PUBLIC COMMENTS SOUGHT ON THE STANDARDS FOR ELECTRONIC HEALTH CARE CLAIMS ATTACHMENTS

(CMS-0050)

X12 TRANSACTIONS, HL7 SPECIFICATIONS, and LOINC CODES

On November 22, 2005, The Department of Health and Human Services (HHS) published notice of a 60 day extension to the comment period for the proposed rule titled: “HIPAA Administrative Simplification: Electronic Health Care Claims Attachments.”  The public comment period will now close on January 23, 2006.  A final rule is expected by the end of 2006.

The industry requested the extension in order to avoid the same standards-related implementation issues as were experienced implementing the first set of HIPAA transactions.  HHS accommodated the request with the expectation that the industry would assess the proposed standards for their viability and relevance to current practices.  For example, are the attachment request options in each specification booklet (HL7 Additional Information Specification) an accurate reflection of  the information requested by most health plans for that claim type?

The comments will be provided to the Standards Development Organizations (SDOs): X12 and HL7, so that they can make necessary revisions and corrections, and re-ballot the standards in time for a final rule in 2006.  

The proposed rule, published on September 23, 2005, recommends the adoption of a set of standards that will facilitate the electronic exchange of clinical and administrative data.  These exchanges, and the standardized data format and content, are intended to improve the claims attachment adjudication process when additional documentation is required of a provider, by a health plan.   

The X12 and HL7 the guides, specifications and LOINC code set should be reviewed by technical experts, but equally importantly, by business subject matter experts, such as medical review specialists and claims examiners.  Without both a business and technical review, covered entities may not be able to implement the standards in the most effective or affordable way. 

The standards are:

• Two X12N transaction standards - one to request the information, and one to respond to that request with the answers or additional information.
• Six Health Level 7 (HL7) specifications for the content and format of communicating the actual clinical information, along with the HL7 implementation guide and Clinical Document Architecture (CDA).
• The LOINC code set:  Logical Observation Identifiers Names and Codes for specific identification of the additional information being requested, and the coded answers that respond to the requests.