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Information Management
© 2005 IBM Corporation
IBM Software Group
IBM Information Integration Solutions, Healthcare Sector Claims Attachments UnderpinningHelen Gurevich - Director Healthcare & Insurance , Healthcare SectorFebruary 13, 2006
II Session #4143
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Agenda
Claims AttachmentsModelsStructures“Human Decision Variant” (HDV) vs. “Computer Decision Variant” (CDV)
Standards: X12, HL7/CDA, LOINCImplementation GuidesAdditional Information Specification (AIS)Transactions Linkage
Attachments WorkflowRequest for Additional InformationFederal Register example
IBM Information Integration Capabilities for Claims Attachments ImplementationWebSphere DataStage TXFuture Direction
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Claims Attachments – the road to adjudication automation and fast payment
Additional informationPayer receives a claim and needs more information…
Prescription for DME (e.g., wheelchair)Consent form signed by patientRehabilitation Treatment Plan informationX-rays (dental, spinal, etc.)Laboratory reports and/or results
A mechanism to transmit clinical information in support of the administrative process Data content standardization will support claims adjudication automationMore extensive collections of quality data will enhance medical managementFraud and Abuse prevention
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Attachment Types Selected for HIPAA Recommendation
1. Ambulance2. Emergency Department3. Rehabilitative services4. Lab results5. Medications6. Clinical notes
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Attachment Models
Unsolicited attachment sent with the claimProvider knows the attachment will be required
e.g., consent form signed by patient
Attachment sent to payer as response to a payer’s request for additional information
HIPAA Standard request for information – 277LOINC-codified request
Attachment response – 275Non-structured, structured, codifiedLOINC matches answer to the question
Entity to entity exchange of patient information
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Unsolicited - electronic transmission from provider to payer
Request for payment by ASC X12N 837 & 275 / HL7 CDA attachment
Provider Payer
Payment advice sent by ASC X12N 835 – could be payment or denial
1
2
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Solicited request - Electronic transmission between the provider & payer
Provider
Request for payment by ASC X12N 837
Payer
Request for additional information by ASC X12N 277
Additional information by ASC X12N 275 / HL7 CDA
Payment advice sent by ASC X12N 835 –could be payment or denial
1
3
2
4
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Non-codified, Structured
Non-StructuredScanned image (fax, pdf, rtf, html, or jpeg)
Submitter (Provider) Information (Name, ID)Receiver (Payer) Information (Name, ID)Patient Information (Name, ID)Claim Information (Date, type, reference, control number)Attachment typeQuestion that was asked by payer (LOINC)Response from provider (LOINC)
<section><caption>History of Present Illness</caption><paragraph><content>
Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his teens. He was h twice last year, and already twice this year. He has not been be weaned off steroids for the past several months.
</content></paragraph>
</section><section><caption>Past Medical History</caption>
Marked-up Text (HL7 v3 XML CDA mark-up)
Codified, Structured<section>
<caption>EMS TRANSPORT, DESTINATION SITE INFORMATION<caption_cd V="15512-7"/>
</caption><paragraph>
<caption>EMS TRANSPORT DESTINATION SITE NAME<caption_cd V="18582-7"/>
</caption><content>Alfred Newman Neurological Institute</content>
</paragraph><paragraph>
<caption>EMS TRANSPORT, DESTINATION SITE ADDRESS<caption_cd V="18583-5"/>
</caption><content>123 Main St; Anytown, UT 85912
<local_markup descriptor="AD"><local_attr name="LIT" value=“123 Main St"/><local_attr name="CTY" value=“Anytown"/><local_attr name="STA" value="UT"/><local_attr name="ZIP" value="85912"/>
</local_markup></content>
</paragraph></section>
HL7 CDA codified (HL7 v3 XML CDA mark-up)
Attachment Structures
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Human Decision Variant (HDV) vs. Computer Decision Variant (CDV)
Human DecisionMatches the most prevalent workflow: a person reviewing the information to make a decision“low-impact” on health plans (easy to display using common tools)“low-impact” on providers (supports low-cost document preparation and “fax-like” use of existing paper or document images)
Computer DecisionPermits computer-assisted adjudication or auto-adjudicationIncludes specifications for breaking data down into computer-accessible elementsIncludes LOINC codes to identify the questionsIncludes answer codes suitable to the questionProcessable in “human-decision” mode by health plans that have not adopted a computer decision approachCan be applied selectively, one attachment at a time
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Linking the Transactions in the same transmissionAttachment submitted with Claim (837 + 275)
ISA Interchange Control HeaderGS Functional Group Header
ST 837 Transaction Set Header: Claim…PWK Contains provider’s control number
SE Transaction Set TrailerGE Functional Group TrailerGS Functional Group Header
ST 275 Transaction Set Header: Add’l Info…TRN contains provider’s control number
SE Transaction Set TrailerGE Functional Group Trailer
IEA Interchange Control Trailer
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CDA Attachment within BINX12 wrapper
ST*275*…BIN*1234* Attachment Information ~SE*16*1001~
BIN segment (BIN02) in the X12N-275 transaction set
This is the XML-based CDA document instance that describes an attachment – in this case, an ambulance service attachment.
