AS_CDATEMPGD_R2_INFORM_2015DEC
HL7 Attachment Supplement Specification:
Exchange Implementation Guide Release 1
For use with:
Consolidated CDA Templates for Clinical Notes, Release 2 or
Additional CDA R2 Templates – Clinical Documents for Payers – Set 1
DEC 2015
HL7 Informative Document: Ballot
Sponsored by:
Attachments Work Group
Durwin Day, Co-Editor/CoChair
Craig Gabron, Co-Editor/CoChair
Robert Dieterle, Co-Editor
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Terminology / Owner/ContactCurrent Procedures Terminology (CPT) code set / American Medical Association http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/cpt/cpt-products-services/licensing.page?
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Logical Observation Identifiers Names & Codes (LOINC) / Regenstrief Institute
International Classification of Diseases (ICD) codes / World Health Organization (WHO)
Table of Contents
1 Important Notes: 3
Preface 10
1.1 Revision History 10
1.2 Acknowledgements 10
2 Introduction 11
2.1 Audience 11
2.2 Purpose 11
2.3 Scope 12
2.4 History 12
2.5 Approach 13
3 Background 14
3.1 Essential Reference Material 14
3.2 Understanding C-CDA 14
3.2.1 Clinical Document Architecture (CDA) 14
3.3 ISO Object Identifiers (OID’s) 15
3.4 Structured/Unstructured Content 16
3.4.1 Structured Content 17
3.4.2 Unstructured Content 17
3.5 Content Types 18
3.6 Base 64 Encoding Content 18
3.6.1 Standard for Base 64 Encoding 18
3.6.2 Uses of Base 64 Encoding 19
3.6.3 Base 64 Encoding Examples 19
4 AttachmentS -- generaL 19
4.1 Attachment Exchange 19
4.1.1 Solicited and Unsolicited Attachments 19
4.1.2 Request Attachment Activity 20
4.1.3 Response Attachment Activity 21
4.1.4 Understanding Attachment Activities 22
4.1.5 Attachment Request/Response Re-Association using Attachment ID 27
4.2 Standards to Accomplish Information Exchange of The Request and Response 29
5 LOINC (Logical observation identifiers name and codes) 30
5.1 Use of LOINC for Attachments 30
5.1.1 Obtaining LOINC and Other Resources From the Regenstrief Institute 31
5.2 Using the LOINC Code As An Identifier In Messages 32
5.3 Using the LOINC Database to Identify Valid Attachment Types 32
5.3.1 Identifying Valid Attachment Types In The LOINC Table 32
5.3.2 Identifying Valid Attachment Types Using RELMA and The Online LOINC Search Application (http://search.loinc.org) 33
5.4 Requesting LOINC Codes for New Attachment Types 35
5.4.1 Process for Requesting New Attachment Types 35
5.4.2 Updates to the LOINC database 35
6 Requesting/responding/submitting attachments 36
6.1 Unsolicited Attachment Exchange 36
6.1.1 Unsolicited Attachments with Claims Submission 36
6.1.2 Unsolicited Attachments with Prior Authorizations 36
6.1.3 Unsolicited Attachments with Notifications 36
6.1.4 Use of LOINC codes with Unsolicite Attachments 36
6.2 Solicited Attachment Exchange 36
6.2.1 Request and Response for Claims Submission 36
6.2.2 Request and Response for Prior Authorizations 36
6.2.3 Use of LOINC codes with Request and Response for Attachments 36
6.2.4 Using “Modifier LOINC Codes” to constrain the Request 36
6.3 Solicited Attachment Exchange 37
6.4 Requesting/Responding/Submitting Attachments 37
6.4.1 Using LOINC Code to Request/Respond Attachment (Solicited) 37
6.4.2 Using LOINC Code to Submit Attachments (Unsolicited) 39
6.4.3 Using “Modifier LOINC Codes” to Constrain The Request 39
7 Attachment Use Cases 41
7.1 Example – Claim Attachment 41
7.1.1 Claim Attachment – Solicited Attachment Example 41
7.1.2 Claim Attachment – Unsolicited Attachment Example 42
7.2 Example – Prior Authorization Attachment 43
7.2.1 Prior Authorization Attachment – Solicited Attachment Example 43
7.2.2 Prior Authorization Attachment – Unsolicited Attachment Example 44
7.3 Example – Referral Attachment 44
7.3.1 Referral Attachment – Solicited Attachment Example 44
7.3.2 Referral Attachment – Unsolicited Attachment Example 45
7.4 Example – Notification Attachment 47
7.4.1 Notification Attachment – Unsolicited Notice of Facility Discharge with Discharge Summary Example 47
7.5 Example – Post Adjudicated Claim Attachment 48
7.5.1 Post Adjudicated Claim Attachment – Solicited Attachment Example 48
8 Important information not Previously addressed in this supplement 50
Appendix A — Definitions, Abbreviations and acronyms. 52
Appendix B — Consolidated Clinical Document Architecture Release 2.1 (C-CDA R2.1). 54
B.1 Overview of Implementation Guide 54
B.2 Document Templates 54
B.3 LOINC Codes 54
What are C-CDA Document Types? 55
Appendix C — Clinical Documents for Payers – Set 1 Release 1.1 (CDP1 R1.1). 58
C.1 Overview of Implementation Guide 58
C.2 Document Templates 58
C.3 LOINC Codes 58
What are C-CDA Document Types? 59
Appendix D — C-CDA Document Transport and payload 62
D.1 Transport Options 62
D.2 Metadata requirements 62
D.3 Overview of X12 (real-time) 63
D.3.1 Security Metadata 63
D.3.2 Error Handling 63
D. 4 Overview of a payload over CONNECT with ASC X12N Message 64
D.4.1 ASC X12N 275 over CONNECT (CORE) 64
D.4.2 CONNECT SAML Assertions 66
D.4.3 IHE XD* Metadata 66
D.5 Overview of a payload over CONNECT with XDR 66
D.5.1 esMD Security Metadata 73
D.5.2 Error Handling 73
D.6 Overview of payload over Direct (X12 Message) 73
D.6.1 Overview of payload over Direct 74
Appendix E — ASC X12N Standards transaction and error flow 76
Appendix F — Fast Healthcare Interoperability Resources (FHIR) 78
F.1 What is FHIR 78
F.2 Introduction to FHIR Resources 78
F.3 Use of FHIR to solict and exchange Attachments 78
Table of Figures
Figure 1: Example - Claims Attachment (Solicited) 42
Figure 2: Example – Claims Attachment (Unsolicited) 42
