Ballot SubmissionTriage & Committee ResolutionBallot Comment Tracking
Comment NumberBallotChapterSectionPage #Line #Artifact IDResource(s)HTML Page name(s)URLVote and TypeSub-categoryTracker #Existing WordingProposed WordingBallot CommentSummaryIn person resolution requestedComment groupingScheduleTriage NotePubsDisposition WGDispositionDisposition Comment or Retract/Withdraw detailsDisposition/Retract/ Withdrawal DateMover / seconderFor AgainstAbstainRetracted / WithdrawnDisposition External OrganizationResponsible PersonChange AppliedSubstantive ChangeSubmitted ByOrganizationOn behalf ofCommenter EmailSubmitter Tracking IDReferred ToReceived FromNotes
1ASIGVIIAA-CSkill sets listed indicate knowledge requirements and resources based on how different organizations are configured (i.e., payer, clearinghouses, provider staff). However, the section does not actually discuss skill sets. Rather, it discusses personnel configuration. The white paper would be clearer and more usable if the actual skills required were aligned with how some organizations structure such skills, rather than relying on the organizational structure alone. E.g., clinical review to analyze consistency with authoriztion and level of service and setting algorithms - common staff considerations = clinicians, medical records expertise (provider), clinical data review = clinicians (payer), etc. The bottom line is that attachments are required to provide necessary clinical information to assure the request for coverage addresses available benefits and services and to align available resources with those requirements. In that regard, the attachments have basic requirements - identification and constraint of clinical summary information specific to the authorization or coverage request. It will help to start out the white paper with something similar to this statements to set the stage.Floyd Eisenberg
2ASIGAppendix BA-CSome examples are unusable due to the complexity of the content (e.g., page 50 - CDA body, page 60-64 - Structured C-CDA R2 Operative Notes Base64 Encoded). Consider more usable examples.Floyd Eisenberg
3ASIGGeneralNEGThe document addresses a number of use cases. However, establishing whether a patient has received services expected with respect to a quality measure is definitely missing. Whether the information needed is constrained using QRDA category I or another constrained cCDA or FHIR measure report, the information may be included in an attachment and the white paper should address that issue.Floyd Eisenberg
4ASIGI7A-SThis white paper is a resource document for implementers to use to help them get started in their implementation planning for the request and receipt of electronic attachments.This white paper is a resource document for implementers to use to help them get started as guidance in their implementation planning for the request and receipt of electronic attachments.This paper is a guide to implementation of standard (matching to the title) Purpose to be aligned to document titleLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
5ASIGI7A-SBackgroundMore additional information to be provided on clinical and administrative data sources to be combined for attachments to payersIt would help understand the combination of EDI transaction (administrative) with the documentation/attachment (clinical) More background information needed to help understand rationale for combining X12 and HL7Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
6ASIGII7A-SFor definitions of abbreviations, acronyms and other terms used throughout this paper refer to Appendix A of the HL7 CDA R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 – US Realm.For definitions of abbreviations, acronyms and other terms used throughout this paper refer to Appendix A of the HL7 CDA R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 – US Realm.Wrong reference to AppendixRemove wrong reference to AppendixLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
7ASIGII7A-SA guidance on how to embed additional information within the applicable ASC X12N transaction.A guidance on how to embed additional information (clinical information in HL7 standards) within the applicable ASC X12N transaction.Not clear why the approach to have the X12 and HL7 combinationReason for the approach to have the X12 and HL7 combinationLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
8ASIGIIIA8A-SIn the course of doing business, payers may need additional information from a provider to determine if the service being billed or requested is consistent with medical policies.This paragraph is missing scenarios that should be included such as prior authorization and unsolicited claim documentation.Missing scenarios as reasons for exchanging attachmentsNeed to elaborate on reasons for exchanging attachments or documentationLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
9ASIGIIIB8A-SWhat Additional Information is Exchanged?Documentation of a Physician Order is not included in C-CDA but is covered in CDP Set 1. A paragraph on the CDP Set 1 standard (covering for payer) will be helpfulMore documentation types to be listedAdditional information on HL7 CDP Set 1.Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
