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Automate Blue Button Initiative Payor Workgroup Meeting. October 12, 2012. Meeting Etiquette. From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute . All Panelists . Remember: If you are not speaking, please keep your phone on mute

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meeting etiquette
Meeting Etiquette

From S&I Framework to Participants:

Hi everyone: remember to keep your phone on mute 

All Panelists

  • Remember: If you are not speaking, please keep your phone on mute
  • Do not put your phone on hold. If you need to take a call, hang up and dial in again when finished with your other call
    • Hold = Elevator Music = frustrated speakers and participants
  • This meeting is being recorded
    • Another reason to keep your phone on mute when not speaking
  • Use the “Chat” feature for questions, comments and items you would like the moderator or other participants to know.
    • Send comments to All Panelists so they can be addressed publically in the chat, or discussed in the meeting (as appropriate).


announcements and reminders
Announcements and Reminders
  • Meeting Reminders
    • Payor Workgroup Meetings are Fridays from 1:00 – 2:00 pm Eastern.
    • The next Community Meeting will be held on Wednesday, October 17, 2012.
    • Meeting information is on the Automate Blue Button Wiki Page:


sub group payor content
Sub-Group: Payor Content

A payor- or PBM-generated Blue Button file must be

both human-readable and machine-readable (interoperable).

Use Cases

A patient can download a copy of his/her

Medical & Rx Claims records, read & print them out

A patient can point an application or service to their Blue Button file and parse it for value-added function, e.g. education; clinical decision support; personal finance

  • File content standard must allow for common data elements in Blue Button ASCII files today
    • Eligibility Dates
    • Diagnosis Codes
    • Procedure Codes
    • Rx Codes
    • Financial Information
  • Leverage existing elements defined by public & private payors
  • Leverage existing standards if possible e.g. X12, HL7, cCDA extension
  • Produce implementation guidance
  • Need for practical, lower-effort & low-maintenance standards that can be implemented, e.g. using existing standards
  • Should be of value to downstream developers, e.g. personal health finance applications, education, decision support providers
  • Should have sufficient data to be of some clinical utility
health financial data issues raised so far
Health Financial Data: Issues Raised So Far

Health Financial Data

  • Is Financial data in-scope?
    • Unlike “traditional” clinical health data
    • Patient advocate organization represented in broader ABBI community meetings have expressed it as a priority, however
    • Could be a “home run” for the ABBI Community if it enables more affordable care. But if not us, who else will tackle this?
    • Solutions are out-of-scope; data standards & interoperability in-scope, and pre-requisite for 3rd-parties to create solutions.
  • How are patients getting it today?
    • Explanations of Benefit (EOBs)  concern about proprietary network discounting information, may need QH Policy-like stipulations!
    • Limited electronic access today (mostly PDF and/or “scraping” aggregators like Simplee & Cake Health)
implications for healthcare affordability
Implications for Healthcare Affordability

Comments from Keith Boone

  • [Patients will not only] be able to track all of their clinical data, but they'll also be able to track costs of particular illnesses.
  • The apps this content will support will be able link EOB data back to clinical data, so that patients can understand the true cost of a given diagnosis.
  • Patients could also agree to share the content anonymously to third parties (in exchange for other services using that data).  
  • Thus, a patient could give access to anonymized data that links services, diagnoses and costs, to particular aggregators.  
  • The aggregators could agree (similar to the QH Policy Sandbox) to certain stipulations on use of the data, with the patient.  See
  • The aggregator would then be able to analyze and generate cost information for illness, by provider, payer, policy and region.  Such data could be used to enable patients to obtain:
    • For a given diagnosis and plan, average costs for services and providers in their region.
    • For given diagnoses, the expected annual out-of-pocket costs for providers that the patient uses, based on historical data.
  • The upside for payers is that access to such data across payers will enable them to drive costs downward.

Source: “What ABBI can do for Healthcare Cost Transparency”, 9/13/12,

implications for personal healthcare quality
Implications for Personal Healthcare Quality

Claims data-driven analytics focused on Clinical Decision Support & Quality are currently available to large self-insured employers, but not directly to consumers

Through analysis of “rough” ICD-9, CPT, and NDC-coded data, these existing organizations can run “n-of-1” quality measures for individual patients & consumers.

implications for personal health affordability
Implications for Personal Health Affordability

Claims data-driven cost prediction is currently available to insurers & large employers, but not yet directly to consumers

Individuals may be able to help predict & budget for their health care spending needs, if they have a level-playing-field & access to the same data used by actuaries & underwriters.

use cases in blue button app ecosystem
Use Cases in Blue Button “App Ecosystem”

