electronic Submission of Medical Documentation (esMD)

electronic Determination of Coverage (eDoC) Workgroup

Oxygen Concentrators and Portable Oxygen (OCPO)

User Story LaunchSeptember 24, 2014

Sponsors & Support

2

PAMELA DURBIN, RN, BSN,CDS, ISSO

Health Insurance Specialist, COR II

CMS / OFM / Provider Compliance Group

DAN KALWA

Health Insurance Specialist,

CMS / OESS

MICHAEL HANDRIGAN, MD

Medical Officer

CMS / OFM / Provider Compliance Group

ROBERT DIETERLE,

Initiative Coordinator

MARK D PILLEY, MD AAFP, AADEP,

ABQAURP

Medical Director

Strategic Health Solutions, LLC

VIET NGUYEN, MD

Chief Medical Information Officer

Systems Made Simple, Inc.

SWETA LADWA, MPH

Project Manager / Epidemiology

ESAC, Inc.

Agenda / Presenter Opening Remarks

S&I Process

Overview of eDoC Workgroup

Related Initiatives

Description of Oxygen User Story

Structured Data

Mapping Oxygen to eDoC and Other Initiatives

Timeline and Summary

Closing Remarks

3

ROBERT DIETERLE

MARK PILLEY, MD

ROBERT DIETERLE

SWETA LADWA, MPH

“…a collaborative community of participants from the public and private

sectors who are focused on providing the tools, services and guidance to facilitate the functional exchange of health information.”

http://siframework.org/whatis.html

Standards & Interoperability (S&I) Framework

Why use the S&I Framework?

It is a robust, repeatable process that will help improve interoperability and adoption of standards and health information technology.

Solution Development Lifecycle

Use Case

• Create Use Case and User Stories• Actors and roles• Activity and Sequence diagrams• Dataset Requirements• Risks, Issues and obstacles• Sub-workgroup effort

• Structured data requirements• Templates for data capture• Decision support

Standards Harmonization

• Identify candidate standards• Create data model(s)• Map data model(s) to candidate standard(s)• Identify gaps, barriers and obstacles• Work with SDOs to address gaps

Implementation Guidance &

Piloting

• Create implementation guide(s) • Identify pilot participants• Develop pilot / demonstration plan• Evaluate success• Modify Implementation guide(s) as

required

Charter• Challenge statement• Timelines and milestones• Goals and outcomes

eDoC Phase Details

5

Related S&I Framework Initiatives

Initiative Description Relationship

Transitions of Care (C-CDA)

Defines the electronic communication and data elements necessary for clinical information exchange to support transfers of care between providers and between providers and patients

Standards for the exchange of clinical information

Provider Directories

Defines transaction requirements and core data sets needed to support queries to provider directories to enable electronic health information exchange

Electronic endpoints for participants in eDoC

Structured Data Capture (SDC)

External template driven capture of structured data within the EHR

Templates and workflow to capture payer required information

Health decisions (HeD)

Decision Support to enable complex workflows based on externally provided rules that enable capture of information and provide guidance for physician ordering

Decision support for data capture and preferred order management

esMD Author of Record

Standards for providing digital signatures to transactions and documentation.

Standards for Digital Signatures on transaction and documents

Direct a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information

Utilize Direct as a transport mechanism between providers, payers and suppliers

Data Provenance (DPROV)

Standards for the provenance of medical record information that is exchanged for clinical or administrative purposes

Provides more detailed information regarding the origin and assembly of data elements in an electronic exchange

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eDoC Workgroup Structure

Sub-WorkgroupsUser Stories

• Power Mobility Devices

• Lower Limb Prostheses

• Home Health Services

• Oxygen Concentrators and Portable Oxygen

Structured Data• Determine documentation

requirements• Evaluate appropriate

clinical elements• Clinical Vocabularies• Define CCDA template

Documentation Templates

• Define template requirements

• Define template workflow• Define EHR data capture

requirements• Specify storage

requirements

Transport

• ASC X12 275, 278, 277• CONNECT• Direct

eDoC Workgroup

Charter Use Case Harmonization Pilots

Consolidated CDA Structured Data Capture esMD eDoC IGs

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esMD Background

Phase I of esMD was implemented in September of 2011. It enabled Providers to send Medical Documentation electronically

Review Contractor

Provider

Request Letter

Paper Medical Record

Phase 1: Doc’n

Request Letter

electronic

electronic

electronicPhase 2:

Before esMD: Healthcare payers frequently request that providers submit additional medical documentation to support a specific claim(s). Until recently, this has been an entirely paper process and has proven to be burdensome due to the time, resources, and cost to support a paper system.

