1. Electronic Submission of Medical Documentation (esMD) Technical Overview
Melanie Combs-Dyer, RN - Deputy Director, CMS/OFM/Provider Compliance Group
Daniel Kalwa - Health Insurance Specialist, CMS/OFM/Provider Compliance Group
Manoj CHAGANTI - esMD Chief Architect, CMS/QSSI
Ranjith Madhusoodanan - esMD Project Manager, CMS/QSSI
Michael Finkel - esMD Project Director, CMS/QSSI
Monday
4:15 P.M.

2. Agenda Technical Overview esMD Business Functionality
Overview of XDR esMD Transporter and Translation Mechanism
Future esMD Enhancement / Use Cases
Overview of CAQH CORE Transport and X12 Translation Mechanism
If time permits: Discussion whether X12 Message be sent thru the XDR Transactions?

3. Today’s Medical Documentation Process
Doc’ n Request Letter
Review Contractor
Paper Medical Record
Provider

4. The Solution: Electronic Submission of Medical Documentation (esMD)
Phase 1:
Doc’n Request Letter
electronic
electronic
Phase 2:

5. CMS Does Not Dictate How an HIH Communicates with Providers
esMD HIHs ingest provider's medical records and metadata by either one of the following :
going onsite to the provider's facility
using a Virtual Private Network (VPN)
using a secure web portal
Some esMD HIHs are considering using DIRECT.
Web Portal
VPN
Onside Pickup
D I R E C T
D I R E C T

6. esMD Phase 1 (In Production) : September 2011
Doc’ n Request
Letter
Medicare
Administrative Contractors
Medicare
Recovery
Auditors
PERM
CONNECT Compatible
PDF
PDF
PDF
DIRECT
CMS Private Network
Content Transport Services
SOAP Message with SAML/XDR
ECM
ECM Built by
SOAP Message with SAML/XDR
esMD
Gateway
Built by
esMD
Metadata
Database

7. esMD Phase 2: October 2012 Medicare Medicare
Administrative Contractors
Medicare
Recovery
Auditors
PERM
CONNECT Compatible
Structured Electronic Requests for Medical Documentation
PDF
XML
PDF
PDF
DIRECT
CMS Private Network
Content Transport Services
SOAP Message with SAML/XDR
ECM
ECM Built by
SOAP Message with SAML/XDR
esMD
Gateway
Built by
esMD
Metadata
Database

8. Definition of an esMD Package
A portion of a patient’s medical record in esMD format which will contain:
Imaged documents (PDF)
Important Metadata Fields:
Intended Recipient – Required Field
Claim ID – Required Field
NPI – Required Field
Case ID – Required If Known
Detailed description for each field can be found in:
the esMD XDR Profile.
the esMD Implementation Guide. ( (

9. esMD Technical Details
System (HIH) to System (CMS) Gateway Communication
HIH Submits XDR (Deferred Document Submission) SOAP Envelope Request to CMS CONNECT gateway with the following details
SAML Assertions and its digital signature, Security Tags in the SOAP Header,
IHE XDR and esMD Meta Data with in the SOAP Body.
MTOM Encoded C62 Payload in the SOAP Body.
SAML Assertions shall contain the HIH Organization Identifier (OID), Review Contractor Organization Identifier (OID), NPI Provider Identification etc.
Authentication
HIH IP Address validation
Mutual TLS v1.0 certificate validation (later used for encryption and decryption of request, responses and its digital signatures)
Exchange and validate FIPS 140/2 TLS Cipher Suites.
Timestamp and SAML Digital Signature validation
HIH OID and Intended Review Contractor validation against HIH and CMS Review Contractor OIDs based on the CMS onboarding Process.
Message and payload integrity verification based on the base 64 encoding - MD5 digest/hashcode algorithms.
Authorization
HIH OID and Intended Recipient OID against the esMD CMS on-boarded data.
Up to 19MB of PDF Payload size

10. Current esMD XDR Transport and Translation Mechanism

11. esMD XDR Implementation

12. esMD XDR Profile and its references
IHE XDR Specification
NHIN Message Platform Specification
NHIN Authorization Framework Specification
NHIN Document Submission Specification
esMD XDR Profile
How esMD implement the XDR Transport and Translation Mechanism?

