1. Introducing Electronic Submission of Medical Documentation (esMD)
2015
Introducing Electronic Submission of Medical Documentation (esMD)
to Providers, Review Contractors, and Health Information Handlers (HIHs)
The Centers for Medicare & Medicaid Services (CMS)
Office of Financial Management (OFM)
Provider Compliance Group (PCG)
Division of Compliance Projects and Demonstrations (DCPD)

2. Benefits of using esMD Quicker turnaround:
Providers have reported the payment turnaround when using esMD is 6 days as opposed to the paper process which is approximately 3 weeks.
Reduce labor costs:
esMD helps to reduce the amount of labor required to fulfill these requests by no longer having to print and mail paper, feed a fax machine or burn CD’s.
Reduced hard costs:
esMD can also reduce hard costs like shipping and handling expenses.

3. Background facts about improper payments
The CMS Office of Financial Management estimates that:
The fiscal year (FY) 2014 Medicare Fee-for-Service (FFS) program improper payment rate was 12.7 percent, representing $45.8 billion in improper payments.
The FY 2013 Medicare FFS program improper payment rate was 10.1 percent, representing $36.0 billion in improper payments.
Most improper payments can only be detected by a human comparing a claim to the medical documentation.
Medicare Fee-for-Service 2013 Improper Payments Report

4. Background facts about medical documentation requests
Medical Documentation Requests are sent by:
Medicare Administrative Contractors (MACs) Medical Review (MR) Departments
Comprehensive Error Rate Testing Contractor (CERT)
Payment Error Rate Measurement Contractor (PERM)
Medicare Recovery Auditors (formerly called RACs)
Supplemental Medical Review Contractor (SMRC)
Claim review contractors issue over 2 million requests for medical documentation each year.
Claim review contractors currently receive most medical documentation in paper form or via fax.
Medical documentation requests are also sent by:
Overseen by:
MAC Cost Report Audit Departments
OFM/FSG
Coordination of Benefit Contractors
HITECH Auditors
QIOs
OCSQ
QICs CM

5. The solution: Electronic Submission of Medical Documentation (esMD)
Phase 1:
Doc’n Request Letter
electronic
Went live Sept 15, 2011
electronic
Phase 2:
Planned for Future Release

6. Pre-esMD paper medical documentation process
Doc’ n Request Letter
Review Contractor
Paper Medical Record
Provider

7. Administrative Contractors
esMD phase 1: September 2011
Medicare
Administrative Contractors
Medicare
Recovery
Auditors
Doc’ n Request
Letter
PERM
CERT
PDF
PDF
PDF
PDF
CONNECT Compatible
CMS Private Network
Content Transport Services
EFT
Gateway
Built by
EFT built by TIBCO

8. esMD phase 2: Future release
Medicare
Administrative Contractors
Medicare
Recovery
Auditors
ZPICs
PERM
CERT
Structured Electronic Requests for Medical Documentation
PDF
PDF
PDF
PDF
PDF
CMS Private Network
Content Transport Services
EFT
CONNECT Compatible
EFT built by TIBCO

9. Current and future use cases for esMD
INBOUND Use Cases Submitted through esMD (esMD Phase 1)
Responses to Documentation Request Letters in PDF
Power Mobility Device (PMD) Prior Authorization Requests in PDF
1st level Appeal Requests in PDF
Advance Determination of Medicare Coverage
Prior authorization request for ambulance in PDF
Prior authorization request for HBO in PDF
Prior authorization request in X12 278
Structured Orders, Progress Notes
Structured esMD Phase 2 Registration
OUTBOUND (esMD Phase 2)
Structured Outbound Documentation Requests
Power Mobility Device (PMD) Prior Authorization Responses
Prior authorization responses
Review Results Letters
Demand Letters
LOOKUP (Future Phase)
Request\Receive Documentation Status
Request\Receive Claim Status
Request\Receive Appeals Status
Request\Receive Eligibility Info
We Are Here
We Are Here

10. Prior Authorization (PA) of Power Mobility Devices (PMD) submissions through esMD
EFT
EFT built by TIBCO
Prior Authorization Requests may be submitted directly to CMS via esMD. A Durable Medical Equipment (DME) supplier will obtain a letter of medical necessity and preauthorization from the provider and will submit the request for approval of health care based on medical necessity via esMD to CMS. The supplier will obtain preauthorization from the DME MAC before the request for DME is processed.

11. Definition of an esMD package
A portion of a patient’s medical record in esMD format which will contain:
Imaged documents (PDF)
Important Metadata Fields:
Intended Recipient – Required field
Claim ID – Required field for ADRs only
optional for First Level Appeals requests
not used for Prior Authorization Requests
NPI – Required field
Case ID – Required field, if known
Document Type Code – Required field
Response to Additional Documentation Request (PDF)
Power Mobility Device (PMD) Prior Authorization Requests (PDF)
Advance Determination of Medicare Coverage (ADMC)
First Level Appeal Requests (PDF)
Non-Emergent Ambulance Transport
Detailed description for each field can be found in:
the esMD XDR Profile.
the esMD Implementation Guide. ( (

12. esMD is not mandatory for providers
CMS recognizes that not all providers are adopting HIT solutions at the same pace.
HIT Adoption Rate
Late Adopter
Still using paper records.
Intends to rely on fax machines, USPS, FedEx, etc. for the for the next 10 years.
Average Adopter
Using imaged & electronic records.
Will wait to see which esMD Service Providers emerge in their area (and at what price).
Early Adopter
Has used EHRs for years.
Ready for esMD now!
Review contractors cannot target providers for medical review just because they use esMD, CMS Program Integrity Manual Chapter 3, Section

13. esMD statistics
As of February 20, 2015, over 84,477 providers have signed up with an esMD HIH.
As of February 20, 2015, over 1,199,038 medical records have been submitted through the CMS esMD Gateway.