The ONC S&I Framework Electronic Submission of Medical Documentation (esMD) initiative is developing solutions to support an entirely electronic documentation request.

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esMD Process Flow

The overall esMD process can be divided into three steps:

• A provider registers with a payer to receive electronic medical documentation requests (eMDRs)

1. Register to Receive eMDRs

• A payer sends an eMDR to a registered provider

2. Send eMDRs• A provider

electronically sends medical documentation to a payer in response to an eMDR

3. Send Medical Documentation

esMD Phase 2 esMD Phase 1

9

Underlying Challenge:

• Enable provider capture of documentation and benefit determination based on payer rules

• Secure exchange of templates, decision support, and documentation between payers, providers, service suppliers and beneficiary

Scope:• Focus on defining the use case, user stories and requirements supporting a standards-

based architecture• Reuse of existing S&I Initiative efforts where possible• Creation of structured data capture templates and supporting exchange standards• General approach to documentation as the Use Case• Specific benefits as user stories (Oxygen Concentrators and Portable Oxygen (OCPO)

Outcome:

• Successful pilot of templates, decision support, information exchange standards over standard secure transactions for the purpose of determining coverage

• Validation of user story for Oxygen Concentrators and Portable Oxygen (OCPO)

Electronic Determination of Coverage (eDoC)

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eDoC General Workflow

Payer

Patient

LCMP / IDTFSpecialist /Service Provider

Physician

Templates and Rules

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Oxygen Concentrator / Portable Oxygen (OCPO)Oxygen Concentrator / Portable Oxygen (OCPO)

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Improper Payment - OCPO Highest Medicare Improper Payment for Service Types

Billed to DME – Oxygen Supplies/Equipment

$1.2 Billion – 75.2% (CERT Improper Payments, 2013)

No Documentation – 0.3%

Insufficient Documentation Errors – 73.2%

Oxygen Concentrators (E1390) - $1 Billion – 75.6% Overpayment Rate

Claims Containing Errors – 68.1%

(Medicare FFS 2013 Improper Payment Rate Report – Supplementary Appendices )

2006 Office of Inspector General (OIG) Report

“Medicare Home Oxygen Equipment: Cost and Servicing”

• 2004 – Home Oxygen Equipment

• 24% of all Medicare DME, Prosthetics, Orthotics and Supplies (DMEPOS) Costs

• $2.7 Billion of $11.1 Billion total payments for DMEPOS

Service Type Improper Payment

Rate

Improper Payment

Amount

Inpatient Hospitals 8.0% $9.4B

Durable Medical

Equipment 58.2% $5.7B

Physician/Lab/Ambulance 10.5% $9.5B

Non-Inpatient Hospital

Facilities 8.2% $11.4B

Overall 10.1% $36.0B

OCPO Definition

OXYGEN CONCENTRATOR, SINGLE DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE

E1390

OXYGEN CONCENTRATOR, DUAL DELIVERY PORT, CAPABLE OF DELIVERING 85 PERCENT OR GREATER OXYGEN CONCENTRATION AT THE PRESCRIBED FLOW RATE, EACH

E1391

PORTABLE OXYGEN CONCENTRATOR, RENTAL E1392

PORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; HOME COMPRESSOR USED TO FILL PORTABLE OXYGEN CYLINDERS; INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA ORMASK, AND TUBING

K0738

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OCPO Reviews require Suppliers to submit:– Evidence of qualifying test results

• Performed within 30 days before initial date of service (DOS)

– Evidence of in-person visit with a treating physician• Performed within 30 days before initial date of service (DOS)

– Detailed written order

– NCD – Home Use of Oxygen (240.2)• Coverage requires patient testing when in the “Chronic Stable State”• All Co-Existing “Diseases or Conditions that can cause hypoxia must be treated

sufficiently.” • Patient “Must have a severe lung disease”:e.g.;

– “COPD, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or hypoxia-related symptoms or findings anticipated to be improved with Oxygen Therapy.”