10ASIGIVA10A-SInternet –trading partners use Secure FTP or other secured protocolsInternet File Transfer or other – trading partners use Secure FTP or other secured protocolsInternet term is too generalSpecific term to be used for method of exchangeLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
11ASIGIVA10A-CClaim Denial - Payer denies payment for a claim, indicating the need for additional information as requested. This would trigger an appeal or resubmission of the claim with the additional information.Not applicable in this list of "methods used today". It is a trigger for exchange but not the method of exchangeNot applicable in the list of methods of exchangeClaim Denial can be a trigger to attachments exchangeLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
12ASIGIVA10A-SExamples of methods used today are:Though relatively low volume, may have to include additional method, Electronic Submission of Medical Documentation (esMD) as implemented for Medicare Fee-for-Service (FFS) programsMissing to add esMD - standards used from ONC guidanceInclude esMD as another method of exchangeLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
13ASIGIVB10A-AParagraph A describes the way attachments are exchanged today and includes a list. Paragraph B seems to make the same statement without the list. Are both needed? Either consolidate the two sections, or make a clearer distinction between the Request and Response. Suggest also indicating that utilization management is connected to prior authorization - here or earlier in the document. Is the content in A and B redundant or is it intended to reiterate what was stated above? Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
14ASIGIVC11A-SIn the case of a small physician practice, the mail typically goes to one location and the routing of documentation may not be an issue. However, larger practices and institutional facilities may receive the information into a central billing office or mailroom. The information is then routed to the appropriate provider or department within the provider’s organization to determine how to respond to the request or if it is necessary to forward on to another department. This manual routing to multiple locations may result in the information getting lost.In the case of a small physician practice, the mail typically goes to one location and the routing of documentation may not be an issue. However, larger practices and institutional facilities may receive the information into a central billing office or mailroom. The information is then routed to the appropriate provider or department within the provider’s organization to determine how to respond to the request or if it is necessary to forward on to another department. This manual routing to multiple locations may result in the information getting delayed, misrouted or lost.thought it might be helpful to have additional dispositions for what happens to information when it is manually routed rather than that it might only get lost. Unless that is all that ever happens with manual routing. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
15ASIGIVC11A-QFor privacy reasons, some information must be redacted before sending to the payer.Suggest reference to considerations about redacting information and privacy to the bottom of this section, since both small and large health care providers will make the same considerations in their submissions. This does not only apply to small providers. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
16ASIGIVE12A-AIf the payer receives a document in response to a request the document is usually imaged or scanned and stored in an image database. If information is received as an image, the image itself is stored.If the payer receives a document in response to a request, the document is usually imaged or scanned and stored in an image database. If information is received as an image, the image itself is stored.added a commaLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
17ASIGVB13A-TWhen the attachment is received through fax, mail or other methods, the payer may have challenges matching it to the claim or prior authorization. This causes delay in finalizing the claim or reacting to the prior authorization. It may also result in denial due to lack of additional information, which results in delayed adjudication or patient care.When the attachment is received through fax, mail or other methods, the payer may have challenges matching it to the claim or prior authorization. This causes delays in finalizing the claim or reacting to the prior authorization. It may also result in denial due to lack of additional information, which results in delayed adjudication or patient care.corrected the word delay - made it delays. If that was the intent.Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
18ASIGVI14A-AThe current workflow for Attachments has significant challenges that can be addressed as the industry moves to the exchange of standard electronic attachments.This paper has described the challenges for the current workflow for Attachments. These can be minimized when the industry moves away from the manual way it exchanges additional information (attachments), and transitions to the use of standard electronic transactions to conduct these activities. Certainly word smith the proposed language. Just trying to make the bridge between what has been described before, and what will be explained in the rest of the paper. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
