Project Overview

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Project Overview

The purpose of the project is to demonstrate the use of the electronic claim attachments between Empire Medicare Services (EMS) and selected providers: Memorial Sloan Kettering Cancer Center, Montefiore Medical Center, and Princeton Medical Group, using the proposed X12 277and 275, and the HL7 CDA-based attachment specifications and LOINC codes. The current state for EMS is that the transactions are not generated or received via the front-end application or the shared systems (FISS or MCS). Instead, requests for additional claim attachment information is a paper report process. The desired state (goal of project) is to generate the requests for additional claim information via the X12 277 version 4050. Our participating providers will translate the 277 request and return the X12 275/CDA version 4050. The 275 will contain codified answers to the 277 questions or imaged/text data placed in the BIN segment. EMS will translate/display the 275/CDA and display the response via a client/server application to the medical review examiners. To accomplish the project's goals, the generation of the 277 must be developed as well as the translation/display of the 275 and the client server application.

Project Scope

The project will require the support of the Medicare Part A and Part B NJ Systems departments, Client Server Systems, Electronic Commerce, Medical Review, and EDISS (front-end application). Support will also be required from Corporate Data Network Engineering and Information Security/Security Oversight. Budget and Cost will be required to provide Productivity Investment (PI) funding tracking reports and resulting CMS reporting. Development of the translation/processing of the 277 and 275/CDA will be outsourced to a selected vendor. CMS and the WEDI Foundation will provide a small oversight/technical advisory committee of volunteers. The committee will provide review of project status reports and the criteria for evaluation of the pilot. This is a proof-of-concept pilot project, and therefore FISS and MCS shared system changes will not be utilized.

Project assumptions are as follows:

The project results will be a proof-of-concept, not a working model, and therefore will not be production-ready.
The translation programs developed with the CMS PI funding will belong to CMS and may be used in the future for the shared system software.
The 275/CDA will not be processed on the mainframe, as additional CPU utilization cannot be accommodated. This design supports a solicited 275/CDA only.
There will be no systematic updates from the receipt of the 275/CDA. All claim adjudication will be based upon the Medical Examiner manual review of the data.

Project Objectives

277 transaction successfully translated by the provider as compared to the paper interpretation.
The provider is able to successfully generate the 275/CDA using the medical record information at their facility/office.
275/CDA transaction successfully translated/displayed by EMS as compared to the paper attachment.
Medical claims examiners are able to make a claim adjudication decision based upon the C/S application display.

External Factors

Pilot completion is dependent on the participating providers’ ability to process the transactions.
Should the NPRM be released, it could impact the version and attachments types used.