The Designated Standard Maintenance Organizations Process July 2010

1. The Designated Standard Maintenance Organizations ProcessJuly 2010

2. Overview • What is the DSMO? • What does this mean in English? • How do I submit a change request? • What happens next? • Resources

3. What is the DSMO? • Designated Standard Maintenance Organizations (DSMO) • Organizations named by the Secretary (HHS) under HIPAA in § 162.910(a) to • Maintain standards adopted under HIPAA • Receive and process requests to adopt new standards or modify existing standards • Member Organizations are standards development organizations (SDOs) and data content committees • Accredited Standards Committee (ASC) X12 • Dental Content Committee of the American Dental Association (DeCC) • Health Level Seven (HL7) • National Council for Prescription Drug Programs (NCPDP) • National Uniform Billing Committee.(NUBC) • National Uniform Claim Committee (NUCC)

4. What is the DSMO? • Process for modification of existing standards and adoption of new standards must include: • Open public access • Coordination with other DSMOs • An appeals process for each of the following, if dissatisfied with the decision on the request: • The requester of the proposed modification. • A DSMO that participated in the review and analysis of the request for the proposed modification, or the proposed new standard. • Expedited process to address content needs identified within the industry, if appropriate. • Submission of the recommendation to the National Committee on Vital and Health Statistics (NCVHS)

5. What is the DSMO? • Process details defined through a Memorandum of Understanding (MOU) • MOU defines Guiding Principles • Public access (single point of entry) • Timely review of change requests • Cooperation and communication • Consider all viewpoints • Evaluate impact of change requests • Maintain a national perspective • Conform to legislation

6. What does this mean in English? • Public access portal for the submission of requests to: • Modify existing standard transactions adopted under HIPAA • Request new standard transactions for adoption under HIPAA • e.g. new business need or data need • e.g. data needs change from current transaction • Submission via Web or Paper • Web-based – reviewed in the following slides • Paper-based – see resources at end of presentation

7. How do I submit a change request? • Web-based process • Requester logs in to web site – requires creation of a login ID • Captures name, email address and contact information • Needed in the event that additional clarification of request is needed during the review process • Information available only to DSMO Secretary and Administrator • EXCEPT for email address, which is viewable on the public Web site • Nothing else distributed to DSMO members • Communication with requester generally occurs through the DSMO Secretary

8. How do I submit a change request? • Step-by-step process • Select request type • Enter Business Reason for change • Provide suggested revision to address the change • Receive DSMO Change Request (DSMO CR) ID # • Complete questionnaire form (X12N requests) • Identify additional guides that may be impacted by CR • Provide information relative to previous change request • CMS FAQs reviewed – Yes/No • Existing DSMO CRs reviewed – Yes/No • New request – Yes/No • Provide and related DSMO CR numbers

9. How do I submit a change request? • Step-by-step process (continued) • Complete questionnaire form (X12N requests) • Identify version, key page numbers and sections of the guide • Identify any specific areas and/or specialties of health care impacted by the request • Provide Subject Matter Expert and Alternate Contact information • Additional information regarding: • X12 group participation • X12 groups contacted • Other industry groups contacted • Information provided by any of the above

10. Create a Log in ID

11. Create a Log in ID

12. Create a Log in ID

13. Identify the Request Type

14. Identify the Business Reason for the Change Request

15. Identify the Suggested Solution for the Change Request

16. Change Request Number Provided

17. Provide Additional Detail for X12 Transactions: Other Implementation Guides Affected

18. Provide Additional Detail for X12 Transactions: Research Conducted

19. Provide Additional Detail for X12 Transactions: Specific Items Impacted in Implementation Guide

20. Provide Additional Detail for X12 Transactions: Other Health Care Areas Impacted

21. Provide Additional Detail for X12 Transactions: Requester Contact Information

22. Provide Additional Detail for X12 Transactions: Other Input Received

23. What happens next? • DSMO Change Request Process • Allows DSMO members to opt-in or opt-out of a change request • Review Process generates batches on a monthly basis • DSMO Review is a 90-day cycle • Details on the following slides • DSMO members may request one 45-day extension • Details on the following slides • Requester or DSMO member may submit an appeal to the DSMO response • Details on the following slides

