Claims Attachment 101 July 10, 2014 - WEDI · 1 Claims Attachment 101 July 10, 2014 Presented by...
Transcript of Claims Attachment 101 July 10, 2014 - WEDI · 1 Claims Attachment 101 July 10, 2014 Presented by...
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Claims Attachment 101
July 10, 2014 Presented by
Mary Lynn Bushman, National Government Services, INC – WEDI SNIP Claim Attachments Sub-Workgroup Co-Chair
Durwin Day, Health Care Services Corp
WEDI SNIP Claim Attachments Sub-Workgroup Co-Chair
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Claims Attachment 101
Agenda
– X12 Claims Attachment Technical Solution
– HL7 Attachment Standards
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Claims Attachment 101
Industry Interest in Attachments
– New Interest in Claims Attachment
– Several Questions on the Technical Solution
– Suggestions to include Claims Attachment
information in future sessions
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Claims Attachment 101
Claims Attachment
– Required by the original HIPAA legislation as well as the Affordable Care Act
– Not widely automated today
– Will allow health plans to request, and providers to send “extra” information needed to adjudicate a claim
– Will be a bridge between administrative and clinical records
– Ties in with movement towards Electronic Health Records
Claims Attachment 101
Claim Attachment Transaction usage requirements
– same as previous transactions
Provider has choice to:
• Request 277 from payer
• Respond to request via 275/HL7
Payer has responsibility to:
• Create 277 when provider elects to receive
• Receive & process a 275 / HL7 when
providers elect to send
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Claims Attachment 101- Technical Solution
X12 Implementation Guides
– ASC X12N Implementation Guide for the 275 Transaction (006020)
Additional Information to Support a Health Care Claim or Encounter
Additional Information to Support a Healthcare Service Review
– ASC X12N Implementation Guide for the 277 Transaction (006020) Health Care Claim Request for Additional Information
Claims Attachment 101- Technical Solution
HL7 Attachment Supplemental Guide
HL7 Consolidated CDA Templates
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Claims Attachment 101- Technical Solution
NPRM issued September, 2005
NPRM named version 4050 of the 277 and 275
NPRM comments addressed with version 5010 and carried in version 6020 as well
Final 6020 X12 Implementation Guides will be posted on the WPC website
Current Claim Attachment Request Process
Current Paper Process:
Currently most Payers use a paper process to
request additional information
Paper process is very slow
Must factor in mail time, can take several days to
deliver
Paper requests are not always routed correctly
within facilities
Provider’s staff must open the letters and interpret
what is needed
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Current Claim Attachment Request Process
Payers lose attachments and may not be able to
re-associate the paper attachment with the claims
Additional information (attachments) is a major
source of pended and/or denied claims
Conclusion – the paper process is costly and takes
longer
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Electronic Claim Attachment Request Process
X12 277 – Health Care Claim Request For
Additional Information Implementation Guide
(IG)
– Based on same standard 277 transaction set as
claim status response
– Used by Payer to request additional
information about a claim
– Claim control number in 277 links back to the
claim for re-association
– Uses LOINC codes - specificity of request
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Electronic Claim Attachment Request Process
– Supports requests for multiple claims
– Transaction Set Type Code – BHT06 with value
of RQ
– Repeating STC01, STC10, STC11 at the claim
and line level
– LOINC Codes (questions and modifiers) use in the
STC segment
– The Payer’s Business rules defines content of the
Response Due Date
Electronic Claim Attachment Request Process
Benefits of using the 277 transaction
−Eliminates the issue with delivery to the
provider’s with multiple sites/facilities
−Allows the ability to receive and respond to the
payer’s request quicker than paper which
results in payment not being delayed
Conclusion – electronic process is less costly,
faster than the paper process and eliminates the
provider delivery problems
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X12 277 Example (Version 5010)
ST*277*1001*006020X313~
BHT*0085*48*277X213000001*20120103*1211*RQ~
HL*1**20*1~
NM1*PR*2*ABC INSURANCE CO*****PI*1234~
PER*IC*MED REVIEW DEPT*TE*5555555555~
HL*2*1*21*1~
NM1*41*2*XYZ SERVICES*****46*A222216~
HL*3*2*19*1~
NM1*1P*2*HOLY HILLS HOSP*****XX*1666666666~
HL*4*3*PT~
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X12 277 Example (Version 5010)
NM1*QC*1*JACKSON*JACK*J***MI*987654320~
TRN*1*1822634840~
STC*R4:11490-0:20120103:LOI*20120103~
REF*BLT*111~
REF*EJ*JACKSON123~
REF*EA*STHHL12345~
DTP*472*D8*20111229~
DTP*106*D8*20120203~
SE*19*1001~
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Current Claim Attachment Response Process
Current Paper Process:
Provider’s have to photocopy documents
Provider’s to pay for mailing costs (these add up)
Must take mailing time into consideration
Payers mailroom costs – staff to open mail, staff
to scan documents, storage costs
Claims may be denied if response is not received
timely
When the claim is denied – provider must submit
an appeal, appeal process is costly for payers 16
Current Claim Attachment Response Process
Conclusion – paper process is costly
and the paper process delays provider’s payments
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Electronic Claim Attachment Response Process
X12N 275 – Additional Information to Support a
Health Care Claim or Encounter (IG)
–When claim & Attachment sent together:
Attachment Control number (TRN) ties back
to 837 ( PWK)
–When attachment in response to 277: Payer’s
control number is in the TRN. Ties back to
payer’s control number from the 277
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Claims Attachment 101 - Technical Solution
–The BGN01 identifies the purpose of the
transaction set
02 – used to indicate unsolicited 275
11 – used to indicate the 275 is in
response to the 277 request.
