esmd background
DESCRIPTION
esMD Background. Review Contractor. Request Letter. - PowerPoint PPT PresentationTRANSCRIPT
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esMD Background
Phase I of esMD was implemented in September of 2011. It enabled Providers to send Medical Documentation electronically
Review Contractor
Provider
Request Letter
Paper Medical Record
Phase 1: Doc’n
Request Letter
electronic
electronic
electronicPhase 2:
Before esMD: Healthcare payers frequently request that providers submit additional medical documentation to support a specific claim(s). Until recently, this has been an entirely paper process and has proven to be burdensome due to the time, resources, and cost to support a paper system.
The Electronic Submission of Medical Documentation (esMD) initiative is developing solutions to support an entirely electronic documentation request.
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esMD eMDR Process FlowThe overall esMD eMDR process can be divided into three steps:
• A provider registers with a payer to receive electronic medical documentation requests (eMDRs) -- must have valid S&I Use Case 2 compliant directory entry with ESI supporting end point for eMDR profile
1. Register to Receive eMDRs
• A payer sends an eMDR to a registered provider’s current ESI obtained from designated PD
2. Send eMDRs• A provider electronically
sends medical documentation to a payer in response to an eMDR
3. Send Medical Documentation
esMD Phase 2 esMD Phase 1
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• Use Case 1 – Provider Registration with Payer to receive eMDRs
esMD UC1/2 Summary
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• Use Case 2 – Secure Transportation and Structured Content of eMDRs
esMD UC1/2 Summary
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S&I Framework esMD eMDR Overview
Provider EntityPayer Entity
PayerProvider
(Individual or Organization)
Contractors / Intermediaries Agent
Payer Internal System
Gat
eway
esMD UC 2: Secure eMDR Transmission
esMD UC 1: Provider Registration
esMD AoR Level 1Digital Identities Bundle Signatures
Certificate Authority
Registration Authority
Provider Directories
User Story • All Actors obtain and
maintain a non-repudiation digital identity
• Provider registers for esMD (see UC1)
• Payer requests documentation (see UC2)
• Provider submits digitally signed document (bundle) to address request by payer
• Payer validates the digital credentials, signature artifacts and, where appropriate, delegation of rights
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AoR -- Phased Scope of WorkLevel 1 – Current Focus
Level 2 - TBD
Level 3 - TBD
Digital signature on aggregated documents
(bundle)
Digital signature to allow traceability of individual
contributions to a document
Digital signature on an individual document
• Focus is on signing a bundle of documents prior to transmission to satisfy an eMDR
• Define requirements for esMD UC 1 and UC 2 Signature Artifacts• May assist with EHR Certification criteria in the future
• Focus is on signing an individual document prior to sending or at the point of creation by providers
• Will inform EHR Certification criteria for signatures on patient documentation
• Focus is on signing documents and individual contributions at the point of creation by providers
• Will inform EHR Certification criteria for one or multiple signatures on patient documentation
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Underlying Challenge:• Enable provider capture of documentation and benefit determination based on
payer rules• Secure exchange of templates, decision support, and documentation between
payers, providers, service suppliers and beneficiary
Scope:• Define the use case, user stories and requirements supporting a standards-based
architecture• Reuse of existing S&I Initiative efforts• Creation of structured data capture templates and supporting exchange standards• Power Mobility Device as initial User Story
Outcome:• Successful pilot of templates, decision support, information exchange standards over
standard secure transactions for the purpose of determining coverage • Validation with initial Generic Use Case through user stories such as Power Mobility Device
Electronic Determination of Coverage (eDoC)
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esMD LandscapePhase Use Case Status Approach Data Relevant Standards
1 Send Medical Documentation
Closed Unstructured - Clinical- Billing- Admin
- X12 275 & PDF- XD*, C62, & PDF
