Announcements

• Thank you for your participation!! As of February 19th, 2013 the esMD eDoC (electronic Determination of Coverage) Workgroup Charter has been finalized. The document below as well as the text embedded within the Wiki reflects updates that were proposed and agreed upon during the formal Consensus Process. Please contact the Workgroup Lead or Support Lead if you have any remaining questions or concerns.

Electronic Determination of Coverage (eDoC) Workgroup Charter

Challenge Statement

The Centers for Medicare and Medicaid Services (CMS) and other Health Plans/Payers need a standardized, implementable, machine-interoperable electronic solution to reduce the time, expense, and paper required to document patient conditions as part of current processing of benefit determination based on payer coverage rules. The key challenges to be addressed include the following:
A. Define coverage determination documentation requirements as structured data sets and templates
B. Determine standards to enable provider (or service supplier) capture of documentation based on payer rules
C. Define decision support rules to facilitate provider decision making and preferred order management in light of payer standards
D. Determine secure exchange of documentation between payers, providers, suppliers and beneficiaries
E. Determine standards for digital signatures on transactions and documents
F. Identify standards, data requirements and process to allow a payer to indicate when a procedure or service may require prior authorization –will be considered during phase 2 or later phases if time and resources permit

Purpose Statement

The purpose of eDoC Workgroup is to define data sets, templates and standards in providing guidance with decision support, enabling provider capture of required structured documentation, and securely exchanging for benefit determination based on Health Plan/Payer’s coverage and payment rules. This eDoC Workgroup will extend to have sub-work groups to fulfill specific requirements for various use cases across Structured Data, Documentation Templates and Decision Support. This will include addressing the above mentioned key challenges by either leveraging the work that might have already been done or participating to work in conjunction with related S&I Framework initiative work groups such as Transitions of Care (Consolidated CDA), Provider Directories, Structured Data Capture, Health eDecisions, esMD Author of Record, Direct and Automate Blue Button Initiative.

Value Statement

The value of the esMD Initiative will be to provide consensus-based use cases, functional requirements, standards references and implementation specifications/guidance representing combined input from a broad range of stakeholders, including CMS, commercial Health Plans/Payers, Providers, and vendors. This will promote a nationally standardized approach to medical document request letters, claims attachments, and the proof of validity and authorship of medical documentation. 

Health Plans/Payers and Providers will benefit from this workgroup’s implementation guidance on electronic determination of coverage by moving away from current paper based or unstructured images of medical documentation for selected specific use cases pertaining to certain payment areas that are high in the list of interest to reduce improper payments and fraud. Additional benefits include:
A. Improved ability in determination of coverage with decision support guidance for providers
B. Standardized data sets, templates, structured data capture and secure exchange of required documentation as per payer coverage and payment rules
C. Saving time, money and resources for CMS, Commercial Health Plans/Payers, and Providers
D. Elimination of the paper or unstructured data processing and its associated labor and error rate
E. Guidance and recommendations on EHR Certification criteria for structured data capture
F. Improved accounts receivable cycle for Providers, so payments are received sooner
G. Reduced time for benefit determination and notification from Payer to Provider
H. Reduced staff time spent handling paper, printing, imaging and mailing

Objective

The eDoC Workgroup will prepare to work on specific determination of coverage requirements conforming to the selected use case in defining the corresponding data set requirements, templates, structured data capture and decision support needs accordingly. The Workgroup will strive to reuse as much as possible from other S&I initiatives and work groups and as well as from the completed use cases.

Workgroup Scope

This Workgroup will focus on defining the use case, user stories and requirements supporting a standards-based architecture. It will reuse existing S&I Initiative efforts where possible and create structured data capture templates and support exchange standards as needed. Power Mobility Devices will be the initial Use Case

Structured Data
A. Determine documentation requirements
B. Evaluate appropriate clinical elements
C. Evaluate appropriate Clinical Vocabularies
D. Define Consolidated CDA (CCDA) template

Documentation Templates
A. Define template requirements
B. Define template workflow
C. Define EHR data capture requirements
D. Specify storage requirements

Decision Support

A. Define rules to guide documentation
B. Define rules to present covered alternatives
C. Determine workflow issues

Targeted Goal & Outcome
A. Goal – Achieve provider/supplier documentation required for the electronic determination of coverage by payer’s rules in an efficient manner for payers and providers
B. Outcome
a. Successful pilot of templates, decision support, information exchange standards over standard secure transactions for the purpose of determining coverage
b. Validation with initial use case for Power Mobility Devices

Timeline
The Workgroup will use an incremental approach to address Structured Data Capture Templates and Decision Support that will build on the foundation of Structured Data defined in Phase 1 of the initial Use Case for Power Mobility Devices. It will coordinate the Discovery, Implementation and Pilot phases for completing both the PMD phases as per the proposed timeline below.

Relevant Policies
(List is exemplary and will be expanded during Use Case development)
A. CMS National Coverage Determination (NCD)
B. CMS Local Coverage Determination (LCD)
C. Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules
D. Applicable State regulations and laws
E. Applicable Federal regulations and laws
F. Specific Medicaid and Commercial Payer coverage guidelines

Potential Standards for Consideration

(List is exemplary and will be expanded during Use Case development)
Related S&I Framework Initiatives
A. Transitions of Care (Consolidated CDA)
B. Provider Directories
C. Structured Data Capture (SDC)
D. Health eDecisions (HeD)
E. Longitudinal Coordination of Care (LCC)
F. esMD Author of Record
G. Direct
H. Automate Blue Button Initiative (ABBI)

Specific Standards Development Organizations and Operating Rules Authoring Entities

A. ASC X12
B. CAQH CORE
C. HL7
D. IHE
E. OASIS
F. IETF
G. W3C
H. ISO
I. NCPDP
J. DICOM

Potential Stakeholders

(List is exemplary and will be expanded during Use Case development)
A. Medicare, Medicaid, and Commercial Payers
B. Providers, Provider Organizations
C. Service suppliers (e.g. DMEs)
D. Health Information Handlers (HIHs)
E. HIT/EHR Vendors and Vendor Associations
F. State HIEs, HIE Vendors
G. SDOs
H. CAQH CORE

Dependencies

A. Current standards and policies on determination of coverage set by CMS and Commercial Health Plans/Payers
B. EHR Technologies
C. Payer and contractor technologies
D. State and/or local regulations and laws
E. Federal regulations and laws

Potential Risks
A. Ensuring secure, trustable communications between Health Plans/Payers, Providers and their respective intermediaries, agents and business associates
B. Compliance with FISMA in sending PHI from Health Plans/Payers to Providers
C. Establishing policy regarding signatures or proof of content authorship Identifying implementable solutions to prove authorship that minimize burden to both Providers and Health Plans/Payers
D. Dependencies on schedule of and deliverables from other S&I initiatives
E. Lack of vendor (PMD and EMR) engagement in process

Works in Progress

All items below are artifacts associated with Electronic Determination of Coverage (eDoc) Workgroup Charter.