esMD Harmonization UC2 Data Element Prioritization 8/1/2012

Overview Karen Shutt, X SME, identified esMD data elements that are not represented in the 277 Request for Information transaction set Workgroup leads reviewed and prioritized unrepresented data elements with additional input from Karen Shutt and WEDI members

eMDR Message (1/2) esMD Data Set Requirement esMD DefinitionPriority /Status Conclusions Individual Provider or Provider Organization Address Location specified for the provider receipt of additional documentation requests LowUnnecessary for electronic communications Individual Provider Prefix LowUnnecessary Payer or Payer Contractor Digital Certificate RequiredMight be able to use 277 REF segment but need additional research. Could this be included in metadata or is this something that needs to remain with the request? Payer or Payer Contractor Signature Artifact Required

eMDR Message (2/2) esMD Data Set Requirement esMD DefinitionPriority/ Status Conclusions Payer Organization vs Payer Contractor Must include the payer and recommend including the specific payer contractor. Should provide contact information for the payer contractor if one is involved. High/ Possibly covered Could use 277 PER Elements within the Payer Information loop or within the Claim Supplemental Information loop for Contractor contact information CMS - Prefer to use OIDs to represent each contractor. Commercial - Need to identify preferences Purpose of eMDR Request Type High/ Covered pending further research Limit to ASC X12 R Request Codes, with potential extensions to codify authority. Request Type Reason Text description of reason for the replacement, follow up, or termination for a prior request LowUnnecessary in structured approach

General Request Information esMD Data Set Requirement CommentsPriority/ Status Conclusions Date of Request Date the eMDR was sentLow/ Covered 277 includes a response due date and transaction date. These may be sufficient for esMD. Cover Letter Text LowUnnecessary in structured approach (pending further review of CMS requirements) Program The type of program sending the eMDR (e.g. MAC, RAC, CERT, ZPIC) High/ TBD Unnecessary if authority of requestor can be communicated via extensions to ASC X12 R Request Codes

Audit Specific Information esMD Data Set Requirement CommentsPriority/ Status Conclusions Scope or Type of Audit Pre certification, Claim Payment Documentation, Audit, Payment Recovery Medium/ Covered Covered via ASC X12 R Request Codes Unique Case Reference Identifier A case number used to track one or more related eMDRs. Serves as a unique external ID. RequiredSubmit change request to ASC X12

Claim Related Information esMD Data Set Requirement CommentsPriority/ Status Conclusions Provider Directory Address Required/ Covered Use existing support for URLs Provider Directory ID HighUse and existing ID element and research possibility of adding additional qualifier to clarify the ID Payer Identifier for the Policy holder An identifier assigned by the payer to the policy holder under which payment will be made for this beneficiary TBDCMS – Unnecessary Commercial - May be required since claims are generated in financial systems based on policy holder and the supporting documents are in clinical system based on patient. Need to be able to tie these together. Beneficiary Date of Birth TBDCMS – Unnecessary Commercial - Need to review requirements

Claim Related Information (Claim Level Detail) esMD Data Set Requirement CommentsPriority/ Status Conclusions Date Claim Received Claim could be submitted multiple times with revisions. This provides a way to differentiate between the multiple claim submissions. Medium/ Internal Discussion Need to decide if this is necessary and of value to providers. Type of Bill Covered277 includes bill type as found in ASC X12N 837, CLM05 which reflects NUBC Form Locator 4 Place of Service High/TBDSubmit to WEDI for community review and feedback Diagnosis Code(s) Code Set Used Related Group Code High/TBDSubmit to WEDI for community review and feedback

Claim Related Information (Line Level Detail) esMD Data Set Requirement CommentsPriority/ Status Conclusions Performing Provider NPI Alternate ID Alternate ID Type 277 supports NPI of Service Provider as identified in Loop 2100C, but Service Line Information does not have data element for additional or different NPI. RequiredSubmit to WEDI for community review and feedback Provider Specialty Low Line Level Diagnosis Code High/TBDSubmit to WEDI for community review and feedback

Return Method Object esMD Data Set Requirement CommentsPriority/ Status Conclusions Return Methods Code set that defines high level transport option that may be used for the return. Examples - Physical, Electronic Transaction, URI RequiredIntroduce concept to WEDI and CAQH CORE for community feedback. Conversation with X12 to follow. Electronic Service Information Required Maximum Electronic Return Size per transaction High Return Constraints Codified constraints for a specific Return Method. Examples - International Code Sets, Extended ASCII Character Sets, Language High Return Format(s) Codified formats allowed for a specific Return Method. Examples – USB drive, CDs, PDFs, UML, XHTML Required

Summary of Analysis (1/3) Covered: 1.Date of Request 2.Scope or Type of Audit 3.Type of Bill 4.Purpose of eMDR / Request Type 5.Provider Directory Address Unnecessary: 1.Individual Provider or Provider Organization Address 2.Individual Provider Prefix 3.Request Type Reason 4.Cover Letter Text 5.Provider Specialty

Summary of Analysis (2/3) Required: 1.Payer or Payer Contractor Digital Certificate 2.Payer or Payer Contractor Signature Artifact 3.Unique Case Reference Identifier 4.Performing Provider NPI / Alternate ID / Alternate ID Type 5.Return Methods 6.Electronic Service Information 7.Maximum Electronic Return Size per transaction 8.Return Constraints 9.Return Format(s)

Summary of Analysis (3/3) Further Discussion Required: 1.Payer Organization vs Payer Contractor (Commercial Payers) 2.Payer Identifier for the Policy holder (Commercial Payers) 3.Beneficiary Date of Birth (Commercial Payers) 4.Line Level Diagnosis Code 5.Provider Directory ID 6.Maximum Electronic Return Size per transaction 7.Return Constraints 8.Program

Next Steps 1.Submit Change Request to X12 for Unique Case Reference Identifier 2.Reach out to commercial payers for additional input on TBD Elements 3.Submit Required Elements to WEDI for community review and feedback 4.Submit Return Method Objects to CAQH CORE for review and feedback 5.Reach out to Claim Adjustment Status Code Maintenance Committee for guidance on extensions to R Request Codes in order to communicate authority 6.Update priorities based on input from esMD workgroup members, commercial payers, and WEDI community 7.Submit necessary change requests to X12 8.Submit necessary change requests to CAQH CORE 9.Submit necessary change requests to Claim Adjustment Status Code Maintenance Committee