Electronic Submission of Medical Documentation (esMD) Technical Overview Melanie Combs-Dyer, RN - Deputy Director, CMS/OFM/Provider Compliance Group Daniel Kalwa - Health Insurance Specialist, CMS/OFM/Provider Compliance Group Manoj CHAGANTI - esMD Chief Architect, CMS/QSSI Ranjith Madhusoodanan - esMD Project Manager, CMS/QSSI Michael Finkel - esMD Project Director, CMS/QSSI Monday 4:15 P.M.

Agenda Technical Overview esMD Business Functionality Overview of XDR esMD Transporter and Translation Mechanism Future esMD Enhancement / Use Cases Overview of CAQH CORE Transport and X12 Translation Mechanism If time permits: Discussion whether X12 Message be sent thru the XDR Transactions?

Today’s Medical Documentation Process Doc’ n Request Letter Review Contractor Paper Medical Record Provider

The Solution: Electronic Submission of Medical Documentation (esMD) Phase 1: Doc’n Request Letter electronic electronic Phase 2:

CMS Does Not Dictate How an HIH Communicates with Providers esMD HIHs ingest provider's medical records and metadata by either one of the following : 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. Web Portal VPN Onside Pickup D I R E C T http://directproject.org http://wiki.directproject.org D I R E C T

esMD Phase 1 (In Production) : September 2011 Doc’ n Request Letter Medicare Administrative Contractors Medicare Recovery Auditors PERM CONNECT Compatible PDF PDF PDF DIRECT CMS Private Network Content Transport Services SOAP Message with SAML/XDR ECM ECM Built by SOAP Message with SAML/XDR esMD Gateway Built by esMD Metadata Database

esMD Phase 2: October 2012 Medicare Medicare Administrative Contractors Medicare Recovery Auditors PERM CONNECT Compatible Structured Electronic Requests for Medical Documentation PDF XML PDF PDF DIRECT CMS Private Network Content Transport Services SOAP Message with SAML/XDR ECM ECM Built by SOAP Message with SAML/XDR esMD Gateway Built by esMD Metadata Database

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 NPI – Required Field Case ID – Required If Known Detailed description for each field can be found in: the esMD XDR Profile. the esMD Implementation Guide. (http://www.connectopensource.org/product/connect-NHIN-specs) (www.cms.gov/esMD)

esMD Technical Details System (HIH) to System (CMS) Gateway Communication HIH Submits XDR (Deferred Document Submission) SOAP Envelope Request to CMS CONNECT gateway with the following details SAML Assertions and its digital signature, Security Tags in the SOAP Header, IHE XDR and esMD Meta Data with in the SOAP Body. MTOM Encoded C62 Payload in the SOAP Body. SAML Assertions shall contain the HIH Organization Identifier (OID), Review Contractor Organization Identifier (OID), NPI Provider Identification etc. Authentication HIH IP Address validation Mutual TLS v1.0 certificate validation (later used for encryption and decryption of request, responses and its digital signatures) Exchange and validate FIPS 140/2 TLS Cipher Suites. Timestamp and SAML Digital Signature validation HIH OID and Intended Review Contractor validation against HIH and CMS Review Contractor OIDs based on the CMS onboarding Process. Message and payload integrity verification based on the base 64 encoding - MD5 digest/hashcode algorithms. Authorization HIH OID and Intended Recipient OID against the esMD CMS on-boarded data. Up to 19MB of PDF Payload size

Current esMD XDR Transport and Translation Mechanism

esMD XDR Implementation

esMD XDR Profile and its references IHE XDR Specification NHIN Message Platform Specification NHIN Authorization Framework Specification NHIN Document Submission Specification esMD XDR Profile How esMD implement the XDR Transport and Translation Mechanism?