OCPO Reviews

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OCPO Reviews require Suppliers to submit:– Certificate of Medical Necessity (CMN)

• Completed, signed, and dated by the treating physician• May act as a substitute for detailed written order• CMS Form 484 (DME form 484.03)

– Proof of Delivery

– Any other medical documentation to support the LCD requirements

OCPO Reviews

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OCPO – Detailed Written Order (DWO)

• Detailed Written Order

– The detailed written order must include: – Patient name; – Detailed description of the items being provided, including:

a. The means of oxygen delivery,

b. The specifics of varying oxygen flow rates and/or non-continuous use of oxygen, and

c. The length of need; – Treating physician’s signature and date order signed; and – Start date of the order (only required if the start date is different from the signature

date)– .

OCPO – Order Requirements

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OCPO DefinitionPORTABLE GASEOUS OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK, AND TUBING

E0431

PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; HOME LIQUEFIER USED TO FILL PORTABLE LIQUID OXYGEN CONTAINERS, INCLUDES PORTABLE CONTAINERS, REGULATOR, FLOWMETER, HUMIDIFIER, CANNULA OR MASK AND TUBING, WITH OR WITHOUT SUPPLY RESERVOIR AND CONTENTS GAUGE

E0433

PORTABLE LIQUID OXYGEN SYSTEM, RENTAL; INCLUDES PORTABLE CONTAINER, SUPPLY RESERVOIR, HUMIDIFIER, FLOWMETER, REFILL ADAPTOR, CONTENTS GAUGE, CANNULA OR MASK, AND TUBING

E0434

• Requires an in-person or face-to-face interaction prior to prescribing• A Written Order Prior to Delivery (WOPD) – required• DMEPOS supplier must have documentation of:

• face-to-face visit, &• completed WOPD prior to the delivery• must be sufficient information documented meeting applicable

coverage criteria are met.

AFFORDABLE CARE ACT (ACA) 6407 REQUIREMENTS

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OCPO Documentation submission methods

– Mail – USPS, FedEx, UPS

– Fax – to secured site

– CD/DVD - Password Protected

– esMD – via HIH

OCPO Submission Methods

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• Order Validation – New

• Prepay Review - Ongoing

• Post-pay Review - Ongoing

Types of Review

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Visits Physician/ Practitioner – Opt Office / EDHospitalized for Respiratory Failure / Exacerbation of COPD / Pneumonia, etc. – Medical Documentation substantiates Requires &/or Benefits from Supplemental O2B

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Documents the in person visit or F2F visit in Medical Documentation, (progress note, medical record, Hospital H&P/Dismissal Summary/Transfer Sheet ) Must include: - Diagnosis supporting need for OCPO, Exam findings, Required

Testing

Writes, signs, and dates DWO andCompletes the CMN

Completes OCPO Delivery

IDTF/Hosp/HomeOrders ABGs, Oximetry, 6-minute walk, PFTs, VO2 Max, etc.Refers for Sleep Study

Obtains Proof of Delivery (POD)

Receives/Files F2F visit progress note, DWO, and CMN

Submits Documentation Package including:• In person visit or F2F visit• DWO• CMN• POD• Other Supporting Documentation

Request Process for OCPO

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Visits Physician/ Practitioner – Opt Office / EDHospitalized for Respiratory Failure / Exacerbation of COPD / Pneumonia, etc. – Medical Documentation substantiates Requires &/or Benefits from Supplemental O2B

en

efi

cia

ry

Ord

eri

ng

P

hysic

ian

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cti

tio

ner

Su

pp

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Documents the in person visit or F2F visit in Medical Documentation, (progress note, medical record, Hospital H&P/Dismissal Summary/Transfer Sheet ) Must include: - Diagnosis supporting need for OCPO, Exam findings, Required

Testing

Writes, signs, and dates DWO andCompletes the CMN

Completes OCPO Delivery

IDTF/Hosp/HomeOrders ABGs, Oximetry, 6-minute walk, PFTs, VO2 Max, etc.Refers for Sleep Study

Obtains Proof of Delivery (POD)

Receives/Files F2F visit progress note, DWO, and CMN

Submits Documentation Package including:• In person visit or F2F visit• DWO• CMN POD• Other Supporting Documentation

Request Process for OCPO - Order Validation

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DWO – Order Validation

eDoC General Workflow

Payer

Patient

DME SupplierPhysician

Templates and Rules

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IDTF / Hosp / Opt Lab

OCPO Documentation & Coverage Requirements

Common Oxygen and Oxygen Equipment Errors MLN ICN 904883 December 2011

1. Missing documentation showing that the patient was seen by a physician within the appropriate timeframes for certification or recertification of the need for oxygen supplies.