<?xml version=*1.0*?><levelone * * * ><clinical_document_header> * * *
<document_type_cd V=*18682-5 DN=* AMBULANCE SERVICE CLAIMS ATTACHMENT */> * * *<patient> * * * (identifies the patient by name, number, etc.) </patient>
</clinical_document_header><body><section> <paragraph>
<caption>EMS TRANSPORT, DISTANCE TRANSPORTED<caption_cd V=*15510-1*/></caption><content>7</content><content>mi<coded_entry.value V=*mi* S=*2.16.840.1.113883.5.141*/></coded_entry></content></paragraph></section>
<section><paragraph><caption>EMS TRANSPORT, ORIGINATION SITE ADDRESS<caption_cd V=*18581-9*/></caption><content>124 Elm St, Elmo, UT 85912</content></paragraph></section> * * *
</body></levelone>
Start End
LOINC description and code
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Request for Additional Information
Provider Payer
Deliver a service
Provider submits a
claim
Pay the claim
Deny the claim
Sufficient to pay?
X12N 837 Need more info to pay?
NO
Yes
Request additional
documentation
X12N 277Request for
Additional InformationAssemble supporting
documentation
X12N 275Additional Information
NO
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Federal Register / Vol. 70, No. 184 / Friday, September 23, ’2005 / Proposed Rules. p. 56011
ProviderBilling
Application
X12N 275 withAttachment asStructured data
Utility splits X12N275 away from
CDA basedattachment
Conversion utilitytranslates CDA
attachment data forPayer application
Conversion utilitytranslates X12N
275 data for PayerApplication
AutoAdjudicate?
NO
Make claim andattachmentavailable for
manualadjudication
Adjudicating staff views attachment via a web browser (using
XSL style sheet)
Yes
Pay provider
Paymentcriteria met?
Notify provider of reason for
denial
Yes
NO
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Effective Information Integration is vital for Claims Attachments realization
InformationIntegrationCapabilities • SOA enablement
• Event driven processing• Content based routing• Complex transformation
• Data search, validation, audit• Standardization• Matching & survivorship• Content integration• Federated information access
• Parallel execution• Metadata management• Data transformation• Connectivity• Federated access• UIMA support• Replication
1. IntegrateAdministration and Financials
2. Master DataIntegration
3. UnderpinAnalytical Services
ClearingHouses
ProvidersInstitutional
/Professional
Pharmacy Benefit Managers & Third Party
Administrators
EmployersSubscribers
Payer
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DentalAdjudication System
EDI Document(837D, 837P, 837I,275)
EDI Document(997, 277, 824, 835)
Healthcare HUB
Claims Adjudication
System
UpdateClaimsSystem
LoadODS
ReturnResult
Retrieveoriginal
Claim DataWebSphere DataStage TXHIPAA & EDI Pack
RouteDentalClaims
1. IntegrateAdministration
& Financials
Claims processing requires timely synchronization of complex information, inside and outside the healthcare enterprise
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2. MasterData
Integration
Synchronized claims processing information can be integrated with member master data in real time
DentalAdjudication System
EDI Document(837D, 837P, 837,275)
EDI Document(997, 277, 824, 835)
Claims Adjudication
System
UpdateClaimsSystem
LoadODS
ReturnResult
Retrieveoriginal
Claim Data
Healthcare HUB
DataStage TXHIPAA & EDI Pack
RouteDentalClaims
Member Information Management
ConsolidatedEHR
On DemandCheckMaster
MemberIndex
SOA EditionQualityStage
& Content Edition
Finance: ABC 123
Patient: 78654-A1
Jerry O’Donnell
Internal: 567-5599-5
Dependent: JJ-99-87Integrate
Structured & UnstructuredInformation
Finance: ABC 123
Patient: 78654-A
J. O’Donnel
Internal: 567-5599-5
Dependent: JJ-99
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IBM Information Integration Solutions provide a mechanism for effective information integration for Healthcare IT initiatives
Market to the
individual
Frauddetection
and control
Health and wellness
management
Single viewof the
member/ patient
Harvestresearch and clinical data
Claimsprocessing
streamlining
Diseasemanagement
Migrate and consolidateapplications
IBM® WebSphere® Information Integration platform
Understand Cleanse Transform Federate
Service-Oriented Architecture
