Electronic Submission of Medical Documentation (esMD) Electronic Determination of Coverage PMD User Story & Harmoniz

1. Electronic Submission of Medical Documentation (esMD)Electronic Determination of Coverage PMD User Story & Harmonization August 7, 2013

2. Meeting Etiquette • Please announce your name each time prior to making comments or suggestions during the call • Remember: If you are not speaking keep your phone on mute • Do not put your phone on hold – if you need to take a call, hang up and dial in again when finished with your other call • Hold = Elevator Music = very frustrated speakers and participants • This meeting, like all of our meetings, is being recorded • Another reason to keep your phone on mute when not speaking! • Feel free to use the “Chat” or “Q&A” feature for questions or comments From S&I Framework to Participants: Hi everyone: remember to keep your phone on mute  NOTE: This meeting is being recorded and will be posted on the esMD Wiki page after the meeting

3. Agenda

4. Schedule • Wednesdays, 1 - 3 PM ET: eDoC Workgroup meeting • 1 - 2 PM ET: eDoC Power Mobility Devices Meeting • 2 - 3 PM ET: eDoC Harmonization Meeting • Fridays, 2 - 3 PM: eDoC Structured Data SWG Meeting

5. esMD Initiative Timeline Today 8/7/13 April ‘13 October‘13 Oct ‘11 April ‘12 Oct ‘12 July ‘13 Jan ‘13 Jan ‘12 July ‘12 Kick-Off/ F2F 11/30-12/7 Charter Consensus Implementation Guide for AoR L1 Pre-Discovery Use Case and Requirements L1 AoR L1 SWGs Pilots (TBD) Author of Record WG Use Case and Requirements L2 Harmonization L2 AoR Workgroup Through April 2014 eDoC Use Case and Requirements eDoC Harmonization Pilots (TBD) Electronic Determination of Coverage PMD User Story SDS

6. PMD User Story • Switch to Word file…

7. esMD Initiative Timeline Today 8/7/13 April ‘13 October‘13 Oct ‘11 April ‘12 Oct ‘12 July ‘13 Jan ‘13 Jan ‘12 July ‘12 Kick-Off/ F2F 11/30-12/7 Charter Consensus Implementation Guide for AoR L1 Pre-Discovery Use Case and Requirements L1 AoR L1 SWGs Pilots (TBD) Author of Record WG Use Case and Requirements L2 Harmonization L2 AoR Workgroup Through April 2014 eDoC Use Case and Requirements eDoC Harmonization Pilots (TBD) Electronic Determination of Coverage PMD User Story SDS

8. Electronic Determination of Coverage Summary Underlying Challenge: • Enable provider capture of documentation and benefit determination based on payer rules • Secure exchange of templates, decision support, and documentation between payers, providers, service suppliers and beneficiary Scope: • Focus on defining the use case, user stories and requirements supporting a standards-based architecture • Reuse of existing S&I Initiative efforts where possible • Creation of structured data capture templates and supporting exchange standards • Power Mobility Device as initial User Story

9. Electronic Determination of Coverage Summary Outcome: • Successful pilot of templates, decision support, information exchange standards over standard secure transactions for the purpose of determining coverage • Validation with initial user story for Power Mobility Device

10. eDoC General Workflow Patient LCMP Physician Specialist / Service Provider Templates and Rules Payer

11. eDoC PMD Workflow Patient Signed Document 3 11 1 LCMP Physician DME Supplier 2 5 6 10c 4 8 7 9a 10a 10b 9b Templates and Rules Payer Payer

12. Scope Out of Scope Specific provider service implementations EHR implementations Provision of Information exchange services (e.g. HISPs for Direct) • In Scope – Phase 1 • Structured and unstructured data requirements • Exchange standards • Digital signature requirements • In Scope – Phase 2 • Templates for Structured Data Capture (SDC) • Decision Support (rules, data capture, order sentences and behaviors) (HeD)

13. Summary eDoC workgroup identifies Best Practice for: • Payer interaction with providers for determination of coverage • Developing, delivering and using structured documentation templates to support coverage determination • Developing and instantiating decision support rules to facilitate provider decision making in light of payer standards • Addressing Author of Record requirements • Secure electronic communication between payers, provider, suppliers and beneficiaries • Creating implementation guides for payers and providers (usually via HIT vendors) for all required eDoC processes and transactions 13

14. The S&I Framework Standards Evaluation Process Goal of the S&I Framework Standards Evaluation Process: To achieve consensus on applicable and relevant standards to be modified or further developed as a resolution to the health information exchange challenge addressed by the Initiative. The process narrows the initial Candidate Standards List toward Selected Standards to be included in the Initiative’s Recommended Standards consensus statement

15. The S&I Framework Standards Evaluation Process • Discuss esMD-specific harmonization issues • Code sets, vocabularies, and security, and signature standards will be discussed in future meetings • Evaluate and analyze standards • Use Standards Analysis Workbook to capture findings and rate applicability of each standard to esMD • Select standards for further development within esMD initiative • Choose standards based on use case and data model requirements and community expertise • Draft Standards Recommendation Consensus Statement