13. Adapting CONNECT 3.1 XDR (Deferred Document Submission) Transportation and Translation Mechanism

14. esMD XDR Document Submission Message Flow – In Deferred Message Mode
Using the Health Information Handler (HIH) Gateway, provider submits a claim document response to a single CMS Additional Documentation Request Letter (ADR), using the Document Submission deferred request (as a part of deferred messaging flow).
esMD implements the NHIN Document Submission with Deferred Messaging mode. In a deferred mode, the Document Submission is a two-way message as shown in the diagram below:

15. Sample Message: XDR Document Submission SOAP Envelope

16. In Sept 2011, esMD successfully implemented the IHE XDR Profile with inbound ADR Use Case.
So, What's Next?
Future esMD Use Cases
How to accommodate ASC X12 transactions?
Does CONNECT Support ASC X12 Transactions?
Are there any NHIN profiles to support the ASC X12 Transactions?
How to allow outbound transactions from CMS esMD Gateway to HIH in compliance with FISMA and other security requirement?
Identify the Technical requirements to expand the esMD Use Cases.
Provider Profile/ Provider Naming Service etc

17. Current and Future Use Cases for esMD
We Are Here
INBOUND
Responses to Documentation Request Letters in PDF
Appeal Requests in PDF
Unsolicited Documentation in PDF (called paperwork or “pwk”)
Structured Orders, Progress Notes, ADMC Requests
Structured esMD Phase 2 Registration
etc
OUTBOUND
Structured Outbound Documentation Requests
Review Results Letters
Demand Letters
LOOKUP
Request\Receive Documentation Status
Request\Receive Claim Status
Request\Receive Appeals Status
Request\Receive Eligibility Info

18. How to accommodate ASC X12 transactions thru esMD Gateway?
Need to build CAQH Transport service (Parallel to XDR) in the CONNECT software by adopting Phase II CORE 270: Connectivity Rule version specifications.
Develop NHIN CAQH CORE X12 Document Submission Profile (Similar to XDR Document Submission)
Develop the esMD X12 Profile based NHIN CAQH CORE X12 Document Submission Profile.
Implement the NHIN CAQH CORE X12 Document Submission Service with in the CONNECT.
Identify the ASC X12 Translator software to process the X12 Messages.

19. esMD XDR & CAQH CORE Transport and X12 Translation Mechanism

21. Sample Message: CAQH Phase II CORE 270: Connectivity Rule version 2. 2
Sample Message: CAQH Phase II CORE 270: Connectivity Rule version X Application Advice Forwarded Acknowledgment SOAP Envelope

22. Enhance CONNECT 3.1 with CAQH Phase II CORE 270: Connectivity Rule version Transport Mechanism and esMD X12 Translator

23. NHIN CAQH CORE X12 Deferred Document Submission (using three CAQH CORE Connectivity Generic Batch message interactions) Communication with Multiple SOAP over HTTP/S Connections

24. Can X12 Message be sent thru the XDR Transactions?

25. QUESTIONS? If more info please contact:
Melanie Combs-Dyer, RN
Deputy Director, CMS/OFM/Provider Compliance Group
Dan Kalwa
Health Insurance Specialist,
Manoj Chaganti
esMD Chief Architect, CMS/QSSI
Ph:

26. esMD System Architecture
CMS QSSI esMD Project Confidential Document – Pl. contact Manoj Chaganti, ,
XDR & X12 HIH
XDR HIH
X12 HIH
< -- X12 Trading Partner Agreement
(TPA) Use Case --
…..
------XDR Orders Use Case --- 
X12 Appeals Use Case --- 
…..
X12 Orders Use Case --- 
XDR Appeals Use Case --- 
< -- X12 Trading Partner Agreement
(TPA) Use Case --
X12 ADR Use Case --- 
XDR ADR Use Case --- 
CONNECT 3.x
XDR Inbound Request /Outbound Response - NHIN Orchestration Document Submission
CAQH CORE X12 Inbound Request / Outbound Response- NHIN Orchestration Document Submission
XDR
Transporter
CAQH CORE
Transporter
ESMD
Gateway
X12 Translator
esMD Translation / Statistical and Business Logic Application