Electronic Submission of Medical Documentation (esMD) Technical Overview
MELANIE COMBS-DYER, RN - Deputy Director, CMS/OFM/Provider Compliance Group
DANIEL KALWA - Health Insurance Specialist, CMS/OFM/Provider Compliance Group
MANOJ CHAGANTI - esMD Chief Architect, CMS/QSSI
RANJITH MADHUSOODANAN - esMD Project Manager, CMS/QSSI
MICHAEL FINKEL - esMD Project Director, CMS/QSSI
Monda
y
4:15
P.M
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Agenda
• Technical Overview
▫ esMD Business Functionality
▫ Overview of XDR esMD Transporter and Translation Mechanism
▫ Future esMD Enhancement / Use Cases
▫ Overview of CAQH CORE Transport and X12 Translation Mechanism
▫ If time permits: Discussion whether X12 Message be sent thru the XDR Transactions?
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Today’s Medical Documentation Process
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Review Contractor
Provider
Doc’ n Request
Letter
Paper Medical Record
The Solution: Electronic Submission of Medical
Documentation (esMD)
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Phase 1: Doc’n
Request Letter
electronic
electronic
electronic
Phase 2:
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esMD HIHs ingest provider's medical records and metadata by either one of the following :
• going onsite to the provider's facility
• using a Virtual Private Network (VPN)
• using a secure web portal
Some esMD HIHs are considering using DIRECT.
Web Portal
VPN
CMS Does Not Dictate How an HIH Communicates with Providers
D I R E C T
D I R E C T
D I R E C TD I R E C T
http://directproject.org
http://wiki.directproject.org
Onside Pickup
esMD Phase 1 (In Production) : September 2011
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esMDGateway Built by
ECM Built by
ECM
CONNECTCompatible
Doc’ n RequestLetter
MedicareAdministrative
Contractors
Medicare Recovery Auditors PERM
Content Transport Services
CMS Private Network
PDF PDF PDF
esMD Metadata Database
SOAP Message with SAML/XDR
SOAP Message with SAML/XDR
DIRECT
esMD Phase 2: October 2012
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esMDGateway Built by
ECM Built by
ECM
CONNECTCompatible
MedicareAdministrative
Contractors
Medicare Recovery Auditors PERM
Content Transport Services
CMS Private Network
XML PDF PDF
esMD Metadata Database
SOAP Message with SAML/XDR
SOAP Message with SAML/XDR
DIRECT
Structured Electronic Requests for Medical
Documentation PDF
Imaged documents (PDF)
Important Metadata Fields:• Intended Recipient – Required Field• Claim ID – Required Field• NPI – Required Field• Case ID – Required If Known
A portion of a patient’s medical record in esMD format which will contain:
Definition of an esMD Package
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Detailed description for each field can be found in: the esMD XDR Profile. the esMD Implementation Guide.
(http://www.connectopensource.org/product/connect-NHIN-specs)
(www.cms.gov/esMD)
esMD Technical Details
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System (HIH) to System (CMS) Gateway Communication HIH Submits XDR (Deferred Document Submission) SOAP Envelope Request to CMS
CONNECT gateway with the following details SAML Assertions and its digital signature, Security Tags in the SOAP Header, IHE XDR and esMD Meta Data with in the SOAP Body. MTOM Encoded C62 Payload in the SOAP Body.
SAML Assertions shall contain the HIH Organization Identifier (OID), Review Contractor Organization Identifier (OID), NPI Provider Identification etc.
Authentication HIH IP Address validation Mutual TLS v1.0 certificate validation (later used for encryption and decryption
of request, responses and its digital signatures) Exchange and validate FIPS 140/2 TLS Cipher Suites. Timestamp and SAML Digital Signature validation HIH OID and Intended Review Contractor validation against HIH and CMS
Review Contractor OIDs based on the CMS onboarding Process. Message and payload integrity verification based on the base 64 encoding -
MD5 digest/hashcode algorithms. Authorization
HIH OID and Intended Recipient OID against the esMD CMS on-boarded data. Up to 19MB of PDF Payload size
Current esMD XDR Transport
and Translation Mechanism
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esMD XDR Implementation
esMD XDR Profile and its references
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IHE XDR SpecificationNHIN Message Platform SpecificationNHIN Authorization Framework SpecificationNHIN Document Submission SpecificationesMD XDR Profile
How esMD implement the XDR Transport and Translation Mechanism?
