Terminology Owner/Contact Current Procedures Terminology (CPT) code set American Medical Association SNOMED CT International Healthcare Terminology Standards Developing Organization (IHTSDO) or info@ihtsdo.org Logical Observation Identifiers Names & Codes (LOINC) Regenstrief Institute International Classification of Diseases (ICD) codes World Health Organization (WHO) NUCC Health Care Provider Taxonomy code set American Medical Association. Please see 222.nucc.org. AMA licensing contact: 312-464-5022 (AMA IP services) Table of Contents
Table 4: ASC X12N Attachment Activity Healthcare Activity ID Originator Activity Type Attachment Activity Basis Example Figure ID ASC X12N Envelope/ Transaction Standard Example Originator Receiver Claims Attachment #1 Request X Payer Provider 2771 #2 Response X Provider Payer 2752 #3 Attachment Submission X Provider Payer 2752 Prior Auth Attachment #4 Request X Payer Provider 2783 #5 Response X Provider Payer 2754 #6 Attachment Submission X Provider Payer 2754 Referral Attachment #7 Request X Payer/ Referring Provider Referred To Provider 2783 #8 Response X Referred To Provider Referring Provider 2754 #9 Attachment Submission X Referred To Provider Referring Provider 2754 Post Adjudicated Claim Attachment #10 Request X Payer Provider 2771 #11 Response X Provider Payer 2752 Notification Attachment #12 Attachment Submission X Facility provider Primary care provider 2754 1 ASC X12N 277 – Health Care Information Status Notification - Technical Report Type 3 for Health Care Claim Request for Additional Information 2 ASC X12N 275 – Patient Information – Technical Report 3 for Additional Information to Support a Health Care Claim or Encounter 3 ASC X12N 278 – Health Care Services Review Information Technical Report 3 for Health Care Services Request for Review and Response 4 ASC X12N 275 – Patient Information – Technical Report 3 for Additional Information to Support a Health Care Service Review
Prior Authorization Attachment – Unsolicited Scenario A provider submits a request for prior authorization to a payer and knows in advance that additional information is needed to complete the approval, the provider may submit the Attachment without waiting for the request. The diagram below depicts the business flow of the examples on for an unsolicited Prior Authorization Attachment. Arrow #1 Prior Authorization Request from a provider to a payer using ASC X12N 278. Arrow #2 Provider submits additional information previously agreed to between payer and provider as an Attachment using ASC X12N 275.. () Figure 7: Example – Prior Authorization (Unsolicited) Referral Attachment – Unsolicited Scenario A provider submits a referral to another provider or a payer and knows in advance that additional information is needed, the provider may submit the Attachment without waiting for the request. The diagram depicts the business flow of the examples on for an unsolicited Referral Attachment. Arrow #1 Referral is submitted from a provider to another provider or payer using ASC X12N 278. Arrow #2 Provider submits additional information previously agreed to between payer and provider as an Attachment using ASC X12N 275. () Figure 8: Example - Referral Attachment (Unsolicited) Notification Attachment – Unsolicited Scenario A provider submits a notifiction to another provider along with additional information as needed. In the example a facility provider discharges a patient of a primary care provider, and forwards a notification to that effect. The diagram below depicts the business flow of the examples on for a Notification Attachment. Arrow #1 Attachment information from the facility provider to the Primary Care Provider using ASC X12N 275. Figure 9: Example - Notification Attachment (Unsolicited)
C.3 LOINC Codes The following table shows the recommended LOINC codes for the C-CDA R2.1 structured documents. These codes should be used to request a “clinical” document and to identify such a document when it is submitted. 6: C-CDA R2.1 Clinical Document Types with Recommended LOINC Code for Requests Clinical Document Type LOINC LOINC Long Description C-CDA R2.1 Table ValueSet Care Plan 52521-2 Overall Plan of Care/Advance Care Directive _ No set Consultation Note 11488-4 Consult Note Table #28 ConsultDocumentType CCD 34133-9 Summarization of Episode Note _ No set Diagnostic Imaging Report 18748-4 Diagnostic imaging Report _ Imaging Document Codes Discharge Summary 18842-5 Discharge Summary Table #37 DischargeSummaryTypeCode History and Physical 34117-2 History and Physical note Table #41 HPDocumentType Operative Note 11504-8 Unspecified Operation Note Table #44 Procedure Note 28570-0 Unspecified Procedure Note Table #48 Progress Note 11506-3 Unspecified Progress Note Table# 51 ProgressNoteDocumentTypeCode Referral Note 57133-1 Referral Note Table# 54 ReferralDocumentType Transfer Summary 18761-7 Unspecified Transfer Summary Table# 57 TransferDocumentType The requester may request a document that conforms to a specific implementation (e.g. R2.1 or C-CDA R1.1) by specifying the appropriate modifier code for that implemenation guide. Clinical Documents for Payers Set 1 Release 1.1 – 1
F.4.2 CONNECT SAML Assertions SAML assertions for transactions with CMS must conform to the “Implementation for Health Information Handlers for Electronic Submission of Medical Documentation Project,” Section 5.3.5.5: esMD SAML Assertions Details, which states: The CONNECT SAML Assertions define the exchange of metadata used to characterize the initiator of a request so that it may be evaluated by the Payer Gateway in local authorization decisions. The purpose of this SAML Assertion exchange is to provide the Payer Gateway with the information needed to make an authorization decision using the policy enforcement point for the requested esMD function. Each initiating SOAP message must convey information regarding the Registration Requestor’s attributes and authentication using SAML 2.0 Assertions. SAML assertions for transactions with Commercial Payers must conform to the eHealth Exchange Authorization Framework Specification v3.0. F.4.3 IHE XD* Metadata Systems using an HPD Plus DSMLv2 document payload over CONNECT or Direct should adopt the IHE Cross Enterprise Document Reliable Interchange (XDR) profile with XDS Repository Submission Request Provide and Register Document set – b (ITI-41) transaction metadata. Cross-Enterprise Document Reliable Interchange (XDR) provides document interchange using a reliable messaging system. This permits direct document interchange between EHRs, PHRs, and other healthcare IT systems in the absence of a document sharing infrastructure such as XDS Registry and Repositories. Cross-Enterprise Document Media Interchange (XDM) provides document interchange using a common file and directory structure over several standard media, including email. This permits the use of email to convey documents. XDM defines no new metadata but leverages the existing XDS metadata. F.5 Overview of a Payload Over CONNECT with XDR This section defines how a transaction may be sent over CONNECT with the eHealth Exchange CAQH CORE X12 Document Submission Service Interface Specification. Figure 13: CONNECT w/ ASC X12N 275 Note: Per specifications, encoding for XDR may be indicated in the metadata, and encoding must be Base64.