2 Register to receive eMDRs
Closed Structured - Admin - X12 274- XD* & HPD
2 Send eMDRs Closed Structured - Billing- Admin
- X12 277
2 Author of Record(L1, L2, L3)
Harmonization Structured - Admin - CDA- XAdES-X-L & XML-DSIG- SAML 2.0
3 eDoC Harmonization Structured - Clinical- Billing- Admin
- X12 275- XD* & CDA
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• Each step in the esMD Process requires the exchange of specific types data
esMD Data Requirements
• Provider Identification• Electronic Service Information
Administrative Data
• Claim Number• Claim Date
Billing Data
• Patient Identification• Procedures Performed
Clinical Data
Register to Receive eMDRs
Send eMDRs
Send Medical Documentation
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Transport Standards
CONNECT
DIRECTX12 Core
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Electronic Submission of Medical Documentation (esMD) Supporting Multiple Transport Standards and Provider
Directory
ECM
Content Transport Services
Payer / Payer Contractors
Internal PD
EHR / HISP
DirectCompatible
Direct
EDITranslator
HIHCONNECT
Compatible
Practice Management
Systems and ClaimsClearinghouse
EDI – CAQH CORECompatible
Federated External
PD
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Purpose Standard
Register with CMS to receive eMDRs ASC X12N 274
Register with Commercial Payers to receive eMDRs
ASC X12N 274IHE HPD Plus
UC 1 Standards
Transport Payload UserPhase II CAQH CORE Rule 270 (Connectivity Rule 2.2.0) ASC X12N 274 Commercial
eHealth Exchange with CORE X12 Document ASC X12N 274 CMS/Commercial
eHealth Exchange HPD Plus Commercial
Direct ASC X12N 274HPD Plus
Commercial
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Purpose Standard
Payer/Contractor sends eMDR to Provider/Agent
ASC X12N 277
Register with Commercial Payers to receive eMDRs
ASC X12N 274IHE HPD Plus
UC 2 Standards
Transport Payload UserPhase II CAQH CORE Rule 270 (Connectivity Rule 2.2.0) ASC X12N 277 Commercial
eHealth Exchange with CORE X12 Document ASC X12N 277 CMS/Commercial
Direct ASC X12N 274HPD Plus
Commercial
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UC 1/2 Standard Message Components
Phase II CAQH CORE 270 eHealth Exchange
SMTP
XDM Submission Set Metadata
XDM Document Metadata
X12 277 Message
S/MIME AttachmentZip File
esMD Security Metadata
Direct
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Standards UsedPayload- ASC X12N 274- ASC X12N 277- IHE HPD Plus- Directory Services Markup Language (DSML v2)
Transport- eHealth Exchange (NwHIN) / CONNECT- CAQH CORE Connectivity Rule 2.2.0- Direct - IHE XD* (XDR, XDS, XDM)
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Considerations for eDoCPurpose Payload Transport User
Claims
Orders
Results
Reimbursement
Eligibility
Prior Authorization
Request for DocumentationDocumentation for SubmissionMetadata
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Considerations for eDoC• Payload – the clinical documentation
• C-CDA (structured and unstructured document templates)• Current ballot for C-CDA R2
• Messaging Standards – required by HIPAA• X12 275
• not yet required by HIPAA• X12 278?
• Will need to check• Can be used to request additional information about a prior auth, but that
information would be sent back as a 275• X12 277 – request for information (claims attachment)
• not yet required by HIPAA• X12 837 with 275
• PWK section in the 837 will specify the association between the two• IHE XDR? (need to determine which category)
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Considerations for eDoC• Operating Rules
• CAQH CORE• Metadata• Conformance and participation standards
• Transports (content-neutral—not dependent on the information transported)• Direct (SMTP)• CONNECT / eHealth Exchange (Healtheways)• SOAP• RESTful
• Security• OAuth (for RESTful)• SAML (for CONNECT or SOAP)• S/MIME for SMTP• IHE DSG
• Document Management• IHE XDS
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Use Cases for “Attachments”• Use Cases
• Support for claims• Prior authorization• Post-payment review• Clinical exchange• Care coordination / management• Fraud / waste prevention• Quality management
• Coordination with HL7 Attachments WG to prevent duplication of effort• HL7 Informative guide dated June 2013
• Coordination with Author of Record• HL7-balloted CDA IG for Digital Signatures / DoR
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Other Considerations• Authentication• Audit trails• Compliance• Certification