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July 26, 2017: Coalition calls for electronic attachment standards

Advocacy Letter - July 26, 2017

Health Information Technology

July 26, 2017

The Honorable Tom Price, MD
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201


Re: Recommendations for the Electronic Health Care Attachment Standards

Dear Secretary Price,

The undersigned organizations representing healthcare stakeholders that include providers, health plans, clearinghouses, and vendors, write today to urge adoption of national standards for electronic healthcare attachment transactions by the Centers for Medicare & Medicaid Services (CMS). These transactions will bring significant return on investment through simplified administrative processes, clinical data exchange improvements, and fraud prevention opportunities. Efficiencies associated with electronic attachments will also directly result in improved flow of clinical information and enhancement of the patient care delivery process. The implementation of these standards will result in substantial cost savings, not only to providers and commercial health plans, but also to government health programs. As part of your efforts to drive out needless waste from our healthcare system and improve the care patients receive, we urge you to take immediate action on these long-awaited transaction standards.

Transmitting clinical data using administrative transactions is commonplace in today’s healthcare environment. Often this data is required to support claim submission and prior authorization requests. Yet even when the claim or prior authorization transaction itself is sent electronically, using national standards adopted by the CMS, the supporting clinical documentation must be sent manually, often via fax or mail. The result is costly and inefficient movement of data that can delay payment for medical services and even delay the care patients need. The adoption of these standards for electronic attachments would greatly improve and streamline administrative transactions and improve clinical data exchange. Transitions of care, care coordination and care management, as well as clinical quality reporting would be enhanced with a standard for electronic attachments. Significant stakeholder savings would result from reduction in phone calls, mailings, claim denials and claim appeals. Further, by simplifying and standardizing the movement of clinical data, electronic attachments would serve to support the nation’s move to alternative healthcare payment models.

The National Committee on Vital and Health Statistics (NCVHS), a statutory advisory committee with responsibility for providing recommendations on health information policy and standards to the Secretary of the Department of Health and Human Services, has on three occasions issued recommendations to move forward with the adoption of a national electronic attachment standards, most recently in its July 5, 2016 letter.

On July 18, 2017, The Division of National Standards, CMS, under the leadership of Madhusudhan Annadata, agreed to meet with the coalition of key healthcare stakeholders to hear the many potential applications and benefits possible with the adoption of these attachment transaction standards, and to review again the NCVHS recommendations that have been made in the past. The broad coalition included representation from the provider community (American Medical Association, American Hospital Association, the American Dental Association, and the Medical Group Management Association); payer community (Blue Cross and Blue Shield of Alabama and Health Care Service Corporation, Humana, National Government Services, Medicare Fee for Service, and UnitedHealthcare); IT vendor community (Cooperative Exchange, The National Clearinghouse Association, and software vendors Cerner and Epic); and Property and Casualty (Jopari Solutions). Please refer to the attached documents regarding the meeting agenda, organization attendees, and presentations.

Collectively, stakeholders communicated the importance of adoption of the standard to ensure that: (i) the adopted healthcare attachment transaction standards are applied to not just claims, but also prior authorization, referrals, and potentially other administrative processes directly related to the claims payment process; (ii) attachment standards are defined and adopted for three types of transactions – query, response, and acknowledgment; (iii) attachment standards support submission of structured and unstructured data; (iv) the attachment transaction process adopted supports both “solicited” and “unsolicited” attachment situations; and (v) data that is already part of the original transaction for which an attachment is being generated, is not allowed to be requested again in an attachment.

The meeting highlighted the unequivocal consensus to move forward expeditiously with adoption of the electronic attachment standards. This consensus included identification of the following standards:
  • ASC X12 275 Attachment Transactions
    • 275 Additional Information to Support a Health Care Claim or Encounter
    • 275 Additional Information to Support a Health Care Services Review
  • Query
    • ASC X12N 277 Health Care Claim Request for Additional Information
    • ASC X12N 278 Health Care Service Review – Request for Review and Response
  • Response
    • X12 275 transaction as a vehicle for transportation, and
    • HL7CDA R2.1 IG Consolidated CDA Templates for Clinical Notes
    • HL7 CDA® R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents
    • ANSI-approved ADA Standard No.1079, electronic dental attachments
    • HL7 Implementation Guide for CDA® Release 2: Periodontal Attachment R1- US Realm
  • Acknowledgment
    • ASC X12 Acknowledgment Reference Model (ARM)
  • Attachment Supporting Code Sets
    • Logical Observation Identifier Names and Codes (LOINC) – HIPAA Panel
    • SNODENT® clinical code set for dental attachments
    • SNOMED CT®

As you seek to modernize and automate the nation’s healthcare delivery system, we urge you to move quickly and adopt this important administrative simplification standard. As representatives from key stakeholder groups, we believe the time is now to release a regulation specifying the electronic attachment standards. Thank you for your consideration of the recommendations outlined in this letter, and we look forward to working collaboratively with you to address this issue and other important challenges. Please feel free to contact Sherry Wilson, Board Chair of the Cooperative Exchange for additional information at or phone at: (510) 504-4100.

The following list of organizations are in support of the electronic attachment standard recommendations stated above. In addition, due to their corporate policies, other Coalition members and industry organizations may send separate letters in support of these recommendations.

American Dental Association
Blue Cross and Blue Shield of Alabama
Change Healthcare
Jopari Solutions
Medical Group Management Association
Office Ally
The Cooperative Exchange, The National Clearinghouse Association
Workgroup for Electronic Data Interchange

CC: The Honorable Seema Verma, Administrator, Centers for Medicare & Medicaid Services
Madhusudhan Annadata, Director, Division of National Standards, Centers for Medicare & Medicaid Services
Cora Tracy, Director, Program Management and National Standards Group, Centers for Medicare & Medicaid Services
Scott Shippy, Deputy Director, Program Management and National Standards Group, Centers for Medicare & Medicaid Services
George C. Hoffmann, Acting Chief Information Officer and Director, Office of Information Technology, Centers for Medicare & Medicaid Services
Janet Vogel, Deputy Director for Operations and Deputy Chief Information Officer, Office of Information Technology, Centers for Medicare & Medicaid Services
Karen Jackson, Deputy Chief Operating Officer, Centers for Medicare & Medicaid Services

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