Structured+Content+-+Dataset+Requirements+of+the+electronic+Medical+Documentaiton+Request+(eMDR)





= The content within this page has been incorporated into the full Use Case posted here =

Cover Letter Section
Time || No || Date and Time of the eMDR || This is a timestamp created by the originator of the request and propagated by all intermediaries ||
 * ** Section ** || ** Data Element ** || ** Multiple Values (yes/no) ** || ** Data Element Description ** || ** Additional Notes ** ||
 * ** Unique eMDR ID ** || Unique eMDR ID || No || Unique ID for this eMDR || eMDR IDs must be globally unique across all payers and able to accommodate expected request volumes (Ex. UUID). Unique ID may be a concatenation of more than one data element. ||
 * ** Timestamp ** || Date
 * **__ Payer Information __** || __ Payer Demographics __
 * Organization Name
 * Organization Address
 * City
 * State
 * Zip Code ||  || The organization’s name, street address, city, state, and zip code ||   ||
 * ^  || Unique Payer Identifier || No || Unique ID of the Payer || In anticipation of a National Health Plan ID (HPID). There are other values that can be used in absence of the HPID ||
 * ^  || * Signature Artifact || No || Signature artifact encrypted by owners private key || Exact nature of artifact to be determined during harmonization ||
 * ^  || * Public Digital Certificate || No || X.509 Token Profile || Signed by trust authority ||
 * ^  || __ Payer Contact information __
 * Person / Role / Department
 * Telephone Number
 * Email
 * Fax
 * URL || No || Information used to contact the organization

The URL to be provided by payer for online communication between provider and payer || Contact would include a person OR department OR Role. Contact information is optional || __ Demographics __
 * **__ Payer Contractor Information __** || __ Payer Contractor __
 * Organization Name
 * Organization Address
 * City
 * State
 * Zip Code ||  || The organization’s name, street address, city, state, and zip code || Payer contractor on behalf of a payer ||
 * ^  || * Signature Artifact || No || Signature artifact encrypted by owners private key || Exact nature of artifact to be determined during harmonization ||
 * ^  || * Public Digital Certificate || No || X.509 Token Profile || Signed by trust authority ||
 * ^  || __ Payer Contractor Contact information __
 * Person / Role / Department
 * Telephone Number
 * Fax
 * Email
 * URL || No || Information used to contact the organization.

The URL to be provided by payer contractor for online communication between provider and payer contractor || Payer Contractor on behalf of a payer. Contact would include a person OR department OR role. Contact information is optional ||
 * **__ Individual Provider Information __** || __ Individual Provider Demographics __
 * First Name
 * Middle Name
 * Last Name
 * Address
 * City
 * State
 * Zip Code || No || The individual’s name, street address, city, state, and zip code || As registered with NPI or Alternate ID ||
 * **__ Provider Organization Information __** || __ Provider Organization Demographics __
 * Organization Name
 * Organization Address
 * City
 * State
 * Zip Code || No || The organization’s name, street address, city, state, and zip code || As registered with NPI or Alternate ID ||
 * ** Other General Information ** || Date of Request || No || The date that the eMDR request is sent ||  ||
 * ^  || Cover Letter text || No || Non computable text corresponding to statements required by statutes, regulations or contract ||   ||
 * ^  || Program || No || The type of program that sends eMDR request || Requesting Program examples include MAC, RAC, ZPICS, CERT, etc. ||
 * ^  || Due Date || No || The date specified on which the additional documentation must be submitted ||   ||
 * ^  || __ Contact information for this specific request __
 * Person / Role / Department
 * Telephone Number
 * Email
 * Fax
 * URL || No || Information used to contact the organization

The URL to be provided by payer or payer contractor for online communication between provider and payer or payer contractor || If different than the Payer or Payer Contractor contact information ||

Audit Information Section

 * ** Section ** || ** Data Element ** || ** Multiple Values (yes/no) ** || ** Data Element Description ** || ** Additional Notes ** ||
 * ** Audit specific Information ** || Scope or Type of Audit || No || It is a codified field that determines the type of request including Pre certification, Claim Payment Documentation, Audit, Payment Recovery etc. ||  ||
 * ^  || Unique Claim Reference Identifier || No || A unique number associated with a specific claim that serves as a common identifier used by both the payer / payer contractor and provider || Internal Control Number (ICN), Document Control Number (DCN) or Claim Control Number (CCN) of the claim. Only one may be used. One field is sufficient because each number identifies the type of control number. ||
 * ^  || Unique Case Reference Identifier || No || A case number used to track one or more related eMDRs. Serve as a unique external ID. || Note – Combination of the Unique Claim Reference Identifier and Unique Case Reference Identifier is unique to a single eMDR ||

