AoR+UC+L1+-+User+Story

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Scenarios are comprehensive description of the actors, interactions, activities, and requirements associated with the information exchange. It is a prototypical sequence of interactions in a business collaboration or the application context. Scenarios pertain to supporting the health information exchange and, describing key flows, and are supplemented by User Story / Stories.

The below content is current as of the 8/8 meeting where it was reviewed and updated.

A Provider Entity with a digital identity has successfully registered with a Payer Entity to receive electronic Medical Documentation Requests (eMDRs) in support of a claim. In response to the eMDR, the Provider Entity is able to send requested Medical Documentation as a digitally signed, aggregated document bundle. The Payer Entity is able to validate the submitter and integrity (not the accuracy of the content) of the Medical Documentation* submission by the Provider Entity.
 * AoR Scenario **

A User Story summarize the interaction between the actors of the Use Case, and specify what information is exchanged from a contextual perspective. Furthermore, the User Stories describe the real world application as an example of the Scenario. These interactions are further described in subsequent sections. Historically, user stories have been utilized to provide clinical context

The below content is current as of the 8/8 meeting where it was reviewed and updated.

In order to participate in esMD, both Payer and Provider Entities obtain and maintain a non-repudiation digital identity. Both actors initiate the process to obtain a digital certificate from a Federal Bridge cross certified Certificate Authority (validate with Commercial payers). Entities approved by a Registration authority will receive Credentials from a Certificate Authority to incorporate into their business process.
 * AoR User Story **

Provider Entity with digital credentials submits a request to the Payer Entity to receive electronic Medical Documentation Request (eMDR). The Payer Entity checks the Provider Entity’s ability to receive such requests with an External Provider Directory. The Provider Entity receives a response either confirming or rejecting the request to receive eMDRs from the Payer Entity. For additional details refer to esMD PPA UC 1.

When a Payer Entity identifies the need for additional documentation, they must first check to see if Provider Entity is registered to receive an electronic request (eMDR). If registered, the Payer Entity requests the current Electronic Service Information (ESI) of the Provider Entity from the External Provider Directory. Upon receiving the current ESI, the Payer Entity is able to send the encrypted and digitally signed eMDR to the Provider Entity. For additional details refer to esMD UC 2.

The Provider Entity, who has satisfied the esMD registration requirements, receives an eMDR from the Payer Entity, assembles the relevant Medical Documentation, applies a non-repudiation digital signature to each document bundle, and sends them to the Payer Entity.

Upon receiving the digitally signed bundle of relevant Medical Documentation, the Payer Entity validates the following: Digital Certificate and chain to Federal Bridge, delegation of rights where required, Signature Artifact and confirms that the signer is a registered Provider Entity or has signature rights delegated by the registered Provider Entity. Additionally, the Payer Entity decrypts the hash of the document bundle and validates data integrity of the Medical Documentation received. (Note - The Payer Entity does not validate the accuracy of the Medical Documentation received.) Payer Entity sends an acknowledgement of the success or failure of the validation performed by the Payer Entity to the Provider Entity.

*Medical Documentation - Clinical documentation or non-clinical documentation necessary to support the process for a claim or preauthorization for the delivery of health care services. Examples include, but are not limited to, medical records created during the delivery of services that are subject of the claim, records related to costs associated with the delivery of services (e.g. receipts for devices or transportation), and records that establish the need for covered services.

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