–CAT segment specifies the format of the
HL7 CDA in the BDS (BIN in 5010)
segment. (Structured or Unstructured)
Claims Attachment 101 - Technical Solution
– BDS segment holds HL7 claims attachment information (Structured and Unstructured)
– BDS segment recommended maximum size = 64 MB
– 275 can relate to either an entire claim or a specific service line
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Claims Attachment 101 - Technical Solution
– The structure only allows for one claim in each 275 transaction
– LX loop handles multiple responses for a specific claim
– Return LOINC code in the STC segment of the 275
– Conclusion – costs less than paper, cuts out mailing time, provider’s are paid quicker and is interoperable with the Electronic Health Record Systems
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X12 275 Example (Version 5010)
ST*275*1001*006020X314~
BGN*11*0001*20120110~
NM1*PR*2*ABC INSURANCE CO*****PI*1234~
NM1*41*2*XYZ SERVICES*****46*A222216~
NM1*1P*HOLY HILLS HOSP*****XX1666666666~
NX1*1P~
N3*2345 WINTER BLVD~
N4*MIAMI*FL*33132~
NM1*QC*1*JACKSON*JACK*J***MI*987654320~
REF*EJ*JACKSON123~
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X12 275 Example (Version 5010)
REF*EA*STHHL12345~
DTP*472*D8*20111229~
LX*1~
TRN*2*1822634840~
STC*R4:11490-0:20120103:LOI*20120103~
DTP*368*D8*20120110~
CAT*AE*MB~
OOI*1*47*ATTACHMENT~
BDS*ASC*6289*……….(represents HL7 standard)~
SE*27*1001~
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Solicited Claim Attachments
Solicited model is when the payer requests the
information from the provider
Provider sends the claim
Payer determines claim information is not
sufficient to process the claim
277 transaction is used to request the information
275 is used to respond to the request
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Solicited Claim Attachments
TRN segment in the 277 is defined by the payer
TRN segment values are returned in the 275
TRN information is used to tie the response
information to the appropriate claim
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Claims Attachment 101 – Technical Solution
Solicited Request
Request for payment by ASC X12N 837
Provider
Payer
Request for
Additional information
by ASC X12N 277
Additional information by
ASC X12N 275 / HL7 CDA
Payment advice sent by ASC X12N 835-
could be payment or denial
Unsolicited Claim Attachments
Unsolicited model is when the provider knows that the payer requires additional information to process the claim
Provider sends additional information when
submitting the claim
Provider sends the 837 with the 275
Sender has the option to send the 275 in the same
Interchange as the 837 OR sender has the option to send the 275 in a separate Interchange Business Concern: What is a reasonable time period to wait for attachments?
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Unsolicited Claim Attachments
PWK segment in the 837 is defined by the
provider
TRN segment has the same value as the PWK
segment
PWK/TRN information is used to tie the response
information to the appropriate claim
Question???? Is there specific criteria that could
be mandated in the Final Rule or should this be
payer defined?
