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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Agenda

– X12 Claims Attachment Technical Solution

– HL7 Attachment Standards

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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

– 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


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


HL7 Attachment Supplemental Guide

HL7 Consolidated CDA Templates

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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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– 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


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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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)


– 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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– 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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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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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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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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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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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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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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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

mailto:[email protected]