19ASIGScopeII7A-SHL7 CDA R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 – US Realm. Please verify that this and every document referenced in the white paper are named correctlyPlease verify naming of all documents referenced in the white paper, and links on appropriate web sites so that stakeholders can easily obtain them. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
20ASIGGeneralA-SASC X12 throughout the document X12 consider updating all references to X12 and removing the ASC since I believe that is no longer used by the organization. Please verify that this is the correct understanding for how the SDO is to be referred to now. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
21ASIGScopeII7A-TA guidance on how to embed additional information within the applicable ASC X12N transactionGuidance on how to embed additional information within the applicable X12 transactionI don't think X12 uses the ASC or "N" when referring to their standards anymore to the best of my knowledge. I could be wrong, but we are not using it in our documents at HHS. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
22ASIGDisclaimer4A-QThis document is Copyright © 2017 by The Workgroup for Electronic Data interchange (WEDIThis document is Copyright © 2017 by The Workgroup for Electronic Data interchange (WEDI), HL7 and X12Since the document will be housed on the websites of all of the authoring organizations, should all of them be referenced in the disclaimer, or is WEDI the organization that will own the document once it has gone through ballot?Just a general question about why the disclaimer only references one organization, but three organizations are named on the front page. Also, in the footer, the name of the document is HL7 guidance, but the author is WEDI. Will there be any confusion for industry? Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
23ASIGVIIB17A-SReference materials For LOINC, please provide citation and link to specific resource that will be needed to implement attachments. Also, discuss issues pertaining to accessibility of the LOINC database when there are firewalls. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
24ASIGVIIC.219A-CThe ASC X12 824 Application Reporting for Insurance may be used to report the error codes for the HL7 contentIt is unlikely the components exist in the Error Code list with the proper granularity to indicate the level of specificity to clearly identify the errored data component in the XML structureWould suggest a complete review of the error message components available for use in the proposed X12 824 transaction.Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
25ASIGVIIC.220A-CUnstructured documents are required to be Base64 encoded when the provider sends the ASC X12N 275/HL7 C-CDA to the payerNAGiven the changes to the environment since the initial Pilot and the uptick in Security rules organizations have had to implement recently, there should be a review of the Stylesheet premise in order to confirm that all platforms can open and view content. Currently my organization's policy does not allow for certain XML payloads to be opened and viewed.Would suggest a simple review of the computer configuration requirements which allow for the human viewing capabilities of the content. May require some type of guidance/cautionary explanation when XML type files are unable to be opened due to corporate security policies.Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
26ASIGVIIB17A-Cmaterials are essential to implementing attachments and are located on the HL7 website. • Quick Start Guide for CDA R2 • HL7 Consolidated Clinical Document Architecture Release 2 (C-CDA R2) • HL7 CDA® R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 – US Realm (STU) (HL7 Guide) • HL7 CDA® R2 Implementation Guide: Exchange of C-CDA Based Documents; Periodontal Attachment, Release 1 - US Realm • HL7 Companion Guide for C-CDA R2 • HL7 Clinical Documents for Payers Set 1 (CDP1) • HL7 Digital Signatures and Delegation of Rights Release 1 There are inconsistencies in the title and specific versions of the documents referenced here and those found oin the HL7 Website. Note: the page numbers in this document do not align with the version of the document on the WEDI websiteThese should be reviewed and correctedLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
27ASIGVIIC18A-SPayers should determine whether to continue using the same document system in place for paper attachments or move to a client server application or an imaging system.Payers should determine whether to continue using the same document system in place for paper attachments or move to a client server application or an imaging different system.client server applications is one of the many waysWith several options including cloud solutions, keeping it generic as different system covers all Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
28ASIGVIIID23A-SThe payer or UMO first determines the appropriate LOINC code for the information required and includes that in the request. Set any applicable parameters around the information being requested (i.e., a time period) by using a LOINC Modifier code. For more information about selecting LOINC codes and LOINC Modifier codes refer to the HL7 Guide. The Payer or UMO then sets any applicable parameters around the information being requested (i.e., a time period) by using a LOINC Modifier code?Not sure if the suggested edit is correct, but the sentence seemed somewhat incomplete just starting with "Set" Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
