Operating Rules for Attachments. Mary Lynn Bushman, NGS Durwin Day, HCSC Theresa Doris, TIBCO

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1 Operating Rules for Attachments Mary Lynn Bushman, NGS Durwin Day, HCSC Theresa Doris, TIBCO

2 What are Operating Rules? Operating Rules as defined by CAQH Core are the business rules and guidelines for electronic exchange of information not defined by a standard or implementation specifications: Address gaps and optionality in message format standards Address security needs Describe uses for code sets and vocabularies if not defined by the standard Require types of infrastructure offerings or transmission modes Recommend workflows for different business scenarios such as when to send unsolicited attachments, or when to use webenabled electronic attachments Provide requirements for business documents flow and formatting Supplement content for solving issues such as using trace numbers to link sender and receivers

Address gaps and optionality in message format standards Address security needs Describe uses for code sets and vocabularies if not defined by the standard Require types of

3 Possible Items for Operating Rules to Cover Unsolicited Attachment Solicited Request limited to the X and 278 Transactions Support of Structured or Unstructured Attachments Phase Implementation by Types of Documents Supported for Unstructured (ex, PDF, DOC, TIF, JPEG, etc. MIME and BASE64 Supported Versions Envelope Structure (X12 275, IHE Profiles) Transport differences Attachments EHRs (EDI, Direct, CONNECT) Others?

of Documents Supported for Unstructured (ex, PDF, DOC, TIF, JPEG, etc.

4 Requesting Attachments Solicited: Payer sends an electronic request to the provider Use the X Request for Additional Information Use the X Request for Additional Information and / or Other: IHE Profile Must contain metadata as described in HL7 Supplemental Guide to C-CDA for Attachments Unsolicited: Payer pre-defined conditions when a provider must always include a specific attachment document with the claim. Example: When submitting a claim with procedure code modifier 22 or 62 the Operative Note must be sent Use the X Additional Information to support a Claim Use the X Additional Information to support a Health Care Services Review HL7 C-CDA w/header and metadata (Could use IHE profile)

provider must always include a specific attachment document with the claim.

5 Any Operating Rules for the Request? 1) Could the Solicited Request be limited to using the X and 278? 2) Could both Solicited and Unsolicited methods be implemented at the same time? Or phased? 3) Are there common operating rules that can be adopted for implementing the Unsolicited method (Criteria for when a certain type of attachment must accompany the claim)? OR Should unsolicited attachment policy be defined by each payer 4) Should the Operating Rules define which LOINC codes could be used for unsolicited attachments. Could this rule be optional. 5) Others?

3) Are there common operating rules that can be adopted for implementing the Unsolicited method (Criteria for when a certain type of attachment

6 Attachment Response The HL7 clinical data can be: Structured Use HL7 Consolidated CDA Defined Content for 8 documents XML header and body (constrained by HL7 RIM) Conformance statements identify required and optional data LOINC Codes identify document type, sections and entries OIDs identify document Computer processed and validated Render human readable Unstructured Use HL7 Consolidated CDA XML header and imaged body No required and optional data LOINC Codes identify document type Stored images Human readable

sections and entries OIDs identify document Computer processed and validated Render human readable Unstructured Use HL7

7 Any Operating Rules for the Response Support of Structured or Unstructured Attachments 1) Could the Operating Rules define requirements for the use of structured attachments? 2) Could the Operating Rules define requirements for the use of unstructured attachments? 3) Should Operating Rules be silent on structured and unstructured attachments?

8 Possible Items for Operating Rules to Cover Phase in Implementation for Attachment Types Should Operating Rules define a required phase in approach for attachments? By attachment type. For example, Operative Reports implemented first followed by the Discharge Summary. By solicited vs unsolicited (as discussed on slide #5) By structured vs unstructured

9 Possible Items for Operating Rules to Cover Types of Documents Supported for Unstructured (ex, PDF, DOC, TIF, JPEG, etc. Should the Operating Rules define the document types which payers are required to support? Should the payers be required to support all document types

Should the Operating Rules define the document types which payers

10 Possible Items for Operating Rules to Cover MIME and BASE64 Supported Versions Since several versions of MIME are available on the internet, should the Operating Rules define the version to be used? Since several versions of Base64 are available on the internet, should the Operating Rules define the version to be used?

Operating Rules define the version to be used?

11 Possible Items for Operating Rules to Cover Envelope Structure (X12 275, IHE Profile, etc.) If the Attachment Regulation is not clear on the envelope structure to be used to send the clinical data, should the Operating Rules provide guidance?

) If the Attachment Regulation is not clear on the envelope

12 Possible Items for Operating Rules to Cover Transport (CORE Connectivity Rule, EDI, Direct. CONNECT) If the Attachment Regulation is not clear on the selection and use of transport to send the clinical data, should the Operating Rules provide guidance?

CONNECT) If the Attachment Regulation is not clear on the

13 Other thoughts? Open Discussion

14 Wrap Up What s next? Questions?

15 Contact Information Mary Lynn Bushman, National Government Services, INC Office Durwin Day, Health Care Service Corp. Office Theresa Doris, TIBCO Software INC. Office

com Office 717-565-3697 Durwin Day, Health Care Service Corp.

14 million. 4th largest U.S. Who is HCSC 9/7/2015. Cultivating EDI into E-Solutions HEALTH DENTAL LIFE DISABILITY CONNECTIVITY PHARMACY HEALTH IT

14 million. 4th largest U.S. Who is HCSC 9/7/2015. Cultivating EDI into E-Solutions HEALTH DENTAL LIFE DISABILITY CONNECTIVITY PHARMACY HEALTH IT Cultivating EDI into E-Solutions HL7 Attachment Standards HL7 C-CDAr2 vs. CDP1 Blue Button Plus HL7 FHIR Durwin Day, Health Care Service Corporation September 14, 2015 1 Who is HCSC HEALTH DENTAL LIFE