esMD AoR Use Case / Harmonization of UC 1&2 Joint Community Meeting
Date of Meeting: 10.26.12 / 2:00pm EDT
Decisions
Author of Record
The afternoon sessions started an hour later this week due to technical issues.
UC 2 IG Review
- The CORE Connectivity Rule is set up so that X12 transactions can be consistently
exchanged using a SOAP envelope / MIME multi-part, including an identifier that
communicates to the gateway what the payload consists of. CORE can support
exchange of 999, TA1 and 824, but the timing and sequencing would be dependent on
the business requirements and the UC as the Rule does not define these things.
- There are 2 ways for a receiving system to confirm receipt:
o Acknowledgement that the gateway received payload can be shown within the
SOAP envelope.
o To show the payload was useable, readable, or correct, the X12 999 TR3 can
show this.
- The 999 can report errors for conformance to a specific version of a TR3. The 824 is
designed to report more information that would be relative to requirements to the
business rather than for the conformance to a TR3.
- An X12 workgroup is looking at the 824 (version 5010X186) to assess gaps in its use in
the process of requesting, exchanging and acknowledging additional documentation. The
current CORE payload ID table already supports the 5010 version of the X12 824, 999,
and TA1 specifications. Currently, the industry is using the 5010 versions as mandated
by HIPAA, and the industry will not likely veer from that support until HIPAA mandates
are updated. The IG will need to make sure the approach to the versioning of these
X12 transactions is clear in how ongoing maintenance is handled. A provision may
also be necessary for noting that Section 1104 of the Affordable Care Act includes
requirements for adoption of operating rules for claims attachments and prior
authorizations.
- The response to a SOAP transaction is synchronous, thus a failure in a SOAP
transaction would occur at the time of transmission. In esMD phase I, a sequence
diagram showed the various handshakes between providers/HIHs and the payer via the
X12 275. It may be useful to include a similar sequence diagram within the UC 2 IG.
Within the CORE Connectivity Rule, for certain transactions, the X12 999 response must
be available within one hour, but not be sent in the same communication as the batch
download. Where there is not guidance from X12 or CORE, the IG will need to
identify gaps and propose solutions while understanding such solutions are
subject to change.
- The X12 824 response is at a different level of business process than the 999/TA1.
Guidance should be solicited from X12 over use of the 824 and 999, and whether
the versions cited in the IG are the correct ones. For the time being, the IG will specify
to look for responses to an X12 277 submission in the SOAP response as a 999/TA1
response, and will require the 824 as part of overall response package, since that is
where the application indicates message receipt. The primary acknowledgement must be
at SOAP/transport layer, however. The harmonization team will ensure there are no
concerns from X12 in this approach, and the community is requested to offer
business reasons for why this approach would not work.
- The IG should be clear that if a failure is reported at the SOAP/transport level, then
no further error messages should be sought. If a TA1 response is received, a 999
response should not be sought. And if a TR1 or 999 response is received, the 824
response should not be sought. The IG will also clarify in its discussion of these error
-
messages that we want to receive confirmation of receipt with no errors, or rejection, or
acceptance of errors.
Will is going to clarify with X12 that, when a transaction is not supported, it would
be reported at the functional later via a 999 response.
If the X12 277 pertains to a claim that cannot be mapped to anything at the provider’s
end, this may be an error situation to include in the IG. The harmonization team will
discuss putting together a list of application-level errors during leads calls.
Action Items
Name
Harmonization
Team / Leads
Harmonization
Community
Subject
UC 2 IG
Task
See all bolded tasks above
Due Date
Ongoing
UC 2 IG
Provide any business reasons for why the following
approach would not work: look for responses to an
X12 277 submission in the SOAP as a 999/TA1
response, while requiring the 824 as part of the
overall response package.
11/2/12