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Claims Attachment 101 – Technical Solution
Unsolicited Request
Request for payment by ASC X12N 837 &
275/HL7 attachment
Provider
Payer
Payment advice sent by ASC X12N 835-
could be payment or denial
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Claims Attachment 101 – Technical Solution
Linking the Transactions
Attachment submitted with Claim (837 + 275)
Note: 837 and the 275 can be sent in separate interchanges w/version 6020
ISA Interchange Control Header
GS Functional Group Header
ST 837 Transaction Set Header: Claim …PWK contains provider’s control number
SE Transaction Set Trailer
GE Functional Group Trailer
GS Functional Group Header
ST 275 Transaction Set Header: Add’l Info
…TRN contains provider’s control number
SE Transaction Set Trailer
GE Functional Group Trailer
IEA Interchange Control Trailer
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Claims Attachment 101 – Technical Solution
Linking the Transactions
REQUEST RESPONSE
ISA Interchange Control Header ISA Interchange Control Header
GS Functional Group Header GS Functional Group Header
ST 277 Transaction Set Header: ST 275 Transaction Set Header:
Request Response
...TRN contains payer’s control number ...TRN contains payer’s
control number
STC specific data requested STC specific data
requested
...BDS specific data response
SE Transaction Set Trailer SE Transaction Set Trailer
GE Functional Group Trailer GE Functional Group Trailer
IEA Interchange Control Trailer IEA Interchange Control Trailer
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Claims Attachment 101 – Technical Solution
Possible Acknowledgements
824 Acknowledgement Transaction
Ability to acknowledge X12
Ability to acknowledge HL7
New codes added to the code set, includes
MIME packaging, Base64 encoding, CDA
header.
If HL7 validation tool is used the 824 does
not currently support
X12/HL7 are working on a solution
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Claims Attachment 101 - Technical Solution
Logical Observation Identifiers Names and Codes (LOINC)
– Provides sets of universal names and ID codes for lab and clinical test results, plus other units of information meaningful for attachments (questions and answers)
– Owned by Regenstrief Institute and LOINC Consortium
– Freeware sponsored by National Library of Medicine
– Used to identify requests and answers for attachments
– Provides specificity
– Code set used in the X12 277 and 275 transactions, as well as in the HL7 CDA
Proposed HL7 Standards
HL7 Implementation Guide for CDA® Release 2: IHE
Health Story Consolidation (aka C-CDA). July 2012. Same Standard as EHR/Meaningful Use II
HL7 CDA R2 Implementation - Supplement to Consolidated CDA for Attachments, Release 1
Supplemental Guide on how to exchange as Attachments
LOINC Code Set, built and maintained by Regenstrief Institute
To identify attachment types being requested To optionally modify the time span of the requested information To identify either a specific document, section or element
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HL7 Standards
Key Terms for Responses
o “Structured” Document o Header + structured xml body
o Defines discrete data at each level: o Document,
o Section,
o Element
o Conformance statements indicate required/optional
o “Unstructured” Document o Header + unstructured body
o Comprised of PDF’s, Word Documents, Tiffs, JPEG, etc
Structured
HL7 C-CDA Document types that are “currently structured” with discrete sections and entries:
Continuity of Care Document
(CCD)
History and Physical (H&P)
Diagnostic Imaging Report
(DIR)
Discharge Summary
Operative Notes Progress Note Consultation
Note Procedure Note
Unstructured
Document type categories (Unstructured), but identified as attachment type needs by industry:
Pharmacy Prior Authorization
Home Health
Consent Forms
Durable Medical Equipment
(DME)
Explanation of
Benefits EOB)
Letters/Reports Skilled Nursing
Facility (SNF)
Rehabilitation Services
Meeting Industry Needs
WEDI Survey (2012) of current user needs
Top 3 Attachment types
Provider - Op Note, Progress Note, Consent Forms
Payer – Op Note, Progress Note, Diagnostic Images
Payer needs for Prior Authorizations
Progress notes, history and physical, and lab results.
Education needed: Little known about standards for attachment exchange
What is CDA?
CDA – Clinical Document Architecture ● The CDA is a document markup standard (XML) for the structure and semantics of an exchanged
"clinical document".
● XML constrained by definition of the HL7 Reference Information Model (RIM)
● A clinical document is a documentation of observations and other services with the following
characteristics:
Persistence - A clinical document continues to exist in an unaltered state, for a time period
defined by local and regulatory requirements.
Stewardship - A clinical document is maintained by a person or organization entrusted with its
care.
Potential for authentication - A clinical document is an assemblage of information that is
intended to be legally authenticated.
Context - meaning that attribution assigned to a structure is applicable to the contents
contained in that structure, and are inherited by nested structures unless overridden
Wholeness - Authentication of a clinical document applies to the whole and does not apply to
portions of the document without the full context of the document.
Human readability – CDA can be human readable or machine readable.