Emerging Blue Button App & Service Categories

  • Patient education
  • Care Coordination & PCMH activities & services
  • Quality-related applications & services for Accountable Care Organizations
  • Clinical decision-making, for both evidence-based decisions as well as preference-sensitive care
  • Finding and understanding more affordable care options (e.g. brand vs. generic medication)
  • Forecasting and planning a personal healthcare budget
  • Chronic disease management, including personal health tracking (e.g. diabetes)
  • Medication reconciliation & adherence tools
  • Integrity (errors, fraud & abuse) detection and assistance services
  • Patient-provider communication and scheduling (e.g. automatic pre-population of initial visit forms, triage of health issues, and scheduling & transportation support)
strawman 1 mymedicare gov blue button
Strawman 1: Blue Button Blue Button Data File

Current footprint = ~35 million eligible lives

  • Demographics
    • Name
    • DOB
    • Address
    • Phone
    • Email
  • Eligibility
    • Effective Date(s)
    • Plan Contract ID(s)
    • Plan Period(s)
    • Plan Name(s)
  • Claims Summary
    • Claim ID
    • Provider ID
    • Service Dates
    • Financial data by claim
      • Charged
      • Approved
      • Paid
      • Patient may be billed
    • Diagnosis Code(s)
    • NDC Drug Code(s)
    • CPT Codes
    • UB04 Codes
    • NPI Codes
  • Include clinical quality data
  • A Codes – unbilled codes used for quality reporting
strawman 2 x12 835 health care claim payment advice
Strawman 2: X12 835 : Health Care Claim Payment/Advice

X12 835 Version 5010 : required for nearly every insurance transaction

  • Header Level
    • Amount
    • Payee
    • Payer
    • Trace number
    • Payment method
  • Detail Level
    • EOB information
    • Adjudicated claims and services
  • Summary level
    • Provider adjustment
potential standards
Potential Standards
  • Standards for sharing claims information with beneficiaries
    • ASC X12 835 (Electronic Admittance Advice) - Health plan that contains multiple patient information to one provider
    • NCPDP D.0 telecommunication for pharmacy claims and remittance
    • ASC X12 837 (Health Care Claim Transaction Set) - File of 837 claims from a healthcare provider will contain multiple claims destined to either one payer or clearinghouse for multiple payers
      • Claim Submission
      • Post Adjudicated Claims
    • No EOB standard identified other than above
      • Typically a proprietary format exchanged
        • Minnesota print standard format
  • Other standards being considered for payer exchange of clinical information
    • Claims attachment to CCD
    • Payer data mapping to CCD
    • PHR to PHR standard being developed by HL7 / WEDI


strawman 3 create a new cda eob template
Strawman 3: Create a new CDA EOB template

Potential XML template for CDA Implementation Guide

  • Insurer Information
    • Payer ID
    • Name
    • Policy Info
  • Patient Info
    • Identifier
    • Name
    • Address
  • Provider Info
    • NPI
    • Identifier
    • Name
    • Address
  • Diagnosis Table
    • Diagnosis
    • Service Performed
    • Date(s) of service
    • Price billed
    • Negotiated Price
    • Amount Paid
    • Patient Responsibility
    • Notes
  • See
generic components of an eob
Generic components of an EOB
  • Payer’s Name & Address
  • Provider of services
  • Dates of service
  • Services or procedure code numbers
  • Diagnosis codes and/or Rx codes
  • Amounts billed by the provider
  • Reductions or denial codes
  • Claim control number
  • Subscriber’s and patient’s name and policy numbers
  • Analysis of the patient’s total payment responsibility
    • Amount not covered
    • Co-payment
    • Deductibles
    • Coinsurance
    • Other insurance payment
    • Patient’s total responsibility
  • Total amount paid by the payer
next steps reminders
Next Steps & Reminders
  • Homework
    • Please come back to next meeting (10/19) with the standard that your current blue button file is getting pulled from. Be ready to present your sample blue button file. Consider sharing it on wiki / send to organizers to post in advance.
    • Everyone: please send or post at least one comment on each straw-man standard so far. Please focus on utility & feasibility of implementing as a standard for payor-generated Blue Button.
  • WEDI 2012 Fall Conference
    • Health IT Business & Policy Impact
    • Monday, October 22
reminders contact
Reminders / Contact
  • Meeting Reminders
    • The next Community Meeting will be held on Wednesday, October 17, 2012.
    • The next Payor Workgroup Meeting is Friday, October 19, 2012 @ 1:00 pm Eastern.
  • For questions, please contact your support leads
    • Initiative Coordinator: Pierce Graham-Jones (
    • Presidential Innovation Fellows: Ryan Panchadsaram (; Henry Wei, MD ( for Payor WG
    • Project Manager: Jennifer Brush (
    • S&I Admin: ApurvaDharia (