eMDR Specific Content

 * ** Section ** || ** Data Element ** || ** Multiple Values (yes/no) ** || ** Data Element Description ** || ** Additional Notes ** ||
 * ** Document Return Requirements ** || Due Date || No || The date on which information must be submitted by || Provider information ||
 * ^  || Provider Directory Address || No || Electronic address of the Provider Directory ||   ||
 * ^  || Return Method Object || Yes || See object definition below. ||   ||
 * ** Processor Information ** || Claim Processor Identifier || No || “The entity that processes the claim submission” || Examples – For CMS it would be the Medicare Administrative Contractors (MACs). Could also be PBMs. ||
 * ** Provider Information ** || National Provider Identifier (NPI) || No || Issued to this provider or provider organization by NPPES ||  ||
 * ^  || Alternate ID || No || ID issued to this provider or provider organization by Alternative ID issuer ||   ||
 * ** Beneficiary Information ** || Beneficiary Name || No || Name of the individual that received health services / care ||  ||
 * ^  || Date of Birth || No || Date of birth of the beneficiary that received health services/ care ||   ||
 * ^  || Account Number || No || Identifier assigned by a provider and associated with a single encounter for the purposes of financial management ||   ||
 * ^  || Medical Record Number || No || A unique number assigned to a beneficiary by the provider to assist in management of medical records ||   ||
 * ^  || Payer Identifier for the Policy holder || No || An identifier assigned by the payer to the policy holder under which payment will be made for this beneficiary ||   ||
 * ^  || Payer Identifier for Beneficiary || No || An identifier assigned by the Payer to identify the beneficiary || Example - Health Insurance Claim Number for CMS ||
 * ** Claim Level Detail (all data elements are from the submitted claim referenced in this section, unless otherwise indicated) ** || Claim Date || No || The date the claim is submitted || Mark / Ken to identify any standard definition currently used by CMS ||
 * ^  || Date(s) of Service || No || Date of service, such as the start date of the service, the end date of the service, or the single day date of the service. || The date of service can be a range ||
 * ^  || Type of Bill || No || A three-digit numeric code which identifies the specific type of bill and represents the setting in which care was provided. || As defined by the National Uniform Billing Committee in Form locator 04. ||
 * ^  || Address ID || ? ||   || Per Joe Keochinda – This field is not used and never get populated on the claim. ||
 * ^  || Diagnosis Code(s) || Yes || A diagnosis code identifying a diagnosed medical condition ||   ||
 * ^  || Diagnosis Code Set || No || Revision of diagnosis code set || For example - ICD 9, ICD 10 ||
 * ^  || Diagnosis Related Group Code || No ||   || Sam Elias following up on definition ||
 * ** Line Level Detail (all data elements are from the submitted claim referenced in this section, unless otherwise indicated) ** || Performing Provider NPI || No || The NPI of the provider rendering the service ||  ||
 * ^  || Performing Provider Alternate ID || No || Alternate ID of the provider rendering the service if the NPI is not available ||   ||
 * ^  || Alternate ID Type || No || A code value for the source of the alternate ID || For example – State license number, Commercial ID or Location ID ||
 * ^  || Date(s) of Service || No || Date of service, such as the start date of the service, the end date of the service, or the single day date of the service. || The date of service can be a range ||
 * ^  || Revenue Code || No || Identifies specific accommodations, ancillary services and billing calculations as determined by the National Uniform Billing Committee ||   ||
 * ^  || Provider Specialty || No || The area of medicine or surgery in which a clinician specializes || For example - Acupuncture, Internal Medicine, Neurology, Pathology etc. ||
 * ^  || Diagnosis Code || Yes || One or more of the diagnosis codes identified in the Claim Level that apply to this line level item || Either the diagnosis code or pointer to the diagnosis code at the claim level ||
 * ^  || Procedure Code || No || CPT Code or HCPCS Code || HCPCS Codes, Healthcare Common Procedure Coding System numbers, are the codes used by Medicare and monitored by CMS, the Centers for Medicare and Medicaid Services. ||
 * ^  || Procedure Modifier(s) || Yes || Specific modifier(s) defined for that CPT or HCPCS code ||   ||
 * ** Documentation Requested ** || Documentation Requested || Yes || Documentation that must be provided in response to this eMDR || This can be medical documentation or other types of documentation necessary to support the claim.

This will need a code set which will be defined during harmonization ||
 * ^  || Description of Documentation Requested || Yes || Description of documentation that must be provided in response to this eMDR || This can be medical documentation or other types of documentation necessary to support the claim. ||
 * ** eMDR Message Signature ** || Public Digital certificate of transmitter || No || X.509 Token Profile || Signed by trust authority ||
 * ^  || Signature Artifact || No || Signature Artifact encrypted by transmitters private key ||   ||

Data Objects for "Return Method Object" data element

 * ** Section ** || ** Data Element ** || ** Multiple Values (yes/no) ** || ** Data Element Description ** || ** Additional Notes ** ||
 * ** Return Method Object ** || Return Method(s) || No || The method by which a provider or provider organization may return the additional documentation requested in the eMDR || Code set will be defined in harmonization. Could be structured and unstructured electronic transactions, paper, URL for online access, Secure electronic access etc. ||
 * ^  || Electronic Service Information (Electronic Service Information Object) || No || Description of electronic services supported by the Payer / Payer Contractor organization. This is an object || Use ESI Object developed in the Provider Directory data model. ||
 * ^  || Physical Return Address (Physical Return Address Object) || No || The physical return address for the organization. || This will be the Address Object from PPA UC 1. ||
 * ^  || Maximum Electronic Return Size per transaction || No || The maximum size allowed per return transactions in megabytes || Payer and Provider will need to support multiple transactions per submission if documentation requirement exceeds maximum return size or use an alternative method ||
 * ^  || Return Constraints || Yes || Return Constraints for this Return Method || This is a code set that will be defined in harmonization. Examples -, International Code Sets, Extended ASCII Character Sets, Language, Constraints related to paper submissions such as staples, holes in the paper, information included only on one side of the paper, etc. ||
 * ^  || Return Format(s) || Yes || Return Formats allowed for this Return Method || This is a code set that will be defined in harmonization. Examples – USB drive, CDs, PDFs, UML, XHTML,etc. Need to consider fax resolution, encryption of returns on CDs or via email, file naming conventions etc. ||