Product Claims Attachments

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Product Brief - Claims Attachments

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Product Name

Claims Attachments

Topics

Standard Category

Implementation Guides

Integration Paradigm

Documents

Type

HL7 IG, HITSP/HIPAA required

Releases

  • AIS0001: Ambulance Service Attachment
  • AIS0002: Emergency Department Attachment
  • AIS0003: Rehabilitation Services Attachment
  • AIS0004: Clinical Reports Attachment
  • AIS0005: Laboratory Results Attachment
  • AIS0006: Medications Attachment
  • AIS0007: Children's Preventive Health Services Attachment
  • AIS0009: Patient Information Unspecified Content Attachment

Summary

Standard Electronic Attachments, either to the claim or other healthcare transactions are a means of electronically exchanging additional information to augment another healthcare transaction, such as a healthcare claim, prior authorization, referrals, or public health reporting. Examples of such information include the clinical and administrative information often necessary to adjudicate claims for ambulance, rehabilitation, or emergency room services. The goal of Standard Healthcare Attachments is to make the process of submitting and adjudicating healthcare claims (and other transactions if desired) more efficient by providing structured, standardized electronic data to payers. In response to the federal mandate under HIPAA, HL7 and ASCX12 collaborated to develop standards for claims attachments. This joint development effort has resulted in standards for attachments to healthcare claims, and pre-certification / pre-authorization transactions. HL7 attachments standards are based on the Clinical Document Architecture (CDA) and have been proposed by the Department of Health and Human Services (HHS) as the standard for claims attachments under HIPAA. In the HHS proposal, six attachment types developed by HL7 have been put forward for adoption: clinical reports; rehabilitation services; laboratory results; medications; ambulance services; and emergency department.

Description

After seeing the model for use with claims attachments, the X12 Work Group addressing Pre-certification and Pre-authorization decided that these standards would also benefit their transaction (X12N 278). As a result we now have ability to do attachments for the X12 278 also. The HL7 standards referenced above are used to convey clinical and other supporting information. The model moves information from provider to payer, either unsolicited (attachment is sent with claim, or 278 for example) or solicited (request is made by payer for the attachment – in our solution it’s made by an X12N 277 transaction). Even though this initiative started out only as development of claims attachments, many different attachment needs have been expressed to the HL7 committee in the recent past. As time permits, these requests will be addressed. So far we’ve seen two very successful pilots of the claims attachments standards (that we know of), both of which moved into production. One case study is below. The payer sharing their story in this case study discusses how the success of their early adoption led them to roll this solution out to all of their Medicare providers, ahead of any Medicare requirement to do so. The HL7 attachment standards are based on the Clinical Document Architecture (CDA) and have been proposed by the Department of Health and Human Services (HHS) as the standard for claims attachments under HIPAA (Health Insurance Portability and Accountability Act of 1996). In the HHS proposal, six attachment types developed by HL7 have been put forward for adoption: Clinical Reports; Rehabilitation Services; Laboratory Results; Medications; Ambulance Services; and Emergency Department (ED), but we expect that the ED will be rolled into the Clinical Reports.

Business Case (Intended Use, Customers)

  • U.S. Payers
  • U.S. Providers

Benefits

For Providers

  • Predictable content allows anticipatory transmission of information and reduced payment delays due to requests
  • ROI available by reducing labor and cost of postage and paper
  • Reduced denials and rework for failure to provider additional documentation

For Health Plans

  • ROI available by reducing labor and cost of postage and paper
  • Reduced rework
  • Fewer pended claims for documentation requests


HL7 Attachments SIG created in 1997 in order to develop standards for claims attachments

  • HIPAA mandate
  • Collaborate with ASC X12 on 837 with 275/HL7 Attachment using CDA R1


Attachment types ultimately selected for development and HIPAA recommendation:

  1. Ambulance
  2. Emergency Department
  3. Rehabilitative Services
  4. Lab Results
  5. Medications
  6. Clinical Notes

Implementations/ Case Studies (Actual Users)

  • Wisconsin Physician Services (WPS),
  • Mayo,
  • Tricare

Resources

Work Groups

Education

Certification Available
  • none

Presentations

From HIMSS 2009

Relationship to/ Dependencies on, other standards

  • CDA R1

Links to current projects in development

Project Insight Project IDS:

  • 314 Additional Information Specifications 0011: Periodontal Attachment
  • 286 Children's Preventive Health Services Additional Information Specification
  • 282 Additional Information Specification 0008: Home Health Attachment
  • 281 Additional Information Specification 0010: Pharmacy Prior Authorization Attachment
  • 218 Patient Information Unspecified Attachment
  • 135 Additional Information Specification Documents Conversion from CDA R1.0 to CDA R2.0

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