates whether the service information request is a CRD or DTR request. - Configure Picklist Values for Service Information Request Detail Fields
Configure the picklist values for the Detail Type and Detail Type Code fields in the Service Information Request Detail object. The Detail Type field captures the type of detail that you add to the service information request such as an issue while processing a DTR request. The Detail Type Code captures the code of the added detail. - Configure Picklist Value for Service Information Request Operation Field
Configure the picklist value for the Operation Type field in the Service Information Request Operation object. The operation type indicates the type of system operation performed for a service information request, such as a questionnaire package operation for a DTR request. - Configure Picklist Value for Service Information Request Operation Outcome Field
Configure the picklist value for the Outcome Type field in the Service Information Request Operation Outcome object. The outcome type indicates the type of outcome of a service information request operation, such as when a questionnaire package operation for a DTR request fails. - Set Up a Custom Object
To represent plan types, code sets, and their associated questionnaires, create a custom object with fields that look up to Code Set and Omni Process, and a Plan Type text field. - Author FHIR-Aligned Questionnaires
Author questionnaires that follow FHIR standards as part of Documentation Templates and Rules (DTR). When you select the FHIR-Aligned Questionnaire usage type in Discovery Framework Designer, the updated component displays a section where you can add additional details to the Omniscript such as purpose, performer type, and display type.
