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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

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Electronic submission of medical documentation esmd technical overview

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.


Agenda
Agenda Technical Overview

  • 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 as to whether X12 Message can be sent through the XDR Transactions.


Today s medical documentation process
Today’s Medical Documentation Process Technical Overview

Doc’ n Request Letter

Review Contractor

Paper Medical Record

Provider


The solution electronic submission of medical documentation esmd
The Solution: Technical OverviewElectronic Submission of Medical Documentation (esMD)

Phase 1:

Doc’n Request Letter

electronic

Phase 2:

electronic

electronic


CMS Does Technical OverviewNot 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

Onside Pickup

VPN

http://directproject.org

D I R E C T

http://wiki.directproject.org

D I R E C T


Esmd phase 1 in production september 2011
esMD Technical OverviewPhase 1 (In Production) : September 2011

Medicare

Recovery

Auditors

Doc’ n Request

Letter

Medicare

Administrative Contractors

PERM

PDF

PDF

PDF

DIRECT

CMS Private Network

Content Transport Services

SOAP Message with SAML/XDR

ECM

CONNECTCompatible

ECM Built by

SOAP Message with SAML/XDR

esMD

Gateway

Built by

esMD

Metadata

Database


Esmd phase 2 october 2012
esMD Phase 2: October 2012 Technical Overview

Medicare

Recovery

Auditors

Medicare

Administrative Contractors

PERM

PDF

Structured Electronic Requests for Medical Documentation

PDF

XML

PDF

DIRECT

CMS Private Network

Content Transport Services

SOAP Message with SAML/XDR

CONNECTCompatible

ECM

ECM Built by

SOAP Message with SAML/XDR

esMD

Gateway

Built by

esMD

Metadata

Database


Definition of an esmd package
Definition of an esMD Technical OverviewPackage

  • 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.

(http://www.connectopensource.org/product/connect-NHIN-specs)

(www.cms.gov/esMD)


Esmd technical details
esMD Technical Details Technical Overview

  • 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 within 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, responsesand 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


Current esmd xdr transport and translation mechanism
Current esMD Technical OverviewXDR Transportand Translation Mechanism


esMD XDR Implementation Technical Overview


Esmd xdr profile and its references
esMD XDR Profile and its references Technical Overview

  • IHE XDR Specification

  • NHIN Message Platform Specification

  • NHIN Authorization Framework Specification

  • NHIN Document Submission Specification

  • esMD XDR Profile

  • How does esMD implement the XDR Transport and Translation Mechanism?


Adapting connect 3 1 xdr deferred document submission transportation and translation mechanism
Adapting CONNECT 3.1 XDR (Deferred Document Submission) Transportation and Translation Mechanism


Esmd xdr document submission message flow in deferred message mode
esMD XDR Transportation and Translation MechanismDocument Submission Message Flow – In Deferred Message Mode

  • Using the Health Information Handler (HIH) Gateway, the 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:


Sample message xdr document submission soap envelope
Sample Message: XDR Document Submission SOAP Envelope Transportation and Translation Mechanism


In sept 2011 esmd successfully implemented the ihe xdr profile with inbound adr use case
In Sept 2011, esMD Transportation and Translation Mechanismsuccessfully implemented the IHE XDR Profile with inbound ADR Use Case.

  • So, What's Next?

    • Future esMD Use Cases

    • How will esMD accommodate ASC X12 transactions?

      • Does CONNECT Support ASC X12 Transactions?

      • Are there any NHIN profiles to support the ASC X12 Transactions?

    • How will esMD 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 Transportation and Translation Mechanism

Current and Future Use Casesfor 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

  • etc

  • LOOKUP

  • Request\Receive Documentation Status

  • Request\Receive Claim Status

  • Request\Receive Appeals Status

  • Request\Receive Eligibility Info

  • etc


How to accommodate ASC X12 transactions Transportation and Translation Mechanismthrough the esMD Gateway?

  • Need to build CAQH Transport service (Parallel to XDR) in the CONNECT software by adopting Phase II CORE 270: Connectivity Rule version 2.2.0 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.


esMD Transportation and Translation MechanismXDR & CAQH CORE Transport and X12 Translation Mechanism


Sample Message: CAQH Transportation and Translation MechanismPhase II CORE 270: Connectivity Rule version 2.2.0 - X12 824 Application Advice Forwarded Acknowledgment SOAP Envelope


Enhance CONNECT 3.1 with Transportation and Translation MechanismCAQH Phase II CORE 270: Connectivity Rule version 2.2.0 Transport Mechanism and esMD X12 Translator


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



Questions for more information please contact
QUESTIONS? CAQH CORE Connectivity For more information, please contact:


esMD System Architecture CAQH CORE Connectivity

CMS QSSI esMD Project Confidential Document – Pl. contact Manoj Chaganti, [email protected] , 847 903 5432

XDR & X12 HIH

XDR HIH

X12 HIH

…..

< -- X12 Trading Partner Agreement

(TPA) Use Case --

…..

------ X12 Appeals Use Case --- 

------XDR Orders 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


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