Adapting CONNECT 3.1 XDR (Deferred Document Submission) Transportation and Translation Mechanism

esMD XDR Document Submission Message Flow – In Deferred Message Mode Using the Health Information Handler (HIH) Gateway, provider submits a claim document response to a single CMS Additional Documentation Request Letter (ADR), using the Document Submission deferred request (as a part of deferred messaging flow). esMD implements the NHIN Document Submission with Deferred Messaging mode. In a deferred mode, the Document Submission is a two-way message as shown in the diagram below:

Sample Message: XDR Document Submission SOAP Envelope

In Sept 2011, esMD successfully implemented the IHE XDR Profile with inbound ADR Use Case. So, What's Next? Future esMD Use Cases How to accommodate ASC X12 transactions? Does CONNECT Support ASC X12 Transactions? Are there any NHIN profiles to support the ASC X12 Transactions? How to allow outbound transactions from CMS esMD Gateway to HIH in compliance with FISMA and other security requirement? Identify the Technical requirements to expand the esMD Use Cases. Provider Profile/ Provider Naming Service etc

Current and Future Use Cases for esMD We Are Here INBOUND Responses to Documentation Request Letters in PDF Appeal Requests in PDF Unsolicited Documentation in PDF (called paperwork or “pwk”) Structured Orders, Progress Notes, ADMC Requests Structured esMD Phase 2 Registration etc OUTBOUND Structured Outbound Documentation Requests Review Results Letters Demand Letters LOOKUP Request\Receive Documentation Status Request\Receive Claim Status Request\Receive Appeals Status Request\Receive Eligibility Info

How to accommodate ASC X12 transactions thru esMD Gateway? Need to build CAQH Transport service (Parallel to XDR) in the CONNECT software by adopting Phase II CORE 270: Connectivity Rule version 2.2.0 specifications. Develop NHIN CAQH CORE X12 Document Submission Profile (Similar to XDR Document Submission) Develop the esMD X12 Profile based NHIN CAQH CORE X12 Document Submission Profile. Implement the NHIN CAQH CORE X12 Document Submission Service with in the CONNECT. Identify the ASC X12 Translator software to process the X12 Messages.

esMD XDR & CAQH CORE Transport and X12 Translation Mechanism

Sample Message: CAQH Phase II CORE 270: Connectivity Rule version 2. 2 Sample Message: CAQH Phase II CORE 270: Connectivity Rule version 2.2.0 - X12 824 Application Advice Forwarded Acknowledgment SOAP Envelope

Enhance CONNECT 3.1 with CAQH Phase II CORE 270: Connectivity Rule version 2.2.0 Transport Mechanism and esMD X12 Translator

NHIN CAQH CORE X12 Deferred Document Submission (using three CAQH CORE Connectivity Generic Batch message interactions) Communication with Multiple SOAP over HTTP/S Connections

Can X12 Message be sent thru the XDR Transactions?

QUESTIONS? If more info please contact: Melanie Combs-Dyer, RN Deputy Director, CMS/OFM/Provider Compliance Group melanie.combs-dyer@cms.hhs.gov Dan Kalwa Health Insurance Specialist, daniel.kalwa@cms.hhs.gov Manoj Chaganti esMD Chief Architect, CMS/QSSI mchaganti@qssinc.com Ph: 847 903 5432

esMD System Architecture CMS QSSI esMD Project Confidential Document – Pl. contact Manoj Chaganti, mchaganti@gssinc.com , 847 903 5432 XDR & X12 HIH XDR HIH X12 HIH < -- X12 Trading Partner Agreement (TPA) Use Case -- ….. ------XDR Orders Use Case ---  ------ X12 Appeals Use Case ---  ….. ------ X12 Orders Use Case ---  ------ XDR Appeals Use Case ---  < -- X12 Trading Partner Agreement (TPA) Use Case -- ------ X12 ADR Use Case ---  ------ XDR ADR Use Case ---  CONNECT 3.x XDR Inbound Request /Outbound Response - NHIN Orchestration Document Submission CAQH CORE X12 Inbound Request / Outbound Response- NHIN Orchestration Document Submission XDR Transporter CAQH CORE Transporter ESMD Gateway X12 Translator esMD Translation / Statistical and Business Logic Application