Figure 3: Example – Prior Authorization (Solicited) 43
Figure 4: Example – Prior Authorization (Unsolicited) 44
Figure 5: Example – Referral Attachment (Solicited) 45
Figure 6: Example – Referral Attachment (Unsolicited) 46
Figure 7: Example – Notification Attachment (Unsolicited) 48
Figure 8: Example – Post Adjudicated Claim Attachment (Solicited) 48
Figure 71: X12 (real-time) 63
Figure 72: CONNECT with ASC X12N Specification 65
Figure 73: CONNECT w/ X12 275 67
Figure 74: Direct Message 74
Figure 75: Direct Message 74
Table of Tables
Table 1: Request Attachment Activity Table 20
Table 2: ASC X12N Attachments Activity Table 24
Table 3: Attachments ID Re-association Table 28
Table 4: Request and Response LOINC Code Usage for Solicited Structured Attachments 38
Table 5: Time Window Modifier LOINC Codes 40
Table 71: XD* Submission Set Metadata 68
Table 72: XD* Document Entry Metadata 69
Preface
1.1 Revision History
The following provides a historical view of the iterations for this document and why each major revision was made.
Date / Purpose /January 2015 / Version 1.0
March 10, 2015 / Version 1.1 Updated references to C-CDA and CDP1 RCD
Nov 23, 2015 / Version 2.0 Change Attachment use
November 30,2015 / Version 3.2 move CDP1 and C-CDA Rx to Appendices, Move defn .. to appendix, reorganize base on new outline
1.2 Acknowledgements
The writers and editors of this document want to acknowledge the years of hard work and dedicated efforts of the current and past members of the Attachments Special Interest Group (ASIG), the Structured Documents and Attachments Work Groups at HL7 in building forward the research and development needed to achieve the goal of information exchange amongst the provider community and health plans/healthcare insurance companies.
The information needs of the industry that were identified and developed over the years became key input into the foundational content found in the HL7 Implementation Guides for CDA Release 2: Consolidated CDA Templates for Clinical Notes Volume 1 Introductory Material and Volume 2 Templates and Supporting Material and Additional CDA R2 Templates – Clinical Documents for Payers – Set 1. These standards are expected to be widely used in the exchange of clinical information between providers as well as between providers and patients in satisfying many exchange criteria established under the Medicare/Medicaid EHR Incentive Program (aka, “Meaningful Use”).
This material contains content from LOINC® (http://loinc.org ). The LOINC table, LOINC codes, and LOINC panels and forms file are copyright © 1995-2015, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and are available at no cost under the license at http://loinc.org/terms-of-use.
2 Introduction
This guide is intended to be used in conjunction with the HL7 Implementation Guides for CDA Release 2: Consolidated CDA Templates for Clinical Notes Volume 1 Introductory Material and Volume 2 Templates and Supporting Material (referred to as C-CDA R2 in this guide) and Additional CDA R2 Templates – Clinical Documents for Payers – Set 1 (referred to as CDP1 in this guide) to describe to HealthCare industry stakeholders how to implement components of the C-CDA R2 and CDP1 for the purposes described in this guide in section 2.2 below. C-CDA Implemenattion Guides will jointly refer to C-CDA R2, CDP1 and other CDA implementation guides based on C-CDA R2. The combined set of document level templates defined in the C-CDA Implementation Guides will be referred to as C-CDA Documents in this guide.
This guide will serve to direct implementers to the appropriate HL7 implementation standard used to format the content based on the clinical document being exchanged as an Attachment. Refer to the Sections 3.0 & 4.0 in the C-CDA Implementation Guides for additional information regarding levels of constraint, conformance statements, conformance verbs, cardinality, vocabulary conformance, and null flavor.
2.1 Audience
The audience for this supplement are implementers responsible for the exchange of Attachments between healthcare providers (hereafter known as ‘providers’), health plans/utilization management organizations and/or their business associates (hereafter known as ‘payers’).
2.2 Purpose
This guide is intended to be used as a supplement to the C-CDA Implementation Guides. It provides guidance to implementers as they exchange additional supporting information needed amongst payers.
Examples of Healthcare Administrative Activities requiring this supporting information include, but are not limited to, Attachments additional information in suport of:
· a healthcare claim or encounter
· healthcare services review (e.g., prior authorizations/precertifications, referrals)
· post adjudicated claim audits
For the purposes of this supplement, healthcare supporting/additional information will be referred to as Attachments. Additionally, a healthcare claim or encounter may be
referred to as a Claim without mention of encounter. Throughout this supplement, Healthcare Administrative Activities will include any or all of the activities listed above.
Attachments are a means of electronically exchanging supporting information to augment each of the examples above. The ultimate goal of Attachments standardization in providing structured, standardized electronic data is to enable the fully automated exchange and processing of supplemental information in the various healthcare activities shown above. While some processes will always require human intervention, use of fully structured Attachments may significantly reduce human intervention and turnaround time for adjudication or resolution.