24. DSMO Process Flow 90-day Batch Cycle Submitter enters Change Request , receives ID # (DSMO CR #) Becomes part of the batch created the next month DSMO Members Opt-in (or out) within 10 business days DSMO Members Review all recommended responses Reach a disposition on the DSMO CR Final Recommendation posted to the Web site DSMO Members have 90-calendary days to deliberate and develop recommendation for the response May request additional information from the requester during this time One 45-day extension may be requested by any DSMO Member Monthly Batch created and DSMO Members notified 5th business day of the Month Requester is notified that the DSMO recommendation has been posted Requester has 15 calendar days to appeal Appeal Submitted? No Yes Appeal Process See slide 29 DSMO CR is Final Recommendation sent to SDO CRs Appeal Remanded

25. DSMO Response Categories • Modifications necessary to permit compliance with the standard/law.According to DHHS, necessary items include: • Something in the adopted standard or implementation specification conflicts with the regulation. • A non-existent data element or code set is required by the standard. (removal of data content that is not supported by the healthcare industry any longer) • A data element or code set that is critical to the industry's business process has been left out. • There is a conflict among different adopted standards • There is an internal conflict within a standard (implementation guide).

26. DSMO Response Categories • Modifications.Classified as additions or deletions of data elements, internal code list values, segments, loops; changes in usage of segments, data elements, internal code list values; changes in usage notes;  changes in repeat counts; changes in formatting notes or explanatory language that do not fall into Category A. • Maintenance.Classified as items that do not impact the implementation of the transaction.  Items classified as Maintenance will require no further DSMO actions.  Items are to follow the SDO process. • No Change.Classified as items that the implementation guides do meet the needs requested, or did go through the consensus building process originally to meet need. May request follow up by the submitter for further action.

27. DSMO Response Categories • DHHS Policy.Classified as items that require follow up by the Department of Health and Human Services in regards to the Final Rule. • Withdrawn by Submitter.Classified as items that have been removed from Change Request System consideration. • Appeal.Classified as items where the DSMOs did not reach consensus on response and will follow the appeal process.

28. DSMO Response Categories • Industry Comment Request Process.Classified as items that require comments from the industry to determine consensus. • Recommendation for adoption of new/modified HIPAA standard.Classified as items that result in the recommendation to the National Committee on Vital and Health Statistics for the adoption of a new/modified HIPAA standard. Examples might include a request for a new transaction, or a new version or release of an already-named standard for a given transaction(s). • Out of DSMO Scope.Classified as items that are not in the scope of the DSMO. An example is change requests for modifications to transactions not named in HIPAA.

29. DSMO Appeal Process Denied Requester submits additional supporting documentation on their appeal Within 15 calendar days of Appeal declaration deadline CRs Denied Slide 30 Appeal Process DSMO Members deliberates appeal using additional information submitted Reaches disposition on the appeal within 30 calendar days Upheld CRs Upheld Slide 31 Requester is notified of the final DSMO recommendation One of three decisions Remanded to DSMO Members CRs Appeal Remanded Slide 24

30. DSMO Appeal Process: Appeal Denied CRs Denied Requester can file another CR with more information Requester can file comments in response to a NPRM Denied One of four actions Requester can discuss further with NCVHS No further action by Requester NPRM = Notice of Proposed Rulemaking

31. DSMO Appeal Process: Appeal Upheld CRs Upheld Upheld The DSMO will re-categorize the Change Request and provide a new recommendation Final Recommendation sent to SDO

32. DSMO Appeal Process Response Categories Appeal Outcome Available Soon Appeal Withdrawn Appeal Upheld Appeal Denied Appeal Remanded

33. Resources • DSMO Web sitewww.hipaa-dsmo.org • ASC X12 ADA DeCCwww.x12.orgwww.ada.org • NCPDP NUBCwww.ncpdp.orgwww.nubc.org • HL7 NUCCwww.hl7.orgwww.nucc.org

34. Resources: To Submit Change Requests via Mail