Electronic Submission of Medical Documentation (esMD)

1. Electronic Submission of Medical Documentation (esMD) Community Meeting

2. Today’s Agenda

3. Quick Review of electronic service information (esi)

4. Query for Electronic Service Information – Data Set Overview – Response Detail • Provider Directory Information • PD identifier and name • Organization Information • Unique Identifier(s) and Status • Name and alias(es) • Address(es) • NPI(s) • Type(s) • Certification(s) • Specialty(ies) • Contact Information (telephone, email) • Organizational Policy Information • Digital Certificate Information • Organization ESI Individual Information • Individual Information • Unique Identifier(s) and Status • Name and alias(es) • Address(es) • Gender and DOB • Type • NPI • Degree(s) • License(s) • Certification(s) • Specialty(ies) • Contact Information (telephone, email) • Digital Certificate Information • Personal ESI Relationship Information Organization Information • Relationship Information • Organization-Organization Relationships • Individual-Organization Relationships • Relationship specific contact information (telephone, email) • Relationship specific certificate • Relationship specific ESI 3

5. Query for Electronic Service Information – Data Set Overview – ESI detail • Unique ESI identifier (required) • Integration Profile Information • Integration Profile (required) • Integration Profile Version • Integration Profile Options • Content Profile Information • Content profile • Content profile version • Content profile constraints • Security Profile Information • Security profile • Security profile version • Security profile options • Address (Electronic) of Service (required) • Preferred Method (required) • Example 1 – Direct (CCD C32 payload) • ESI ID: f81d4fae-7dec-11d0-a765-00a0c91e6bf6 • Integration Profile: DirectProjectSMTP • Content Profile: HITSP C32 • Content Profile Version: 2.5 • Address: https://john.smith@direct.health.org • Preferred: 2 • Example 2 – NwHIN • ESI ID: 550e8400-e29b-41d4-a716-446655440000 • Integration Profile: PatientDiscovery:2.0 • Address: https://health.org/PatientDiscovery.wsdl • Preferred: 1 • Example 3 – X12 (Core X12 270/271) • ESI ID: eb424026-6f54-4ef8-a4d0-bb658a1fc6cf • Integration Profile: CAQH CORE Connectivity Rule • Content Profile: X12N 270/271 • Content Profile Version: 005010 X279 X279A1 • Address: https://health.org/Core5010x279.wsdl • Preferred: 1 4

6. Review of updated context diagrams

7. PPA Use Case Context Diagram – Information Exchange Paths – General Case Provider Information Directories Provider / Provider Organization Payer Organization Contractors / Intermediaries Gateway Agent / Access Access

8. PPA Use Case Context Diagram – CMSProvider Registration Provider Information Directories In to CMS 2. CMS sends ESI query to PD to determine capability of provider / HIH to receive medical documentation request (eMDR). Out from CMS 3. ESI query response sent to CMS Provider / Provider Organization CMS Contractors / Intermediaries esMD Gateway HIH CMS PD Connect 1. HIH/Provider Sends electronic registration request to CMS 4. Confirmation of registration sent from CMS Key : ESI – Electronic Services Information

9. PPA Use Case Context Diagram – CMSSecure MDR transmission from Contractors Provider Information Directories In to Contractor Out from Contractor Out to Provider 3. Sends request to retrieve updated ESI information 4. Receives updated ESI Information 1. Sends request for provider registration status Provider / Provider Organization Contractors / Intermediaries CMS esMD Gateway 2. Receives validation of registration status HIH Connect CMS PD 5. Electronic medical documentation request (MDR) sent securely to Provider or HIH as needed * Key : ESI – Electronic Services Information * Electronic MDR is sent only when CMS identifies the need for documentation.

10. PPA Use Case Context Diagram – Commercial Payer Provider Registration Provider Information Directories In to Payer 2. Payer sends ESI query to PD to determine capability of provider / Agent to receive medical documentation request (eMDR). Out from Payer 3. ESI query response sent to Payer Provider / Provider Organization Commercial Payer Contractors / Intermediaries Gateway Agent Payer PD Connect 1. HIH/Provider Sends electronic registration request to Payer 4. Confirmation of registration status sent from Payer Key : ESI – Electronic Services Information

11. Use Case 2 – (We will cover this once we start UC 2)PPA Use Case Context Diagram – Secure eMDRtransmission from Commercial Payer via Contractor Provider Information Directories In to Contractor Out from Contractor Out to Provider 3. Sends request to retrieve updated ESI information 4. Receives updated ESI Information 1. Sends request for provider registration status Provider / Provider Organization Contractors / Intermediaries Commercial Payer Gateway 2. Receives validation of registration status Agent Payer PD Connect 5. Electronic medical documentation request (eMDR) sent securely to Provider or Agent as needed * Key : ESI – Electronic Services Information * eMDR is sent only when Payer identifies the need for documentation.

12. Use Case 2 – (We will cover this once we start UC 2)PPA Use Case Context Diagram – Secure eMDRtransmission from Commercial Payer Provider Information Directories 1. Sends request to retrieve updated ESI information Out to Provider 2. Receives updated ESI Information Provider / Provider Organization Contractors / Intermediaries Commercial Payer Gateway Agent Connect Payer PD 3. Electronic medical documentation request (eMDR) sent securely to Provider or Agent as needed * Key : ESI – Electronic Services Information * eMDR is sent only when CMS identifies the need for documentation.