PPA+UC+1+-+Commercial+Payer+User+Story

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= The content within this page has been incorporated into the PPA UC 1 - Provider Registration =

= = The below sections have been drafted for Provider Registration with Commercial Payers using the Generic User Story as a baseline.

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 * Use Case 1 – Provider Registration **

The Provider Profile Authentication (PPA) work stream is a two part process. The first part is covered in this Use Case and is associated with the provider sending a registration request or Trading Partner Agreement to a payer entity in order to receive the Medical Documentation Request (MDR) electronically.
 * User Story (Commercial Payer) **

The provider or Agent submits a registration request to the payer. A secure, trusted registration request is received by the payer entity and provider eligibility to receive electronic Medical Documentation Requests (including provider identity) is validated by the payer. The payer then requests Electronic Service Information (ESI) from an External Provider Directory using the validated provider’s identity to determine the capability of provider or agent to receive an electronic medical documentation request (eMDR). If a valid ESI for eMDR is received by the payer entity from the External Provider Directory, a confirmation is sent to the provider or agent as appropriate to notify them of their registration status.

The provider’s registration request can be either confirmed or rejected by the payer entity. If the registration request is confirmed, the payer will attempt to send all future MDRs electronically. If the provider registration request is rejected, the provider does not receive electronic MDRs and can submit another registration request.


 * 5.0 Assumptions – UC 1 **
 * 1) The electronic provider registration request will be in a structured electronic format (to be determined through harmonization process).
 * 2) Providers will be identified by their National Provider Identifier (NPI) for registration. In the absence of an NPI, other unique provider identification can be used.
 * 3) Each provider registration request is for one individual or entity identified by a single NPI. In the absence of an NPI, other unique provider identification can be used.
 * 4) The External Provider Directory can be a Provider's Internal PD, Payer entity’s Internal PD, or provided by a third party like Council for Affordable Quality Healthcare (CAQH), Regional Health Information Organization (RHIO) or Health Information Exchange (HIE) Provider Directory (PD) (community or state).
 * 5) Gateways, if used by the payer, will support provider registration activities.
 * 6) All transactions will follow national standards.
 * 7) All transactions will have appropriate security to ensure data is transmitted securely, reliably, and with authentication of both the sender and receiver.
 * 8) Providers and/or Agents will register ESI information with the appropriate PD.
 * 9) Registration will not expire, but may be subject to reasonable update and termination conditions as determined by each payer.

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 * 6.0 Pre-Conditions - UC 1 **
 * 1) Provider or Agent can submit all required information electronically to payer entity to begin registration process.
 * 2) Payer entity can receive and process electronic request for registration.
 * 3) Provider entity or Agent supports the required transaction and payload standards for the registration request.
 * 4) Participating entities have completed any required on boarding processes and signed any required participation or data use agreements.
 * 5) Payer internal information system are established and in place for timely information verification.
 * 6) External Provider Directories are established and in place for timely information verification.
 * 7) External Provider Directories have the ability to receive information request queries sent from payer entities, process them, and respond back to payers using the S&I PD data sets.
 * 8) Payer entities can receive and process ESI information from External Provider Directories.
 * 9) Providers or Agents can receive and act on registration request confirmations (both affirmative and rejection) from Payer entities.


 * 7.0 Post Conditions - UC 1 **
 * 1) Providers and Agents will maintain the ability to receive electronic MDRs after successful registration.
 * 2) Provider registration information is maintained by the payer and available for use by the payer or other users of the provider registration system.

Section 8.Use Case Actors and Roles
This section describes the Business Actors that are participants in the information exchange requirements for each scenario. A Business Actor is an abstraction that is instantiated as an IT system application that a Stakeholder uses in the exchange of data needed to complete Use Case action(s). Furthermore, the systems perform specific roles in this Use Case as listed below: __ NOTE: __ A role can be carried out by actors not included in this table; however, for the purposes of this Use Case, we are focusing on the content within the table below. In addition, the same actor may perform a combination of roles.


 * **Business Actor - Generic** || **Business Actor - Specific** || **System** || **Role** ||
 * Registration Requestor || Registration Requestor || Registration Requestor's Information System || * Provider Information Source
 * Registration Requestor and Confirmation Receiver ||
 * Provider Agent / Access || Health Information Handler (HIH) || Agent/Access Information System || * Information Requestor/Collector
 * Information Combiner/Router ||
 * Payer (Healthcare and Disability) || Medicare

Medicaid

SSA - Disability

Commercial || Payer Information System || * Validates Providers against current enrolled provider list
 * Confirms ESI to receive MDRs electronically
 * Respond to registration request ||
 * External Provider Directory || External Provider Directory || Provider Directory || * Manage Provider Information
 * Stores and responds to queries for Provider Information ||
 * Payer Gateway || esMD Gateway || Payer Gateway Information System || * Auditing
 * Transaction Logging
 * Routing
 * Transforming ||

Expanded descriptions of the terms corresponding to the table above can be but are not limited to:
 * __Registration Requestor__ - Provider, Provider Organization, Agent
 * __Registration Requestors Information System__ - Provider Directory / Billing System / Medical Records System
 * __Agent/Access Information System__ - Transforming/routing system, Auditing System, (Provider Directory)
 * __Payer Information System__ - Claims System, (Provider Registration System (Provider Directory), Business to Business Systems
 * __Payer Gateway Information System__ - Transforming/routing system, Auditing System

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