Electronic Submission of
Medical Documentation
(esMD) Technical
Overview
MELANIE COMBS-DYER, RN Deputy Director, CMS/OFM/Provider Compliance Group
DANIEL KALWA Health Insurance Specialist, CMS/OFM/Provider Compliance Group
MANOJ CHAGANTI esMD Chief Architect, CMS/QSSI
RANJITH MADHUSOODANAN esMD Project Manager, CMS/QSSI
MICHAEL FINKEL esMD Project Director, CMS/QSSI

Agenda
• Technical Overview
▫ esMD Business Functionality
▫ Overview of XDR esMD Transporter and Translation Mechanism
▫ Future esMD Enhancement / Use Cases
▫ Overview of CAQH CORE Transport and X12 Translation Mechanism
▫ If time permits: Discussion whether X12 Message be sent thru the XDR
Transactions?
2

Doc’ n
Request
Letter
Review Contractor
4
Paper
Medical
Record
Provider

Phase 1:
Doc’n
Request
Letter electronic
Phase 2: electronic electronic
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 esMD HIHs ingest provider's medical records and metadata by either one of the following :
• going onsite to the provider's facility
• using a Virtual Private Network (VPN)
• using a secure web portal
 Some esMD HIHs are considering using DIRECT.
http://directproject.org
http://wiki.directproject.org
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esMD Phase 1 (In Production) : September 2011
Doc’ n Request
Letter
Medicare
Administrative
Contractors
Medicare
Recovery
Auditors PERM
CONNECT
Compatible
PDF
PDF PDF
CMS Private Network
Content Transport Services
ECM
ECM Built by esMD
Gateway
Built by esMD
Metadata
Database
6

Medicare
Administrative
Contractors
Medicare
Recovery
Auditors PERM
CONNECT
Compatible
Structured Electronic
Requests for Medical
Documentation
XML
PDF
PDF
CMS Private Network
PDF
Content Transport Services
ECM
ECM Built by esMD
Gateway
Built by esMD
Metadata
Database
7

A portion of a patient’s medical record in esMD format which will contain:
 Imaged documents (PDF)
 Important Metadata Fields:
• Intended Recipient – Required Field
• Claim ID – Required Field
• NPI – Required Field
• Case ID – Required If Known
Detailed description for each field can be found in:
 the esMD XDR Profile. (http://www.connectopensource.org/product/connect-NHIN-specs)
 the esMD Implementation Guide.
(www.cms.gov/esMD)
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esMD Technical Details
 System (HIH) to System (CMS) Gateway Communication
 HIH Submits XDR (Deferred Document Submission) SOAP Envelope Request to CMS
CONNECT gateway with the following details

SAML Assertions and its digital signature, Security Tags in the SOAP Header,

IHE XDR and esMD Meta Data with in the SOAP Body.

MTOM Encoded C62 Payload in the SOAP Body.
 SAML Assertions shall contain the HIH Organization Identifier (OID), Review
Contractor Organization Identifier (OID), NPI Provider Identification etc.
 Authentication
 HIH IP Address validation
 Mutual TLS v1.0 certificate validation (later used for encryption and decryption of request, responses and its digital signatures)
 Exchange and validate FIPS 140/2 TLS Cipher Suites.
 Timestamp and SAML Digital Signature validation
 HIH OID and Intended Review Contractor validation against HIH and CMS
Review Contractor OIDs based on the CMS onboarding Process.
 Message and payload integrity verification based on the base 64 encoding -
MD5 digest/hashcode algorithms.
 Authorization
 HIH OID and Intended Recipient OID against the esMD CMS on-boarded data.
 Up to 19MB of PDF Payload size
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12






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Adapting CONNECT 3.1 XDR (Deferred Document
Submission) Transportation and Translation Mechanism

esMD XDR Document Submission Message Flow –
In Deferred Message Mode
 Using the Health Information Handler (HIH) Gateway, provider submits a claim document response to a single CMS
Additional Documentation Request Letter (ADR), using the Document Submission deferred request (as a part of deferred messaging flow).
 esMD implements the NHIN Document Submission with Deferred Messaging mode. In a deferred mode, the
Document Submission is a two-way message as shown in the diagram below:
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Sample Message: XDR Document Submission SOAP Envelope
15

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In Sept 2011, esMD successfully implemented the IHE
XDR Profile with inbound ADR Use Case.

• Future esMD Use Cases
• How to accommodate ASC X12 transactions?
o Does CONNECT Support ASC X12 Transactions?
o Are there any NHIN profiles to support the ASC X12 Transactions?
• How to allow outbound transactions from CMS esMD
Gateway to HIH in compliance with FISMA and other security requirement?
• Identify the Technical requirements to expand the esMD Use Cases.
• Provider Profile/ Provider Naming Service etc

INBOUND
 Responses to Documentation Request Letters in PDF
 Appeal Requests in PDF
We Are Here
 Unsolicited Documentation in PDF (called paperwork or “pwk”)
 Structured Orders, Progress Notes, ADMC Requests
 Structured esMD Phase 2 Registration
 etc
OUTBOUND
 Structured Outbound Documentation Requests
 Review Results Letters
 Demand Letters
 etc
LOOKUP
 Request\Receive Documentation Status
 Request\Receive Claim Status
 Request\Receive Appeals Status
 Request\Receive Eligibility Info
 etc
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How to accommodate ASC X12 transactions thru esMD
Gateway?
 Need to build CAQH Transport service (Parallel to XDR) in the CONNECT software by adopting Phase II CORE 270:
Connectivity Rule version 2.2.0 specifications.
 Develop NHIN CAQH CORE X12 Document Submission Profile (Similar to XDR Document Submission)
 Develop the esMD X12 Profile based NHIN CAQH CORE X12 Document
Submission Profile.
 Implement the NHIN CAQH CORE X12 Document Submission Service with in the CONNECT.
 Identify the ASC X12 Translator software to process the
X12 Messages.

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Sample Message: CAQH Phase II CORE 270: Connectivity Rule version 2.2.0 -
X12 824 Application Advice Forwarded Acknowledgment SOAP Envelope
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Enhance CONNECT 3.1 with CAQH Phase II CORE 270: Connectivity
Rule version 2.2.0 Transport Mechanism and esMD X12 Translator

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NHIN CAQH CORE X12 Deferred Document Submission (using three CAQH
CORE Connectivity Generic Batch message interactions) Communication with Multiple SOAP over HTTP/S Connections

Can X12 Message be sent thru the XDR Transactions?
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QUESTIONS?
If more info please contact:
• Melanie Combs-Dyer, RN
Deputy Director,
CMS/OFM/Provider Compliance Group melanie.combs-dyer@cms.hhs.gov
• Dan Kalwa
Health Insurance Specialist, daniel.kalwa@cms.hhs.gov
• Manoj Chaganti esMD Chief Architect, CMS/QSSI mchaganti@qssinc.com
Ph: 847 903 5432
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CMS QSSI esMD Project Confidential Document – Pl. contact Manoj Chaganti, mchaganti@gssinc.com , 847 903 5432
XDR & X12 HIH
XDR HIH X12 HIH
…..
…..
XDR
Transporter
XDR Inbound
Request
/Outbound
Response - NHIN
Orchestration
Document
Submission
ESMD
Gateway
CAQH CORE
Transporter
CAQH CORE X12
Inbound Request
/ Outbound
Response- NHIN
Orchestration
Document
Submission
X12
Translator esMD Translation / Statistical and Business Logic
Application CONNECT 3.x