On this page:
   59.3    Matching Logic
  • Explanation
  • 59.0 Overview
  • 59.1 Actors, Roles & Data Scope
  • 59.2 Solution Modules & Standards
  • 59.3 Matching Logic
  • 59.4 Data Exchange Patterns
  • 59.5 Security & Privacy Framework
  • 59.6 Glossary of Terms
    • 59.5    Security & Privacy Framework   
    Table of Contents

    Data Exchange Patterns

    59.4.1Data Exchange Patterns

     

    This document describes the data exchange patterns used in Smile CDR Payer-to-Payer solution, including request models, consent handling, and data scope.

    59.4.1.1Pull-Based Exchange Model

    The Payer-to-Payer solution implements a pull-based exchange model where the requesting payer initiates all data transfers.

    59.4.1.1.1How the Pull Model Works

    1. Requesting Payer initiates a data request via $sdh.s2s.invoke-export.
    2. Responding Payer validates consent and authorization.
    3. Data Export occurs using FHIR Bulk Data operations.
    4. Requesting Payer retrieves exported data.

    59.4.1.1.2Benefits of Pull Model

    BenefitDescription
    Requester ControlRequesting payer controls when data is retrieved
    Consent VerificationEach request validates current consent status
    ScalabilityResponding payer handles requests as capacity allows

    59.4.1.1.3Included Data Types

    Data CategoryContentExamples
    Administrative DataCoverage, enrollment, member demographicsPatient, Coverage resources
    Claims DataClaims and encounter informationClaim, ExplanationOfBenefit resources
    Clinical DataClaims-derived clinical informationCondition, Procedure, Observation resources
    Pharmacy DataMedication fills and prescriptionsMedicationRequest, MedicationDispense resources
    Prior AuthorizationsAuthorization requests and decisionsClaim resources with authorization extensions
    External Payer DataPreviously received data from other payersAll resource types with provenance tracking

    59.4.1.1.4External Payer Data Handling

    When sharing data previously received from other payers:

    1. Original Data Preserved - Data stored in DocumentReference resources as received.
    2. Provenance Tracked - Provenance resources identify original source payer.
    3. Consent Respected - Only shared if member's current consent allows.
    4. Format Maintained - FHIR-formatted data shared as-is.
       59.3    Matching Logic
  • Explanation
  • 59.0 Overview
  • 59.1 Actors, Roles & Data Scope
  • 59.2 Solution Modules & Standards
  • 59.3 Matching Logic
  • 59.4 Data Exchange Patterns
  • 59.5 Security & Privacy Framework
  • 59.6 Glossary of Terms
    • 59.5    Security & Privacy Framework