Discover, define, model, and govern information quality
and structure
Standardize, merge,and correct information
Transform and enrich information
Virtualize access to disparate information
Data ContentConnect
Access, publish, and replicate information
Integrated Metadata ManagementParallel Processing
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WebSphere Business Integrator Message Broker with WebSphere DataStage TX: Unparalleled Capabilities, Unparalleled Value
WebSphere Business IntegratorWebSphere Business IntegratorMessage Broker Message Broker
WebSphere DataStage TX PlugWebSphere DataStage TX Plug--in for in for WebSphere Message Broker WebSphere Message Broker
XSLTXSLTtransformationtransformation
Compute Compute ESQLESQL
transformationtransformation
WebSphere DataStage TX WebSphere DataStage TX ““Complex Transformation EngineComplex Transformation Engine””
Compute Compute Java Java
transformationtransformation
MappingMappingtransformationtransformation
Complex, Hierarchical Data Transformation
and additional support for industry standards
Powerful Enterprise Services Bus
Solution
+
The Most Powerful
Any-to-AnyIntegration Broker
in the Market
Industry Packs (SWIFT, EDI, HIPAA, HL7) optionalIndustry Packs (SWIFT, EDI, HIPAA, HL7) optional
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Enhance the Transformation Capabilities of your ESB
Scenario
Value
Core:WebSphere BusinessIntegration Message BrokerWebSphere DataStage TX
Extended:Industry Packs, Adapters
WebSphere Offerings
Customer needs to enhance existing transformation capabilities for complex, hierarchical data processingCustomer needs broad industry-standard data format libraries and support
Reduce your hand-coding and development time for new applications and complex integrationsExtends your current MQ & Broker investmentsCommon, codeless method for all transformation types
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HIPAA Data Integration Ingredients
MessageMessageQueueQueue
DatabaseDatabase
FileFileSystemSystem
ApplicationsApplications
INTERNET
VAN /PRIVATE
NETWORK
Hospitals
Doctors
Patients
HC Data services
Clearing Houses
ResourceIntegration
HTTPHTTPFTPFTPEmailEmailVANsVANs
Ro
uti
ng
an
dD
istr
ibu
tio
n
Output marshallingOutput marshallingTarget resolutionTarget resolutionAdapter invocationAdapter invocation
SemanticTransformation
UB92 to HIPAAUB92 to HIPAANSF & CMS flat filesNSF & CMS flat filesXML to HIPAAXML to HIPAAAdjudication API to HIPAAAdjudication API to HIPAA
Trading Manager
PartnerPartnerProfilesProfiles
Partner administrationPartner administrationTransaction validationTransaction validationAuditing / error handlingAuditing / error handlingAlert generationAlert generationMessage routingMessage routingLogging / archivingLogging / archiving
EventManage-mentMessage queuesMessage queues
DatabasesDatabasesFile directoriesFile directories
ResourceIntegration
ApplicationsApplicationsMiddlewareMiddlewareDBMSsDBMSsFile systemsFile systemsSystem servicesSystem services
IBM WebSphere DataStage™ TX
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The IBM WebSphere DataStage™ TX Healthcare products and services
Pack for HL7
Ver. 2.1, 2.2, 2.3
Ver. 3.0 XML DTDs & Schemas Importers and adapters
CDA Schemas Importers
Pack for NCPDP
Batch 1.1, Communication 5.1
Pack for HIPAA EDI
All X12, NSF, UB92, CMS Flat Files
Trading Manager
X12, HIPAA, EDIFACT
Healthcare HUB Solution
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The Benefits of a Standards-based Approach to Information Integration
Healthcare compliance solutions leveraging a standards-based approach to enterprise data integration provide:
The Fastest Time to market and Highest Value impactThe Easiest to maintain and most Responsive to changesThe Highest ROI in terms of technology, hardware and personnelExtremely Scalable and Reliable solutions adaptable to existing IT infrastructuresSupport for the Complexity of integration paradigms
LOWEST COST OF OVERALL OWNERSHIP
LOWEST-RISK INTEGRATION APPROACH
GREATEST OPPORTUNITY FOR SUCCESS
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Information Management
© 2005 IBM Corporation
IBM Software Group
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