2. Missing documentation of original blood gas or saturation test results.

3. Missing documentation indicating that the patient needs or is using oxygen and supplies.

4. Missing documentation to show that the patient is mobile within the home (for portable oxygen).

5. Missing physician order for oxygen supplies.

6. Missing the most recent Certificate of Medical Necessity (CMN).

OCPO Documentation & Coverage Requirements

Overlooked Policy Requirements MLN ICN 904883 December 2011

1. Medicare requires home oxygen to be ordered by a physician after evaluating a patient’s medical need. This visit must occur either prior to, but no earlier than, 2 days prior to the inpatient hospital discharge date, or while the patient is in a chronic stable state. The physician notes must establish the need for oxygen based upon Local Coverage Determination (LCD) requirements and show that the visit (and test) does not exceed 30 days from the Initial Date on the CMN.

2. For Medicare to pay for oxygen equipment, a patient must have both a continued need for oxygen in the home and must also be using the equipment.

3. For patients to qualify for portable oxygen, they must be mobile within the home and be tested under specific conditions (during exercise or at rest).

4. Medicare requires all patients who use home oxygen to first be tested either by arterial blood gas (ABG) or oximetry test (SAT). There must be a record of the test results in the physician’s notes to verify that the test occurred.

OCPO Documentation & Coverage Requirements

Oxygen Documentation Checklist

Medicare requires the following documentation for Medicare oxygen therapy:MLN ICN 904883 December 2011

Detailed Written Order

The detailed written order must include: • Patient name; • Detailed description of the items being provided, including:

– a. The means of oxygen delivery, – b. The specifics of varying oxygen flow rates and/or non-continuous use of

oxygen, and – c. The length of need;

• Treating physician’s signature and date order signed; and • Start date of the order (only required if the start date is different from the signature

date)

OCPO Documentation & Coverage Requirements

Oxygen Documentation Checklist

Medicare requires the following documentation for Medicare oxygen therapy: MLN ICN 904883 December 2011

Coverage – Home oxygen therapy is covered only if all of the following conditions are met:– The treating physician has determined that the patient has a severe lung disease or hypoxia-related

symptoms that might be expected to improve with oxygen therapy. – The patient’s blood gas study meets the criteria stated below.

• The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services.

• The qualifying blood gas study was obtained under the following conditions (a or b): – a. If the qualifying blood gas study is performed during an inpatient hospital stay, the

reported test must be the one obtained closest to, but no earlier than, 2 days prior to the hospital discharge date; or

– b. If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the patient is in a chronic stable state (that is, not during a period of acute illness or an exacerbation of his or her underlying disease).

• Alternative treatment measures have been tried or considered and deemed clinically ineffective.

OCPO Documentation & Coverage Requirements

Oxygen Documentation Checklist

Medicare requires the following documentation for Medicare oxygen therapy: MLN ICN 904883 December 2011

Medicare Qualifying Saturation Test Results – Medicare covers home oxygen therapy only if the patient’s arterial saturation

test results meet the following criteria: – The patient’s test results must be within 48 hours of the date of delivery,

unless the arterial saturation tests were taken during an outpatient encounter or during the patient’s sleep. If tests were taken during an outpatient encounter or during the patient’s sleep, the patient’s arterial saturation test results must be within 30 days of the date of delivery.

