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HIPAA claims attachments manageable with XML

Publish date: JUN 01, 2004

Although claims attachments are one of the mandated electronic transactions under HIPAA, the Dept. of Health & Human Services (HHS) has not yet issued a regulation for them. This transaction has special challenges because the data is more diverse and complex.

There is also considerable animosity between health plans and providers regarding attachments. Providers suspect health plans of using attachment requests to stop the "prompt payment clock," so they feel justified in copying the entire record and attaching it to the claim. This volume of paper represents a substantial administrative cost for the health plans, even those that request few attachments.

A New ApproachDuring 2003, HL7-working closely with ASC X12N-balloted a recommended approach to meeting the HIPAA requirement for electronic claims attachments. HHS hopes to offer the new approach in a Notice of Proposed Rulemaking (NPRM) in late 2004. The new approach sends the attachment data in XML formatted according to the HL7 Clinical Document Architecture (CDA) standard.

The recommendation is based on a principle of predictable content. For a given type of claim, the questions that a health plan can ask are spelled out in the standard. This will go a long way toward reducing the care delivery organizations' (CDOs') perceived need to submit everything. Even in the case where a CDO does oversubmit electronically, the administrative cost to the health plan of notifying the CDO that the electronic information was not retained will be substantially less than the costs of filing, destroying or returning massive amounts of paper.

A second principle is to support human-decision and computer-decision use cases. The human-decision use case supports what will be, by far, the most common workflow for electronic attachments. They will come from a provider that does not have access to online, structured clinical data to a payer that will use a person to make the adjudication system.

The recommendation supports low-impact implementations of this workflow on both the provider and payer sides. Providers can respond with scanned images of paper documents through EDI or directly to a Web server operated by a payer under the direct data entry exemption for HIPAA standards. Because the attachment information is sent using XML, payers can also choose a very low-impact approach. Using only a Web browser or other ubiquitous software, payers can convert the attachments to a human-readable format for printing, entering into a document management system or other workflows.

Some payers have told HL7 that they could achieve substantial additional efficiencies by autoadjudicating certain claim types if their attachment had structured data. For example, the attachment for some periodontal claims really has only one data item of interest: pocket depth. This recommendation permits the providers to include structured data within the XML. Payers that offer to pay faster through autoadjudication of claims with specific attachments would create an incentive for providers to code data. Payers that don't wish to autoadjudicate can use the stylesheet to format the attachment for a person.

It would be very difficult to use regulations to move the industry from the human-decision to the computer-decision variant. Not all plans will be interested in autoadjudication of a specific attachment in the same time frame, and not all providers will create the computer-decision variant because of system limitations. We hope that neither payer nor provider will be forced to move to the coded format. MHE

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