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esMD Background

esMD Background. Review Contractor. Request Letter.

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esMD Background

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  1. esMD Background Review Contractor Request Letter 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. Before esMD: Phase I of esMD was implemented in September of 2011. It enabled Providers to send Medical Documentation electronically Phase 1: Doc’n Request Letter electronic Phase 2: electronic Paper Medical Record The Electronic Submission of Medical Documentation (esMD) initiative is developing solutions to support an entirely electronic documentation request. Provider electronic

  2. esMDeMDR Process Flow The overall esMDeMDR process can be divided into three steps: esMD Phase 1 esMD Phase 2

  3. esMD UC1/2 Summary • Use Case 1 – Provider Registration with Payer to receive eMDRs

  4. esMD UC1/2 Summary • Use Case 2 – Secure Transportation and Structured Content of eMDRs

  5. S&I Framework esMDeMDR Overview Registration Authority Certificate Authority Provider Directories Gateway Provider Entity Payer Entity esMD UC 1: Provider Registration Contractors / Intermediaries Agent esMD UC 2: Secure eMDR Transmission Provider (Individual or Organization) Payer Payer Internal System esMD AoR Level 1 Digital Identities Bundle Signatures

  6. AoR -- Phased Scope of Work Level 1 – Current Focus • Digital signature on aggregated documents (bundle) • 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 Level 2 - TBD Digital signature on an individual document • 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 Level 3 - TBD • Digital signature to allow traceability of individual contributions to a document • 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

  7. Electronic Determination of Coverage (eDoC)

  8. esMD Landscape

  9. esMD Data Requirements • Each step in the esMD Process requires the exchange of specific types data Register to Receive eMDRs Send eMDRs Send Medical Documentation

  10. Transport Standards

  11. Electronic Submission of Medical Documentation (esMD) Supporting Multiple Transport Standards and Provider Directory EDI – CAQH CORE Compatible Practice Management Systems and Claims Clearinghouse EDI Translator EHR / HISP ECM Direct Compatible Internal PD Content Transport Services Payer / Payer Contractors Direct Federated External PD HIH CONNECT Compatible

  12. UC 1 Standards

  13. UC 2 Standards

  14. UC 1/2 Standard Message Components eHealthExchange Phase II CAQH CORE 270 Direct

  15. Standards Used • Payload • 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)

  16. Considerations for eDoC

  17. 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)

  18. 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

  19. 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 WGto prevent duplication of effort • HL7 Informative guide dated June 2013 • Coordination with Author of Record • HL7-balloted CDA IG for Digital Signatures / DoR

  20. Other Considerations • Authentication • Audit trails • Compliance • Certification

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