– Arterial saturation test results that qualify for coverage are classified into Group I or Group II. The group determines specific CMN requirements. The criteria for each group are listed in Table 1 and Table 2 below. (Following Slides)

Structured Information for OCPO

• Supports• Data collection by providers during in person visit or face-

to-face visit• Reporting of clinical information for coverage

determination• Clinical decision support and automated determination of

coverage

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Evaluation Process for OCPO Structured Documentation

• Examination of individual clinical elements for each section of the template

• Determine if a clinical element is codifiable (e.g. Diagnosis), requires a narrative (e.g. History of Present Illness), or is mixed (e.g. Review of Systems)

• Compare coded elements to existing standard coding systems (e.g. SNOMED-CT, ICD) and CDA components

• Map to CDP1 Template Sections and Entries based on User Story Requirements

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References/Contact Information

LinksesMD Initiative: http://wiki.siframework.org/esMD+Initiative

esMD Program: http://www.cms.gov/esmdesMD eDoC Initiative:

http://wiki.siframework.org/esMD+- +Electronic+Determination+of+Coverage

Contact InformationRobert Dieterle – esMD Initiative Coordinator (rdieterle@enablecare.us)

Sweta Ladwa – ESAC (sweta.ladwa@esacinc.com )

Dan Kalwa – CMS (Daniel.Kalwa@cms.hhs.gov)

Pamela Durbin – CMS (Pamela.Durbin@cms.hhs.gov)

Dr Mark Pilley – Co Lead (m.pilley@strategichs.com)

Dr. Viet Nguyen – Co Lead (viet.nguyen@systemsmadesimple.com

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References for Coverage and Documentation Requirements

• Complete coverage and documentation requirements are outlined in the following policy and CMS Publication:

National Coverage Determination (NCD) for OCPOhttp://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=169&ncdver=1&DocID=240.2&SearchType=Advanced&bc=IAAAABAAAAAA&

CMS MLN Matters - https://www.cms.gov/Outreach-and Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM4389.pdf• Provides further guidance and clarification about

documentation for physicians and treating practitioners when ordering OCPO

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References for Coverage and Documentation Requirements

• Additional Guidance regarding coverage and documentation requirements are outlined in the following CMS Transmittals:

The NCD can be found in transmittal 57, CR4389, athttp://www.cms.gov.Regulations-and-Guidance/Guidance/Transmittals/downloads/R57NCD.pdf

on the CMS website

Claims processing instructions are available in Transmittal 961, CR4389, which is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads?R961CP.pdf on the CMS website

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References for Coverage and Documentation Requirements

• Additional Guidance regarding coverage and documentation requirements for Home Oxygen Use for Cluster Headache (CH) are outlined in the following CMS Transmittals:

Assigned Codes for Home Oxygen Use for Cluster Headache (CH) in a Clinical Trial (ICD-10) – MM7820 – Transmittal #: R2465CP

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7820.pdf

The official instruction, CR7820, is located at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R2465CP.pdf on the CMS website

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References for Coverage and Documentation Requirements

• DME MAC policy regarding coverage and documentation requirements are outlined in the following policies:

• LCDs and LCD Articles for OCPOJurisdiction A LCDJurisdiction B LCDJurisdiction C LCD Jurisdiction D LCD

http://www.cms.gov/medicare-coverage-database/search/search- results.aspx?SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Both&s=All&CntrctrType=10&KeyWord=Oxygen+and+Oxygen+Equipment&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAAAAAAAAAAA%3d%3d&

 

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References for Coverage and Documentation Requirements

• DME MAC policy regarding coverage and documentation requirements are outlined in the following policies:

• LCDs Oxygen and Oxygen Equipment (OCPO)Jurisdiction A LCDhttp://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=11468&ContrId=137&ver=69&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Both&s=All&CntrctrType=10&KeyWord=Oxygen+and+Oxygen+Equipment&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&

Jurisdiction B LCDhttp://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=27221&ContrId=138&ver=44&ContrVer=1&SearchType=Advanced&CoverageSelection=Local&ArticleType=SAD%7cEd&PolicyType=Both&s=All&CntrctrType=10&KeyWord=Oxygen+and+Oxygen+Equipment&KeyWordLookUp=Title&KeyWordSearchType=Exact&kq=true&bc=IAAAABAAAAAAAA%3d%3d&