14. The eHealth exchange (formerly Nationwide Health Information Network)
Is a set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the public internet.
Is overseen by the Office of the National Coordinator for Health IT (ONC)
Includes a standard for a secure “Gateway”
Are not funded by CMS or ONC
CMS
Dallas Area
Providers
esMD transactions are SAFE and SECURE because
the esMD system uses NHIN standards

15. CMS esMD Gateway
CMS
Dallas Area
Providers
CMS has built an Exchange Gateway to accept esMD transactions from providers.
The CMS esMD Gateway went live September 15, 2011.
CMS uses the “CONNECT” brand of gateway.

16. esMD is open to providers and
provider networks:
May communicate directly with providers, or
May communicate through entities who have formed a provider network

17. Medicare and Medicaid review entities can join the eHealth exchange
Option 1:
Join esMD
Option 2:
Build your own Gateway
Option 3:
Hire a Health Information Handler (HIH)
or join a Health Information Exchange (HIE)
(see slide 24 for more information)

18. Providers who want to submit via esMD
STEP 1: Find out if your Review Contractors accept esMD STEP 2: Obtain access to an esMD “gateway”

19. Step 1: CMS Review Contractors that accept esMD
Approved CMS Review Contractors
Region A Medicare Recovery Auditor
JA DME Durable Medical Equipment MAC
Region B Medicare Recovery Auditor
JB DME MAC
Region C Medicare Recovery Auditor
JC DME MAC
Region D Medicare Recovery Auditor
JD DME MAC
J5 Medicare Administrative Contractor (MAC)
Zone 1 Zone Program Integrity Contractor (ZPIC)
J6 MAC
Zone 2 ZPIC
J8 MAC
Zone 3 ZPIC
J10MAC
Zone 4 ZPIC
J11MAC
Zone 5 ZPIC
J15 MAC
Zone 7 ZPIC
JE MAC
U.S. Railroad Retirement Board (RRB)
JF MAC
Supplemental Medical Review Contractor (SMRC)
JH MAC
Comprehensive Error Rate Testing (CERT)
JK MAC
Program Error Rate Measurement (PERM)
JL MAC
JN MAC
For updated list, visit:

20. esMD Review Contractors
Participate voluntarily
Receive no funding from CMS or ONC
Attend calls with CMS (scheduled)
Obtain connectivity to the Electronic File Transfer system
Successfully onboard and test with the CMS esMD team

21. Step 2: How can providers obtain access
to a Gateway?
Providers can build their own gateway
Providers can contract with a Health Information Handler (HIH)

22. CMS-certified HIHs that offer esMD “Gateway” services
CMS Certified esMD HIHs
IVANS / ABILITY Network
Bluemark, LLC
Cobius Healthcare Solutions
Craneware
Dorado Systems
Episode Alert
eSolutions, Inc.
HealthPort
IOD Incorporated
LOISS, Ltd.
Medical Electronic Attachment (MEA)
MedFORCE Technologies
MRO
Proficient Health
Rycan Technologies, Inc.
RISARC
SSI
SunCoast RHIO, Inc.
Verisma Systems
Note: HIHs are not funded by CMS or ONC
For an updated list, visit:

23. Using Health Information Handlers to provide Gateway services
A Health Information Handler (HIH) is any company that handles health information on behalf of a provider. Examples include:
Health Information Exchange (HIE)/Regional Health Information Organization (RHIO)
Release of Information (ROI) Vendor A company that manages the release of information for providers. Their services may include logging and tracking the request, retrieving the patient record from multiple locations in multiple formats, identifying the information needed to fulfill the request, requesting additional authorization, if needed, copying, packaging and mailing, and invoicing.
Electronic Health Record (EHR) Vendor
Claim Clearinghouse
Health Internet Service Provider (HISP)
An entity that provides services that enable providers or health
organizations to exchange health information using the internet.

24. CMS does not dictate how an HIH communicates with providers
Some esMD HIHs plan to ingest a provider's medical records and metadata by:
going onsite to the provider's facility
using a Virtual Private Network (VPN)
using a secure web portal
Some esMD HIHs are considering using DIRECT.
VPN
D I R E C T
D I R E C T

25. esMD Health Information Handlers (HIHs)
esMD HIHs:
Participate voluntarily
Receive no funding from CMS or ONC (Note: they may bill providers)
Attend calls with CMS (scheduled)
Build a CONNECT-Compatible Gateway
Obtain a certificate, IP address, and share key with CMS Gateway Contractor
Successfully onboard with the CMS esMD team and test with CMS Gateway Contractor
Recruit providers to join

26. Want to be an esMD HIH but don’t know how to build a Gateway?
Consider contacting the esMD HIHs
Consider contacting one of the esMD HIH subcontractors
Consider contacting one of the IT vendors
Visit the CMS and QSSI websites

27. For more information To contact the esMD Team: esMD@cms.hhs.gov
CMS esMD Website:
CONNECT Website:
Follow Us on Twitter: @CMSGov (Look for #CMS_esMD)

28. Questions