Standards for Electronic Healthcare
Claims Attachments
H. Requirements (Health Plans, Covered
Health Care Providers and Health Care
Clearinghouses)
Health plans would be required to be
prepared to receive and send only the
standards specified in § 162.1915 and § 162.1925 for the identified
transactions. No other electronic
transaction format or content would be
permitted for the identified transactions.
We intend for covered entities to use the
standard transactions and the approved
attachment specifications as they apply
to the six named attachment types.
The use of the standard electronic
health care claims attachments would
not preclude the health plan from using
other processes or procedures to verify
the information reported in the
attachment documentation.
Under the proposed rule, health plans
may continue to use manual processes
(such as paper forms, letters, faxes, etc.)
to request additional documentation
from a health care provider, even for the
attachment types listed in this proposal.
However, whenever such a request is
made electronically, it must be made
using the standard. Furthermore, if the
health care provider asks that the
transaction be sent using the standard,
the health plan must comply.
As stated earlier, it is possible that
multiple AIS apply to a particular
electronic claim attachment request.
The clinical reports, medications, and
laboratory results AIS could be used to
request additional information about
any service in a particular claim.
However, the ambulance, emergency
department, and rehabilitation services
AIS can only be used to request
information about the specific type of
services to which they refer. When the
ASIG developed the first set of
attachment types, three were for specific
types of services—ambulance,
emergency department, and
rehabilitation. Since those services often
necessitated tests and reports, the
supporting attachment specifications—laboratory results clinical reports and
medications—were created. These latter
specifications also represented claim
types that were subjected to additional
documentation requests in their own
right, so the six together were a practical
fit. Thus, for example, if a health plan
needs additional information about an
ambulance service, and needs
information about the medications an
individual is taking in order to
adjudicate the ambulance claim, both
the ambulance and medication AIS
would be used and sent within the same
X12N transaction.
Covered Health Care Providers
We would require covered health care
providers to be prepared to receive and
send the standards specified in § 162.1915 and § 162.1925 for the
specific electronic health care claims
attachment transactions, if they choose
to receive and send requests and
responses electronically for any of the
six proposed attachments. No other
electronic formats would be permitted
for these specific business purposes. For
information required for other business
purposes, the standards proposed here
would not limit the type and format of
electronic or paper transaction could be
used. Health care providers generally
have the option of using paper as their
regular mode of communication. Any
information requested after the claims
adjudication process, such as for postadjudication
medical review or quality
assurance review, would not be subject
to the standards proposed here. In either
case, covered health care providers
would continue to have the option of
using electronic or manual means of
conducting business, including
responding to a request for attachment
information electronically or on paper.
However, if they choose to respond
electronically to an attachment request
for which a standard has been adopted,
that standard would have to be used.
Any electronic attachments covered
by the rule and that accompany a new
claim would have to be submitted based
on an advanced instruction from the
receiving health plan. These "unsolicited" electronic attachments
should not be sent without prior
agreement or understanding between
trading partners.
Health Care Clearinghouses
Health care clearinghouses would be
required to be prepared to receive and
send only the standards specified in §162.1915 and §162.1925 for the
specific electronic health care claims
attachment transactions, or to translate
proprietary information from their
clients into standard format for retransmission.
Health care
clearinghouses must already comply
with the requirements set out in §162.930, adopted by the Transactions
Rule.
1. Additional Information Specification
(AIS) Uses: Attachment Types That May
Be Used for Any Service
The proposed rule would require that
attachment requests, responses, and the AIS be used in the following situations,
when the transaction is being conducted
electronically:
a. Clinical Reports
Used when the health plan is
requesting, or the health care provider is
supplying, clinical report information
needed to support the adjudication of a
claim for any service. The request may
cover a wide variety of questions that
require information from clinical
reports, such as surgical and diagnostic
procedures and discharge summaries.
b. Laboratory Results
Used when the health plan is
requesting, or the health care provider is
supplying, information on laboratory
results needed to support the
adjudication of a claim for any service.
The request may cover the entire set of
laboratory tests, from allergy to
toxicology.
c. Medications
Used when the health plan is
requesting, or the health care provider is
supplying, information on medication
information needed to support the
adjudication of a claim for any service.
The request may cover medications
administered during a service,
medications sent home with the
individual, or medications currently
being taken by the individual.
2. Additional Information Specification
(AIS) Uses: Attachment Types for
Specific Services
a. Rehabilitation Services
Used when the health plan is
requesting, or the health care provider is
supplying, rehabilitation services
information needed to support the
adjudication of a claim that includes
one or more of the nine disciplines
designated for rehabilitation services
(for example, occupational therapy,
cardiac rehabilitation, or substance
abuse therapy).
b. Ambulance Services
Used when the health plan is
requesting, or the health care provider is
supplying, information needed to
support the adjudication of a claim that
includes ambulance services.
c. Emergency Department
Used when the health plan is
requesting, or the health care provider is
supplying, information needed to
support the adjudication of a claim that
includes emergency department
services.
3. Maximum Data Set
Each AIS is considered to include the
maximum data set for each of the named
electronic attachment types. We propose
to prohibit health plans from asking for
additional data beyond those that are
specified in the AIS for that service.
Four of the attachment specifications
(ambulance services, emergency
department, medications, and
rehabilitation services) have a finite set
of LOINC codes that can be used to ask
the questions (request the information)
for those services. The specifications for
Laboratory Results and Clinical Reports
do not contain pre-defined lists of codes
because clinical developments in those
two areas necessitate the ability to use
and request information about new tests
and reports. Any of the laboratory and
clinical reports codes in the LOINC
database could be used for these
requests and responses.
The proposed AIS documents were
drafted several years ago when business
practices related to health care claims
attachments were likely different than
they are today. Therefore, the electronic
health care claims attachment data
elements, questions, and the cardinality
of these elements must be validated for
each specification. It is imperative that
each AIS be thoroughly reviewed by
covered entities to ensure that the
proposed data set meets current and
projected future business needs. Thus,
we ask that during the comment period,
health plans and health care providers
engage fully in the process of evaluating
this maximum data set and the required,
situational, and optional elements, and
provide us with comments on these
issues.
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