Adapting CONNECT 3.1 XDR (Deferred Document Submission) Transportation and Translation Mechanism
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esMD XDR Document Submission Message Flow – In Deferred Message Mode
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Using the Health Information Handler (HIH) Gateway, provider submits a claim document response to a single CMS Additional Documentation Request Letter (ADR), using the Document Submission deferred request (as a part of deferred messaging flow).
esMD implements the NHIN Document Submission with Deferred Messaging mode. In a deferred mode, the Document Submission is a two-way message as shown in the diagram below:
Sample Message: XDR Document Submission SOAP Envelope
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So, What's Next? • Future esMD Use Cases• How to accommodate ASC X12 transactions?
o Does CONNECT Support ASC X12 Transactions?o Are there any NHIN profiles to support the ASC X12 Transactions?
• How to allow outbound transactions from CMS esMD Gateway to HIH in compliance with FISMA and other security requirement?
• Identify the Technical requirements to expand the esMD Use Cases.
• Provider Profile/ Provider Naming Service etc
In Sept 2011, esMD successfully implemented the IHE XDR Profile with inbound ADR Use Case.
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Current and Future Use Casesfor esMD
We Are HereINBOUND Responses to Documentation Request Letters in PDF Appeal Requests in PDF Unsolicited Documentation in PDF (called paperwork or “pwk”) Structured Orders, Progress Notes, ADMC Requests Structured esMD Phase 2 Registration etc
OUTBOUND Structured Outbound Documentation Requests Review Results Letters Demand Letters etc
LOOKUP Request\Receive Documentation Status Request\Receive Claim Status Request\Receive Appeals Status Request\Receive Eligibility Info etc
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Need to build CAQH Transport service (Parallel to XDR) in the CONNECT software by adopting Phase II CORE 270: Connectivity Rule version 2.2.0 specifications.
Develop NHIN CAQH CORE X12 Document Submission Profile (Similar to XDR Document Submission)
Develop the esMD X12 Profile based NHIN CAQH CORE X12 Document Submission Profile.
Implement the NHIN CAQH CORE X12 Document Submission Service with in the CONNECT.
Identify the ASC X12 Translator software to process the X12 Messages.
How to accommodate ASC X12 transactions thru esMD Gateway?
esMD XDR & CAQH CORE Transport
and X12 Translation Mechanism
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Sample Message: CAQH Phase II CORE 270: Connectivity Rule version 2.2.0 - X12 824 Application Advice Forwarded Acknowledgment SOAP Envelope
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Enhance CONNECT 3.1 with CAQH Phase II CORE 270: Connectivity Rule version 2.2.0 Transport Mechanism and esMD X12 Translator
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NHIN CAQH CORE X12 Deferred Document Submission (using three CAQH CORE Connectivity Generic Batch message interactions) Communication
with Multiple SOAP over HTTP/S Connections
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Can X12 Message be sent thru the XDR Transactions?
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QUESTIONS?
If more info please contact:
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• Melanie Combs-Dyer, RNDeputy Director,CMS/OFM/Provider Compliance [email protected]
• Dan KalwaHealth Insurance Specialist,[email protected]
• Manoj ChagantiesMD Chief Architect, CMS/[email protected]: 847 903 5432
CONNECT 3.x
esMD System Architecture
XDR HIH
CMS QSSI esMD Project Confidential Document – Pl. contact Manoj Chaganti, [email protected] , 847 903 5432
XDR Inbound Request
/Outbound Response - NHIN
Orchestration Document
Submission
CAQH CORE X12 Inbound Request / Outbound
Response- NHIN Orchestration
Document Submission
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ESMD Gateway
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esMD Translation / Statistical and Business Logic Application