Example of CDA
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Supplement to C-CDA for Attachments
● How to Implement C-CDA for Attachment purposes
How to use Consolidated-CDA for exchange with health plans
Meta-data defined (sender, receiver, type of document)
Matching Attachments with the Claim
Requests defined – Solicited, Unsolicited
Responses defined – Structured, Unstructured
How to find, obtain new, and use LOINC codes
Transport Agnostic
Examples
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Enveloping Metadata
Required:
Payer (Requestor) - Name & Plan ID
Receiver - Name & ETIN
Provider of Service - Name & NPI
Patient - Name & ID
Payer Claim Control Number (re-association key)
LOINC code – Information Requested & Date Requested
Response Due Date
Payer Contact Info
Date of Service
Situational:
Patient Control Number assigned by Provider on claim
Medical Record Number assigned by Provider on claim
Institutional Bill Type
Property and Casualty claim number
Adoption of LOINC
Logical Observations Identifiers Names &Codes
All the “big” labs
All health-related federal agencies
Lots of care organizations
HIE’s
Insurance companies
IAIABC for unstructured reports
EHR vendors
Free, used world wide, updated twice a year 46
LOINC for Structured Attachment Types
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LOINC Codes for Unstructured Types
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Modifier LOINC Codes
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New Attachments
“New” attachment type process:
1. Entities needing new type of attachment can initiate the process at HL7 Attachment Work Group (AWG)
2. AWG, working with OESS evaluate for appropriateness under HIPAA (if not, adoption voluntary between trading partners)
3. Requests initially developed as “Unstructured” and evaluated for migration into “Structured” (not all types meant for structured)
4. If structured candidate, AWG would develop content.
Work in Progress
● HL7 Consolidated-CDA R2 Templates for Clinical Notes
Adds document templates (balloted):
Care Plan
Referral Note
Transfer Summary
Patient Generated Document
● HL7 Complete Document Templates (esMD-balloted)
Report Null values for any data not collected or reported
Adds new document and section templates
● CORE Operating Rules (TBD)
● WEDI – How to Guide (being developed)
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Next version of C-CDA
● HL7 C-CDA R2 – Templates for Clinical Notes
Includes 9 R1.1 Document Templates
Continuity of Care Document, Consultation Note, Diagnostic
Imaging Report, Discharge Summary, History & Physical,
Operative Note, Procedure Note, Progress Note, Unstructured
Adds 4 New Document Templates:
Care Plan, Referral Note, Transfer Summary,
Patient Generated Document
Adds Digital Signature
Allows Null values at Section Levels
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esMD Project
● HL7 C-CDA Complete Document Templates (balloted)
Defines 5 new Document Templates
Complete Encounter, Complete Hospitalization,
Complete Operative Note, Complete Procedure Note, Time Boxed
Defines 4 new Section Templates
Additional Documentation Section, Externally Defined Clinical Data
Elements, Placed Orders, Transportation
Additional Constraints on 4 existing Section Templates Plan of Treatment, Social History, Functional Status, Mental Status
Requires Affirmative Attestation, via the use of Null Flavors,
for any data not reported (may be defaulted by system or
template)
NI - no information, NA – not applicable
Supports exchange of the entire contents of the medical
record related to a specific encounter
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Potential Operating Rules
CORE Infrastructure Rules from previous Phases: Batch Acknowledgements Companion Guide Rule Connectivity (related to transport) System Availability
Additionally – current CORE survey: Define which services require unsolicited attachments and require
payers to have the capability to accept them (either universally or by mutual agreement between payers and providers
Create rules defining what solicited attachments can be requested for different purposes
Define attachments specific to dental claims Allow attachment standard to be used for more purposes than just
claim attachments. Align with standards being used for meaningful use and provider to provider exchange
Summary of HL7 Attachments
HL7 CDA Standards
CDA = XML constrained by HL7 RIM
C-CDA = Template Documents
Defines the clinical content
Allows for Structured or Unstructured
Allows for human and machine readable
Draft Standard for Trial Use
Aligns Attachments with EHRs
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Milestones for Attachments
ACA Admin. Simplification (sec.1104)
Nov 2012 – NCVHS Hearing on Attachments
Feb 2013 – NCVHS Testimony on Attachments
June 2013 – NCVHS Letter of Recommendation
June 2014 – NCVHS Hearing on Attachments
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Jan 2014 - Publish Rule on Attachments!!
Jan 2016 - Implement Stds. and Op Rules??
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Thank You
Thank you for participating in the
Attachment 101 Audiocast
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Questions
Questions?
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Contact Information
WEDI SNIP Claim Attachments Sub-Workgroup Co-Chair Contact Information:
Mary Lynn Bushman – [email protected] (717) 565-3697 Durwin Day – [email protected] (312) 653-5948 Craig Gabron – [email protected] (803) 763-1790 Susan Langford – [email protected] (423) 535-5730