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201809 Attachments

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to Jan 2019 Proposals


Attachments

Submitting WG/Project/Implementer Group

Attachments Work Group (AWG)

Justification

Electronic attachments are a high priority for processing claims and other payer/provider interactions. Current thinking has attachment submissions occurring via X12 transactions. However, there is substantial interest in experimenting with FHIR-based messaging for exchanging attachments. This track will explore the feasibility of this approach.

Proposed Track Lead

See Connectathon_Track_Lead_Responsibilities

  • Christol Green
    • Co-leads, Durwin Day

Expected participants

  • BCBS
  • HCSC
  • BCBSAL
  • Anthem
  • Optum
  • Hyland
  • ZeOmega
  • HealthLX
  • UHIN
  • Availity

Roles

Please include information here regarding how much advance preparation will be required if creating a client and/or server.

Payer

Plays the role of a payer who may request and receive attachments. This is loosely analogous to the "FHIR Client - Claims Attachment Requestor" and "FHIR Client - Claims Attachment Processor" roles in the Financial Management track, but with a focus on content instead of process.

Provider

Plays the role of a provider who may receive requests for attachments and send attachments (solicited or unsolicited). This is loosely analogous to the FHIR Client - Claims Attachment Submitter role in the Financial Management track, but with a focus on content instead of process.

Clearinghouse

Serves as an intermediary/aggregator between multiple parties (usually payers and providers), and thus needs to play both submitter and processor roles. The clearinghouse will need to change the sender/receiver information in the Communication and CommunicationRequest resources appropriately (i.e. when forwarding a request from a Payer to a Provider, the sender should be changed from the Payer to the Organization resource for the clearinghouse.

Scenarios

For all scenarios below, the following types of attachments are allowed:

  • PDF attachment
  • Unstructured C-CDA attachment
  • Structured C-CDA attachment
  • C-CDA on FHIR attachment

Below are some sample resources we can use during the Connectathon. Most of these will need to be linked to the CommunicationRequest and Communication resources you will create.

Patient

Clearinghouse

Payer

Provider

Claim

Extension (for attachment type) 

   <extension url="http://hl7.org/fhir/us/attachments/StructureDefinition/attachment-type">
       <valueCodeableConcept>
           <coding>
               <system value="http://loinc.org"/>
               
               <display value="Summarization of Episode Note"/>
           </coding>
       </valueCodeableConcept>
   </extension>

Here is a link to the main Connectathon 19 page with test servers, other tracks, etc.

http://wiki.hl7.org/index.php?title=FHIR_Connectathon_19

Solicited

Action: Payor sends an attachment request to the provider. Onus is on the payer to create the staple between the request and the attachment. Provider must return the payer's electronic staple (i.e. ID) with the attachment.
Here is an example of a request for an attachment from a payer:
http://hl7.org/fhir/communicationrequest-example-fm-solicit-attachment.xml.html
Here is an example of a solicited attachment from a provider (the payload would point to the PDF, C-CDA, or C-CDA on FHIR attachment):
http://hl7.org/fhir/communication-example-fm-solicited-attachment.xml.html
Precondition: None
Success Criteria: Provider receives the request, responds with the attachment, payer receives the attachment and is able to view it in their system.
Bonus point: Send to an adjudication engine in the Financial track.

Basic script for provider:

Basic script for payer:


Unsolicited

Action: Provider sends an attachment to the payer in support of a claim without a request. Onus on the provider to create the electronic staple (i.e. matching IDs) between the claim and the attachment. Here is an example of a Communication resource for an unsolicited attachment from a provider (the payload would point to the PDF, C-CDA, or C-CDA on FHIR attachment):
http://hl7.org/fhir/communication-example-fm-attachment.xml.html
Precondition: Prior agreement in place between payer and provider.
Success Criteria: Payer receives the attachment and is able to view it in their system.
Bonus point: Send to an adjudication engine in the Financial track.


Prior Authorization

Action: Provider creates an attachment and sends it to the payer. Here is an example of a Communication resource for prior authorization (the payload would point to the PDF, C-CDA, or C-CDA on FHIR attachment):
http://hl7.org/fhir/communication-example-fm-attachment.xml.html
Precondition: Prior authorization has occurred, and the provider has an id (i.e. electronic staple) to associate the attachment with the prior authorization request.
Success Criteria: Payer receives the attachment and is able to view it.
Bonus point: Send to an adjudication engine in the Financial track.

You may post this to http://www.pknapp.com:8081/con19/Claim/$submit and it will return an acknowledgement (ClaimResponse).

Then you can Post your attachment (Communication) to http://www.pknapp.com:8081/con19/Communication to release the Pre-Auth for adjudication and pick up the response via a ProcessRequest 'poll' or we can do for you.

I should have the updated code on pknapp.com within 15 minutes.


TODO: Paul, how does the payer respond to the provider with an auth number and other info?

TestScript(s)

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