29ASIGVIIIC231st PA-CThere is a problem with corporate configurations of computers that precludes the installation of the tools that support the LOINC lookup. This causes the user to revert to the manual research on the LOINC webpage and adds to complexity and can create errors. Suggest the committee work with the LOINC committee to potentially develop a version which will be compatible with stakeholder systems who will be using the HIPAA Claims Attachment, especially organizations that might have strict corporate computer configurations which preclude users from installing non-approved software locally. Vetting through a process to obtain entry to a corporation's approved software list is not a short timeline, if the approval can be obtained at all. This might be a good topic for inquiry across industry. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
30ASIGVIIIF252nd PA-CIn addition to the ASC X12N 275 listed above a variety of transport options are available for exchanging any C-CDA document. For more detail on these options refer to Appendix E in the HL7 Guide.Appendix E does not exist in the document. Should correct and revise the document. Also, should probably be specific when referencing "HL7 Guide" and indicate exactly which Guide is being discussed. Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
31ASIGVIIIG25A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
32ASIGIXA26A-SFigure 1: Solicited Claim FlowInclude Transaction sets X12N 277, X12N 275 being used in the figure at the applicable locationsMissing transaction namesAdd transaction names for more detail in the figureLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
33ASIGIXA27A-SFigure 2: Unsolicited Claim FlowInclude Transaction set X12N 275 being used in the figure at the applicable locationMissing transaction nameAdd transaction name for more detail in the figureLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
34ASIGIXB28A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
35ASIGIXC31A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
36ASIGIXD33A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
37ASIGIXE34A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
38ASIGXA43A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
39ASIGXB47A-ALorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
40ASIGAdd section or a question related to using HL7 FHIR resources Lorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
41ASIGAdd section or a question related to using Health Information Exchanges who may already have the documentation needed by the payerLorraine DooCenters for Medicare & Medicaid Services/CPI/PCG
42ASIGIVA10A-SClaim Denial - Payer denies payment for a claim, indicating the need for additional information as requested. This would trigger an appeal or resubmission of the claim with the additional information.This isn't a "method for attachment submittal", it's a different use case when an attachment is requested. Either specify how the response to a Denial follows different methods from the other items in the list, or remove this bullet from the list entirely.Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
43ASIGIVC11A-SFor prior authorizations, requests for additional information are routed to appropriate clinical staff (physicians, nurses, clinical coordinators, practice administrators) to complete before providing the requested treatment, which can often delay patient care.For prior authorizations, requests for additional information are routed to appropriate clinical staff (physicians, nurses, clinical coordinators, practice administrators) to complete before providing the requested treatment.It's not clear what is trying to be conveyed here - are we saying that OBTAINING prior authorizations from providers delays patient care? Given that we're simply talking about processes in this section, recommend removing the qualifier that this "can often delay patient care".Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
44ASIGIVD11A-SFor Prior Authorizations…For Prior Authorizations, payers review the content provided to determine whether or not to provide the requested authorization, and while Internal Utilization Management (UM) workflows are unique, most have standard turn-around times to complete the review and provide an adjudication of the request.This section as written doesn't provide an explanation of the high-level Payer objective when reviewing Prior Authorizations. It would be good to add clarifying information to the introduction sentence. Proposed wording provided, but please rewrite as you see fit to accomplish this goal.Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
45ASIGVE13A-SThe provider may struggle with what the payer is requesting and to what degreeThe provider may struggle with understanding exactly what information the payer is requesting and what degree of documentation is required.Rewriting for better clarityChris HillsDOD/VA Interagency Program Officerott@deloitte.com
