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Standards for Electronic Healthcare
Claims Attachments
E. Electronic Health Care Claims
Attachment Content and Structure
[If you choose to comment on issues
in this section, please include the
caption "ATTACHMENT CONTENT
AND STRUCTURE" at the beginning of
your comments.]
As noted, there are two separate
transactions associated with the
electronic claims attachment. One
transaction is a health plan's request for
health care claims attachment
information, and the other is the health
care provider’s response, which
includes submission of the attachment
information.
Each of these transactions contains
administrative information that
identifies the individual, date of service,
and other information that permits the
health care provider to identify the
appropriate individual and claim, and
enables the health plan to associate the
electronic attachment material with the
proper claim. In addition, the
attachment request must have an
unambiguous way to specify the clinical
or other information needed, and the
attachment response must have an
unambiguous way to label the
information being provided and to
convey responses in a consistent,
predictable manner.
Example: ABC Ambulance Company
submits a claim for transporting M.
Smith on a certain date. The health plan
cannot adjudicate the claim without
knowing M. Smith's weight. The health
plan sends a request for the individual's
weight to ABC Ambulance Company
and includes the individual's name,
date of service, type of service, the
control number it is using to identify the
claim, and other information that will
allow ABC to locate the individual's
record. This information, when returned
along with the response, will also
enable the health plan to associate this
new piece of data with the correct
claim. The ABC Company sends the
requested information back to the health
plan, it is associated with M. Smith's
claim, and the claim continues through
the adjudication process.
In this example, the health plan wants
the individual's weight as reported by
the individual (rather than an estimate
made by the attendants) expressed in
pounds, not kilograms. The request will
contain a code that reflects this exact
request, and the response will return the
code with the individual's weight,
expressed in pounds.
Thus, the standards we are proposing
for any of the named electronic
attachments types will specify:
- The administrative information
contained in the request and response;
- The attachment information (also
referred to as the additional information
specification) contained in the response;
- A code set for specifically
describing the attachment information;
- A code set modifier for adding
specificity to the request; and
- The format that will contain all of
this information.
The size of the file in the response
transaction will be impacted by the
option the health care provider chooses
for the submission—either text and
imaged documents or coded data. With
imaged documents, the size of the file
within a single response transaction
could become large. The
implementation guide for the X12 275
response transaction permits up to 64
megabytes of data in a single
transaction. Industry comment on file
size is also welcome.
In sum, the proposed standards are
those that have been under development
for over eight (8) years by the HL7 ASIG.
Meanwhile, the health care industry
itself has undergone significant change.
It is, therefore, critical that appropriate
industry representation reviews and
then weighs in on these standards: The
attachment content, and format, and the
transaction’s function. As discussed
throughout this preamble, we are
soliciting comments from all affected
covered entity types (covered health
care providers, health plans, health care
clearinghouses and Medicare prescription drug discount card
sponsors) and their business associates
(practice management vendors, software
vendors, document storage contractors
and others) about these proposed
standards. In this paragraph, we
reference Medicare prescription drug
discount card sponsors as a covered
entity. These organizations are
considered covered entities until 2006,
when the new Medicare prescription
drug program becomes effective. Based
on the timing of the electronic health
care claims attachments final rule, the
requirements of that final rule may or
may not be relevant to such
organizations.
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