Jurisdiction C LCD 

http://www.cms.gov/medicare-coverage-database/shared/handlers/highwire.ashx?url=http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx@@@LCDId$$$11446***ContrId$$$140***ver$$$75***ContrVer$$$2***SearchType$$$Advanced***CoverageSelection$$$Local***ArticleType$$$SAD|Ed***PolicyType$$$Both***s$$$All***CntrctrType$$$10***KeyWord$$$Oxygen+and+Oxygen+Equipment***KeyWordLookUp$$$Title***KeyWordSearchType$$$Exact***kq$$$true***bc$$$IAAAABAAAAAAAA$$$$$$***&session=phelks45atn2ebmyr5z3ot55&

kq=876734436

Jurisdiction D LCD http://www.cms.gov/medicare-coverage-database/shared/handlers/highwire.ashx?url=http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx@@@LCDId$$$11457***ContrId$$$139***ver$$$72***ContrVer$$$2***SearchType$$$Advanced***CoverageSelection$$$Local***ArticleType$$$SAD|Ed***PolicyType$$$Both***s$$$All***CntrctrType$$$10***KeyWord$$$Oxygen+and+Oxygen+Equipment***KeyWordLookUp$$$Title***KeyWordSearchType$$$Exact***kq$$$true***bc$$$IAAAABAAAAAAAA$$$$$$***&session=phelks45atn2ebmyr5z3ot55&kq=1789128138 

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References on OCPOs from the DME MACs

• Jurisdiction A: NHIC, Corp.

• http://www.medicarenhic.com/dme

• Jurisdiction B: National Government Services (NGS)

• http://www.ngsmedicare.com/wps/portal/ngsmedicare/home

• Juridiction C: CGS

• http://www.cgsmedicare.com/jc

• Jurisdiction D:Noridian Administrative Services, LLC (NAS)

• https://www.noridianmedicare.com/dme

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Sub Workgroup LLP Structured Data

OCPO – User Story Development

OCPO Pilots

Kick-Off

Oct ‘14 Dec ‘ 14 Feb ‘15Sept ‘14 Nov ‘14 Jan ‘15 Mar‘15

Standards/Data Model/Harmonization

eDoC OCPO Timeline

38

OCPOImplementation

Guide

Apr ‘15

eDoC Timeline

February ‘14October ‘13 December ‘13

eDoC Harmonization and Structured Data

April ‘14 June ‘14 August ‘14 October ‘14 December ‘14 February ‘15

PMD and LLP e-Clinical Template Pilots

LLP User Story

eDoC Administrative Documents Templates IG for HL7 Ballot

We are here

Electronic Determination of Coverage WG

Home Health User Story

eDoC HL7 Clinical Documents for Payers Set 1 Ballot Reconciliation

Oxygen Concentrators and Portable Oxygen User Story

Call for Public ParticipationAs an S&I Initiative, esMD is requesting public participation and input to identify and assess existing standards and define requirements for the eDoC OCPO User Story

• Targeted Participants:• Medicare, Medicaid, and Commercial Payers• Providers, Provider Organizations • Service suppliers (e.g. DMEs)• Health Information Handlers (HIHs)• HIT/EHR Vendors and Vendor Associations• State HIEs, HIE Vendors• SDOs• Others with Expertise/Interest in Coverage Determination, Structured

Documentation, Decision Support, and Pre-authorization,

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Summary

eDoC workgroup identifies Best Practice for:1) Payer interaction with providers for determination of coverage

2) Developing, delivering and using structured information to support coverage determination

3) Addressing Author of Record requirements

4) Establishing secure electronic communication between payers, provider, suppliers and beneficiaries

5) Creating implementation guides for payers and providers for all required eDoC processes and transactions

The focus for next user story is on Oxygen Concentrators and Portable Oxygen (OCPO)

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Next Steps• The electronic Determination of Coverage Workgroup is open for anyone

to join. This community will meet weekly by webinar and teleconference from 1:00 to 2:00 pm ET on Wednesday see S&I Framework calendar for webinar information: http://wiki.siframework.org/Calendar

• Information on how to join the esMD Community can be found on the electronic submission of Medical Documentation (esMD) page: http://wiki.siframework.org/esMD+Initiative

• In order to ensure the success of the eDoC efforts, we encourage broad and diverse participation from the community. Wide community participation will ensure that the standards reflect technology that is useable across the industry and meets the needs of all stakeholders.

• This is your chance to have an impact on the evaluation and selection of standards, in addition to the creation of business requirements and implementation guides for the electronic Determination of Coverage OCPO User Story

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Thank You

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