1. RWJF & HHS Provider
Network Challenge
Robert Wood Johnson
Foundation & U.S. Health &
Human Services Provider
Network Challenge
Informational Webinar
November 19, 2014
2. On Today’s Call:
Katherine Hempstead, Director of Coverage
Robert Wood Johnson Foundation
Richard Kronick, Director, Agency for Health Care Research & Quality
U.S. Health & Human Services
Reed Mollins, Vice President, Business Development
Doctor.com
John Riney, Technical Evangelist
PokitDok
Alicia Davis, Challenge Manger
Health 2.0
Graeme Ossey, Senior Challenge Manager
Health 2.0
3. Agenda for the Webinar
• Challenge Background and Goals
• Overview of the Data Set
• Overview of Challenge Details
• Additional Resources
• Q&A
4. Katherine Hempstead
Director, Robert Wood Johnson Foundation
Richard Kronick
Director, Agency for Health Care Research & Quality
5. Focus of Challenge
• Allow consumers to determine which providers in
their network are conveniently located
• Method of verification to determine if providers are
accepting patients under each insurance
• Allow & crowd source patient reviews for providers
• Allow consumers to search for providers based on
specific health needs and determine if insurance
covers specific procedures.
6. What Are We Looking For?
• Effective integration of the Health Insurance Carrier
Provider Network data
• Creativity and innovation
• Design, usability and intuitiveness of application
• Potential to help consumers understand provider networks
and make informed decisions on choosing a provider
• Potential and realistic plans for adoption in the community
7. Criteria to Apply
• Business & nonprofit entities must be formed and
maintain a principal place of business in the U.S.
• Individuals must be citizens or permanent residents of
the U.S.
• Teams must have no more than 5 members
• Individuals must be of legal age of majority, at the
time of entry, to form valid contracts I their respective
jurisdiction of legal residence
8. Submission Requirements
The challenge will take place in two phases. Phase I will require teams to submit
concepts and wireframes, while phase II will require working prototypes. The
submission requirements for each phase can include (but not limited to):
Phase I:
• A text description of the app or tool (no
more than 1500 characters) including what
data were used, how they were used, need,
solution and business plan for
dissemination and use
• Wireframes or similar design layout of the
application
• Slide deck of no more than 10 slides
describing the app and operating plan (in
PDF format)
Phase II:
• All of the above
• A video pitch (no more than 5 minutes)
describing the app/tool and how it
would be used by the public to make
better health plan purchasing decisions
• Link to working application
9. Prizes & Timeline
• Prizes
• Phase 1:
• Five (5) finalist will receive $5000
• Phase 2:
• First Place: $50,000
• Second Place: $15,000
• Third Place: $10,000
• Timeline
• Challenge Launched September 22, 2014
• Applications for Phase I will be due on March 6, 2015
• Phase I Finalist Announcement : April 3, 2015
• Applications for Phase II will be due on July 10, 2015
• Phase II Winners Announced in August 2015
16. API Overview
With our platform, access simple X12 processing, our comprehensive provider listings, and proprietary cash
pricing data for healthcare procedures. Our documentation guides you through testing the APIs from the
command line & how to use our open-source client libraries for Python, Ruby, Java, C#, NodeJS, and PHP.
17. The Power of our Platform
E-Commerce Marketplace APIs
Providers
Search for providers from one of the largest provider directories. Our directory provides biographical
information, education, credentialing and other quality and business information. Use this API to let
customers select providers based on a variety of factors.
Cash Prices
Based on our proprietary database, this API calculates the average cash price providers within a
certain geographic area charge for a specific service. This is a good reference point for customers to
use when selecting a provider for services or for selecting a geographic area to obtain those services.
Insurance Prices
Based on our proprietary database, the Insurance Prices API calculates the average price for a service
that providers are submitting to insurance carrier within a specified area. This information can be
used by customers to get an idea of how much they might save between a cash price or insurance
price. It can also be used as a guide to select a geographic location for obtaining health care services.
18. X12 Claims & Eligibility
Authorization API (ANSI 278)
The Authorizations API allows an application to submit a request for the review of health care in order
to obtain an authorization for that health care. This lets you determine if a given procedure or service
is covered under a patient’s plan.
Claims API (ANSI 835/837)
Submits a Professional CMS 1500 claim to the specified insurance carrier. Please note, the Claims API
only submits claims to an insurance carrier, it does not scrub claims. This API can be used to make
sure a patient’s up front cash payment counts against their deductible.
Claims Status API (ANSI 276/277)
Checks with the insurance carrier what the status of a claim is. It has information on the outstanding
claims for a patient, and what claims have been received, are being processed, or have been
finalized. This is especially important for office billing managers who need a complete picture of
where high dollar claims stand on a real time basis.
Eligibility API (ANSI 270/271)
Checks to see if your customer is a current and active member of specific health plan. It’s currently
available for 152 health plans, covering 71% of covered lives across the U.S. It provides information
on what the customer’s deductible is and how much has been satisfied, helping to calculate a
customer’s out-of-pocket expense for a healthcare transaction.
19. X12 Claims & Eligibility, Continued
Enrollment API (ANSI 834)
The Enrollment API allows the enrollment of new members into an insurance plan, updating of
information, or changes the status of a member’s enrollment. An insurance broker or plan
administrator would use this API to electronically enroll a customer or make benefit changes in the
case of a life event.
Plans API
The Plans API can check a customer’s insurance carrier and see what their plan design is. This
information is used in determining the benefits, copayments or coinsurance a patient has.
Referrals API
The Referrals resource allows an application to request approval for a referral to another health care
provider.
Trading Partners API
This utility API lets you determine what trading partners we connect with and what transactions they
support.
20. Getting Started
Sign up at
platform.pokitdok.com
Questions?
platform@pokitdok.com
