CMS Seeks to Support Communications between Providers and Carriers

Originally Posted on PCG’s Health Policy News on January 26, 2023.

Author: Eliza Mette

In December 2022, the Centers for Medicare and Medicaid Services (CMS) published a Proposed Rule aimed at improving administrative simplification related to healthcare providers sharing HIPAA-protected information with insurance carriers. The intent of the proposed rule is to ease administrative burdens by simplifying the process providers use for providing carriers with supplemental information about patients and their courses of treatment. Examples of supplemental information can include, for example, a consult note or discharge summary, both of which are protected under HIPAA.  

Healthcare providers are frequently required to submit supplemental documentation to assist carriers in determining whether a service is covered and/or medically necessary, and for other reasons, such as corroborating health care claims and prior authorizations. Providers generally submit additional information to carriers via paper mail, fax, and phone, despite having the option of submitting information electronically as an attachment, as there are no adopted HIPAA standards for healthcare attachments. With this proposed rule, CMS is suggesting new and updated standards for healthcare attachments in order to streamline the process for providers to submit additional information to carriers.  

The key changes outlined in the rule are: 

  • The proposed rule newly defines “attachment information,” to which the new standards apply, as documentation outside of healthcare claims/encounter information transactions and referral certifications/authorization transactions that then enables a carrier to make a healthcare decision. 
  • The proposed rule adds a new Health Care Attachments section to delineate the types of healthcare attachment transactions to which the new standards apply, which include: 
    • Transmissions sent from a provider to a carrier in which the information transmitted is attachment information supporting referral certification and authorizations or healthcare claims; and 
    • Transmissions sent from a carrier to a provider in which the information transmitted is a request for attachment information. 
  • The proposed rule adopts new requirements to better facilitate the transmission of electronic healthcare attachment information: 
    • Adopting the Logic Observation Identifiers Names and Codes (LOINC) code set is intended to help both providers and health plans indicate what kind of attachment information is being requested and shared.  
    • Adopting several X12 Technical Report implementation specifications and Health Level Seven (HL7) attachment implementation guides from those American National Standards Institute (ANSI)-accredited organizations is intended to support healthcare transactions that involve attachment information. Additionally, these standards provide guidance with respect to the content and format of the clinical documentation to be included in those attachments. The specific proposed standards include: 
      • X12N 275 Additional Information to Support a Health Care Services Review 
      • X12N 275 Additional Information to Support a Health Care Claim or Encounter 
      • X12N 277 Health Care Claim Request for Additional Information 
      • X12N 278 Health Care Services Request for Review and Response (Version 6200) 
      • HL7 CDAR2: Attachment Implementation Guide: Exchange of C-CDA Based Documents 
      • HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Draft Standard for Trial Use 
      • HL7 Implementation Guide for CDA Release 2: Consolidated CDA Templates for Clinical Notes (US Realm) Draft Standard for Trial Use 
  • The proposed rule includes a new definition and standards for Electronic Signature, defining “electronic signature” broadly but within the context of electronic health care attachments transactions allowing providers/carriers to approve and verify documentation submitted as attachment information. Electronic signature is defined as “an electronic sound, symbol, or process, attached to or logically associated with attachment information and executed by a person with the intent to sign the attachment information.” The rule proposes adopting the following HL7 standard to support the use of electronic signatures:  
    • The HL7 Implementation Guide for CDA Release 2: Digital Signatures and Delegation of Rights, Release 1 for electronic signatures for attachment information transmitted by a health care provider in an electronic health care attachments transaction. 

Should this proposed rule go into effect, it will aide providers and carriers in transmitting and requesting supplemental patient information by simplifying and standardizing the processes for doing so. The proposed compliance date for the final standards is 24 months after the effective date of the final rule. Anyone interested in providing feedback on the proposed rule should do so by the close of business on March 21, 2023, at which point the public comment period will close. 

Posted by PCG

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