46ASIGVIIC.118A-SThe HL7 C-CDA examples are created using the R2 version.There's no version "R2" of the C-CDA. The primary versions in use are 1.1 (ONC 2014 Edition Certification Criteria), and 2.1 (ONC 2015 Edition Certification Criteria)Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
47ASIGVIIC.218A-SPayers should determine whether to continue using the same document system in place for paper attachments or move to a client server application or an imaging system.Payers should determine whether to continue using the same systems they've used for paper attachments, or if technology changes would be beneficial, such as adopting an imaging system, document management system, or other modern application infrastructure.I wouldn't be so specific about types of solution architectures Payer might want to adopt.Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
48ASIGVIIIA22A-AThe HL7 Guide used for the clinical portion of the Attachment allows for two situations. The submission of additional information as a response to a request from the payer (Solicited). The additional information may also be based on a set of pre-defined rules by the payer or in state mandates without a specific request (Unsolicited).The HL7 Guide used for the clinical portion of the Attachment allows for two situations: - The submission of additional information as a response to a request from the payer (Solicited). - The submission of additional information based on a set of pre-defined rules by the payer or in state mandates without a specific request (Unsolicited).A slightly different organization with bullets will increase readibilityChris HillsDOD/VA Interagency Program Officerott@deloitte.com
49ASIGVIIIB22A-SIt is imperative that the appropriate template be used when available. For example, if an operative note is being used, the operative note template must be used, not the progress notes template.Different document templates in the C-CDA exist to reflect different use cases, and each has a different collection of information designed to align to that use case. Once a given document type has been selected to be used, it's important to to ensure implementations are compliant with the corresponding document template in the C-CDA guide.As written it didn't really make sense what was trying to be conveyed - I drafted alternate language that might make more sense.Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
50ASIGVIIIB22NEGA structured body does not necessarily require all the data to be codified and may include narrative text.Each section within a structured body does not necessarily require all the data to be codified and may only include narrative text.As written the statement is inaccurate - all sections REQUIRE "human-readable" text, and only some require coded data.Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
51ASIGVIIIB22NEGC-CDA also allows for unstructured documents in formats supported by HL7 Guide for CDA®, Release 2: Unstructured Documents. Implementers should refer to the C-CDA Implementation Guides for more information about unstructured documents.Each version of C-CDA also contains a Document Template for an Unstructured Document, which can be used to effectively attach a standard C-CDA document header to many different types of common files, instead of building a XML-based document body. Implementers should refer to the C-CDA Implementation Guides for more information about unstructured documents.To really be using "C-CDA", you need to follow the Unstructured Document Templates within the versions of the C-CDA standard, not other guides that might have guidance on Unstructured Documents.Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
52ASIGVIIIG25A-SThe ASC X12N 275 BDS segment doesn’t currently require the HL7 standard in the BDS03 element to be Base64 encodedThe ASC X12N 275 BDS segment doesn’t currently require an HL7 C-CDA document in the BDS03 element to be Base64 encodedI think we're talking about encoding a "C-CDA Document" not an "HL7 Standard".Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
53ASIGAppendix B47A-CThe following examples are not complete and are only meant to show what a Base64 encoded document looks like.I'd recommend adding a link to the ONC site hosting C-CDA samples: https://github.com/chb/sample_ccdas You also might want to include a link to the searchable HL7 CDA Example Search tool: http://hl7-c-cda-examples.herokuapp.com/Chris HillsDOD/VA Interagency Program Officerott@deloitte.com
54ASIGA-TA. How is Additional Information Exchanged Today?Check dashses '-' in bulleted listSome are word dashes, others are missing spaces.Brett MarquardDOD/VA Interagency Program Officebrett@waveoneassociates.com
55ASIGI-VA-CN/AN/AVery nice background, clearly outlines the challenges.Brett MarquardDOD/VA Interagency Program Officebrett@waveoneassociates.com
56ASIGHL7 Reference MaterialsA-CHL7 Consolidated Clinical Document Architecture Release 2 (C-CDA R2)update to 2.1C-CDA R2.1 is the version EHRs have implemented.Brett MarquardDOD/VA Interagency Program Officebrett@waveoneassociates.com
57ASIGHL7 Reference MaterialsA-CHL7 Companion Guide for C-CDA R2update to 2.1C-CDA R2.1 is the version EHRs have implemented.Brett MarquardDOD/VA Interagency Program Officebrett@waveoneassociates.com
58ASIGHL7 Reference MaterialsA-CHL7 Guide for CDA®, Release 2: Unstructured Documents.N/AUjpdate to Unstructured Document in C-CDA R2.1Brett MarquardDOD/VA Interagency Program Officebrett@waveoneassociates.com