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    Proposal defines contents of XML-based claims attachments

    Proposal defines contents of XML-based claims attachments

    Payers can process electronic claims faster if attachments include standard information

    One strength of XML coding is its ability to support a mixture of structured information and natural-language text. The Health Level Seven (HL7) group and Accredited Standards Committee X12 are working on a proposal for HIPAA claims attachments that exploits this strength. The proposal includes definitions for ambulance, rehabilitation, emergency, medications, lab results and general clinical reports.

    For example, an ambulance attachment consists of 14 predefined questions, such as distance driven and patient weight. Because each attachment has specified questions, care delivery organizations (CDOs) can collect the information in advance of an attachment request.

    Under this proposal, CDOs would send claims attachments to providers as XML documents formatted according to the HL7 Clinical Document Architecture (CDA), an American National Standard Institute standard and embedded within a published-standard X12 275 transaction so that they can be handled using the same software and networks as claims and other HIPAA transactions. The CDA standard defines XML tags to represent clinical documents. Although it is primarily designed for text documents such as transcribed dictation, the CDA also supports coded information and images, including scanned medical record pages.

    Booklets provided by HL7 list the standard questions for each attachment and describe how to prepare the corresponding CDA documents.

    Payers can easily accept attachments in both formats: Using an HL7-supplied extensible stylesheet language, they can use common software (such as Web browsers) to render the XML document and associated images on a screen, into an image-based workflow system or on paper so the electronic submission can be handled using existing workflows.

    Very few CDOs have online access to structured clinical data, so most CDOs will prefer to send the human-decision variant. At the same time, most payers will continue their current practice of having adjudicators read the information on an attachment and make the adjudication decision, so the human-decision variant will meet their needs.

    The new proposal also supports bypassing the practice management vendor and EDI channel altogether. Because of the XML approach, it is easy for health plans to define "direct data entry" Web pages. The output from the Web dialog will be the same XML document as would have been sent through EDI. This allows outreach to small practices without setting up separate applications to process Web-based input.

    The industry has had enough problems with the one-size-fits-all HIPAA approach to recognize that the human-decision variant will provide more immediate benefits. This proposal is a start but retains the ability to evolve through economically based decisions to use autoadjudication in specific situations. MHE

    Visit gartner.com/healthcare or e-mail:info@gartner.com.

    Wes Rishel
    Wes Rishel is research director for healthcare technology at Gartner.