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esMD Initiative Charter
Challenge Statement
CMS and other appropriate payers need a standardized, implementable, machine-interoperable electronic solution to reduce the time, expense, and paper required in current manual processing of both medical documentation request letters and the relevant claims attachments exchanged between providers to payers. To support the electronic sending of medical document request letters and the electronic submission of medical documentation, the following solutions will be required:
- Standardized Electronic template to be used for medical document request letters
- Process for Provider Registration with CMS to receive electronic request letters
- Secure sending of the medical document request letters to registered providers
- Verifiable alternative for wet signatures on electronic medical documentation: a method of verifying the origin and authenticity of data submitted to CMS for payment determination
- Standardized structured content for claims attachments*
* Structured Content for claims attachments is currently out of scope for the S&I Framework esMD Initiative, but is a long-term esMD objective, and may be addressed following the completion of other esMD priorities.
Purpose and Goals
The purpose of the S&I Framework esMD initiative is to enable the electronic sending of medical document request letters to providers, and identify author-level signature solutions needed to enable acceptance of electronic claims attachments. These goals will be addressed in multiple phases, aligned with CMS esMD Implementation objectives. The S&I Framework will support CMS’ esMD Phase 2 goals by developing simplified mechanisms to electronically send medical document request letters to providers. To support acceptance of structured claims attachments from providers to CMS (future esMD phase), the S&I Framework esMD Initiative will also develop solutions to enable signing of content records that can be trusted by CMS or other valid recipients, replacing the currently-used paper or scanned wet signatures.
Scope Statement
The Electronic Submission of Medical Documentation (esMD) Initiative intends to replace current paper processes for medical documentation requests and claims attachments with an electronic alternative. This initiative was begun to provide solutions that address gaps raised by CMS post-payment reviews specifically; however, through the participation of other relevant stakeholders, the outputs of this initiative will reflect the requirements of other payers, providers, and additional relevant stakeholders.
The initial phase of this Initiative will focus on the electronic sending of a structured medical documentation request letters, in alignment with CMS’ goals for the CMS esMD Phase 2 implementation. This initial phase will also investigate solutions for proof of authorship within electronic claims attachments, a key first step that will be needed before CMS can receive structured electronic claims attachments.
In order to address these needs, this Initiative will focus on the following three workgroups:
- Provider Profiles Authentication workgroup: Discusses the registration process, technical transport and authentication needed to allow CMS/Payers to identify Providers and send requests to them. This workgroup will be dependent on the Provider Directories (Use Case #2) outputs, as well as the Exchange support for secure transport and other infrastructure.
- Structured Content workgroup: Determine the structured electronic format of medical document request letters to be sent to Providers, with consideration for the expected response and fields needed to support the response
- Author of Record workgroup: Evaluate the business needs and discuss implementable solutions to prove the authorship and authenticity of any submitted claims content, to validate who takes responsibility for the document
This initiative will not address the following:
- Guidelines and Policies for the medical documentation request letter, including limitations on the frequency and volume of the request letters, and what scenarios will warrant a need for additional claims attachments
- Standards for Structured Content of claims attachments sent from providers to payers/CMS (however, this may become in scope for future phases of the esMD Initiative)
Value Statement
The value of the esMD Initiative will be to provide consensus-based use cases, functional requirements, standards and implementation specifications representing combined input from a broad range of stakeholders, including CMS, commercial payers, providers, and vendors. This will promote a nationally standardized approach to medical document request letters, claims attachments, and the proof of authorship of medical documentation.
The outputs of this initiative will ultimately be implemented by CMS, in the implementations of esMD Phase 2, 3 and other future releases. CMS implementations stemming from this initiative will also test provider directories and consolidated CDA solutions in a real world setting. It is intended that the outputs and implementations of this Initiative could be reused outside of CMS, such as within the Payer community. This initiative also benefits national interoperability by expanding the health IT infrastructure to incorporate and validate signatures as part of structured documents.
Both payers and providers will benefit from this Initiative’s implementation of electronic medical document request letters and claims attachments. Some of the benefits of replacing the current paper process with an electronic option include:
- Saving time, money and resources for CMS/Payers and Providers
- Eliminates print/mail operations required for sending or processing medical documentation request letters
- Eliminates need for postage costs
- Increases the accuracy of the information requested and received
- Improved receipt time for both providers and payers
- Improved timeliness results in improved accounts receivable cycle for provider, so payments are received sooner
- Reduced staff time spent handling paper
Potential Standards for Consideration
- ASC X12n Administrative Transactions, HL7 CDA, security and digital certificate standards
- HL7 Standards for Claims Attachments
- HL7 RM-ES Functional Profile for EHR requirements for medical records
- CAQH CORE Eligibility and Claim Status Operating Rules
- Other Standards as appropriate
Potential Risks
- Ensuring secure, trustable communications between CMS and providers
- Compliance with FISMA in sending PHI from CMS to providers
- Establishing policy regarding signatures or proof of content authorship within structured content
- Identifying implementable solutions to prove authorship that minimize burden to providers
- Inordinate amount of time trying to ensure CMS solution aligns with private payer solution
Stakeholders
- Providers, Provider Organizations (AMA, AHA)
- HIT/EHR Vendors and Vendor Associations (e.g. AHIMA, HIMSS)
- State HIEs, HIE Vendors
- HIHs, Claims Clearinghouse, HIOs, ROI Vendors
- Medicare, Medicaid, and Commercial Payers
- SDOs
- CAQH CORE
- DEA
- X12