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esMD Harmonization UC2 Data Element Prioritization 8/1/2012

esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

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esMD Harmonization UC2 Data E lement Prioritization 8/1/2012. Overview. Karen Shutt , X12 277 SME, identified esMD data elements that are not represented in the 277 Request for Information transaction set - PowerPoint PPT Presentation

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Page 1: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

esMD HarmonizationUC2 Data Element Prioritization

8/1/2012

Page 2: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Overview• Karen Shutt, X12 277 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

Page 3: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

eMDR Message (1/2)esMD Data Set Requirement

esMD Definition Priority/Status

Conclusions

Individual Provider or Provider Organization Address

Location specified for the provider receipt of additional documentation requests

Low Unnecessary for electronic communications

Individual Provider Prefix Low Unnecessary

Payer or Payer Contractor Digital Certificate

Required Might 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

Page 4: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

eMDR Message (2/2)esMD Data Set Requirement

esMD Definition Priority/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 eMDRRequest 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

Low Unnecessary in structured approach

Page 5: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

General Request InformationesMD Data Set Requirement

Comments Priority/Status

Conclusions

Date of Request Date the eMDR was sent Low/Covered

277 includes a response due date and transaction date. These may be sufficient for esMD.

Cover Letter Text Low Unnecessary 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

Page 6: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Audit Specific InformationesMD Data Set Requirement

Comments Priority/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.

Required Submit change request to ASC X12

Page 7: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Claim Related InformationesMD Data Set Requirement

Comments Priority/Status

Conclusions

Provider Directory Address Required/Covered

Use existing support for URLs

Provider Directory ID High Use 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

TBD CMS – 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 TBD CMS – Unnecessary

Commercial - Need to review requirements

Page 8: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Claim Related Information (Claim Level Detail)esMD Data Set Requirement

Comments Priority/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 Covered 277 includes bill type as found in ASC X12N 837, CLM05 which reflects NUBC Form Locator 4

Place of Service High/TBD Submit to WEDI for community review and feedback

Diagnosis Code(s)Code Set UsedRelated Group Code

High/TBD Submit to WEDI for community review and feedback

Page 9: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Claim Related Information (Line Level Detail)esMD Data Set Requirement

Comments Priority/Status

Conclusions

Performing Provider NPIAlternate IDAlternate 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.

Required Submit to WEDI for community review and feedback

Provider Specialty Low

Line Level Diagnosis Code High/TBD Submit to WEDI for community review and feedback

Page 10: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Return Method ObjectesMD Data Set Requirement

Comments Priority/Status

Conclusions

Return Methods Code set that defines high level transport option that may be used for the return. Examples - Physical, Electronic Transaction, URI

Required Introduce 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

Page 11: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Summary of Analysis (1/3)

Covered:1. Date of Request2. Scope or Type of Audit3. Type of Bill4. Purpose of eMDR / Request Type5. Provider Directory Address

Unnecessary:6. Individual Provider or Provider Organization Address7. Individual Provider Prefix8. Request Type Reason9. Cover Letter Text10. Provider Specialty

Page 12: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Summary of Analysis (2/3)

Required:1. Payer or Payer Contractor Digital Certificate2. Payer or Payer Contractor Signature Artifact3. Unique Case Reference Identifier4. Performing Provider NPI / Alternate ID / Alternate ID Type5. Return Methods6. Electronic Service Information 7. Maximum Electronic Return Size per transaction8. Return Constraints9. Return Format(s)

Page 13: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

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 Code5. Provider Directory ID6. Maximum Electronic Return Size per transaction7. Return Constraints8. Program

Page 14: esMD Harmonization UC2 Data E lement Prioritization 8/1/2012

Next Steps1. Submit Change Request to X12 for Unique Case Reference Identifier2. Reach out to commercial payers for additional input on TBD Elements3. Submit Required Elements to WEDI for community review and feedback4. Submit Return Method Objects to CAQH CORE for review and feedback5. 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 X128. Submit necessary change requests to CAQH CORE9. Submit necessary change requests to Claim Adjustment Status Code

Maintenance Committee