SGML: Medical Claims Processing Briefing: SGML Application

Medical Claims Processing Briefing: SGML Application

Subject: Medical Claims Processing Briefing: SGML Applications
Date: Sun, 15 Jun 1997 20:45:08 -0400
From: Liora Alschuler <>
Newsgroup: comp.text.sgml
----------------------------------------------------------- BRIEFING ON AUTOMATED CLAIMS PROCESSING: NOTE BENE: The following is supplied for the benefit of vendors and consultants who wish to address claims processing requirements in their demonstrations or presentations. (See the previous post annoucing the HL7 SGML Mixer.) Please note, however, that this conference is not focused solely on the government requirements. While the implementation of the recent legislation will influence the industry, there are many forces shaping healthcare information requirements. Unlike the defense industry of the late 1980's where the DoD CALS program was pushing the development of SGML technology, we expect that in healthcare private industry will play the leading role over the next several years. That said, and while there is no open or formal RFP from either the government insurers or their providers, there is substantial interest in innovative solutions for claims attachment processing on the part of both the government and private industry. We feel that there are substantial opportunities to influence this process by demonstrating solutions both to the current mandate and to future requirements. Background The Health Insurance Portability and Accountability Act (HIPAA, also known as Kennedy-Kassebaum) passed by the US Congress and signed in 1996 mandates that standards for claims submission and supporting transactions be selected by the Secretary of the Department of Health and Human Services. HL7, the parent organization of the HL7 SGML SIG, is working closely with X12N, the insurance sector of X12 (EDI), to support the HIPAA requirement for claims attachment processing. A Proof of Concept (POC) initiative is taking place under the direction of the US Health Care Financing Administration (HCFA). A joint working group (JWG) comprised of representatives of both X12N and HL7 participated in an orientation on June 4, in Chicago. Claims Processing Today HCFA has experience and a track record in accepting Medicare claims as X12N transactions. Each X12 transaction (which is essentially the same as an HL7 message) is known by a number and has a fixed purpose and data definition. Several transactions are used for claims submission from providers to payors and for notification of results from payors to providers. While X12N and HL7 messages are quite similar in syntax and the semantics overlap (there is a data modeling and reconciliation effort underway), in most implementations X12N has been used for exchange between enterprise boundaries while HL7 has been used within a single enterprise, between systems using different proprietary data formats. Each transaction/message is the equivalent of a single paper claims form. When additional information is required to support a claim, the subsequent submission is called an attachment. Ideally, an attachment is defined as "only what is required to adjudicate a claim." Under the current system, while claims are submitted electronically, attachments submission and processing is paper-based. For the most part, attachments conform to more-or-less agreed-upon paper forms. Paper attachments can be any one of these three basic types: 1. "Standard" forms -- Each provider and each payor may have their own list of standard attachment forms with data elements that differ, slightly, from similar attachment forms used by other providers and payors. A single agency may use 75 or more different attachment forms and may add a form at any time. 2. Data elements -- The payor can request a single piece of information (a reading, result, report or date, for example). 3. The patient record -- The payor can request an entire medical record. New Requirements HIPAA legislation mandates that by 2/99 the Secretary of the Department of Health and Human Services select a standard for automated attachments. This standard must service the commercial insurance industry as well as the government. The legislation does not define "automated". It could be interpreted as transfer of a bit-mapped image of an attachment document or transfer of fielded data automatically processed on the receiving end by intelligent engines. The current requirement does not define the granularity or functionality required from the transmitted attachment. All indications are that the proof of concept initiative will interpret this as the submission of fielded data organized and defined as if on a paper form for the first type of attachment. The initiative has not formulated a strategy to address the second and third types of attachments and it is here that the largest opportunity to demonstrate innovative and forward-looking solutions lies. The first tasks assumed by the X12 HL7 JWG are a census of forms in current use, identification of the top five, most-used forms, creation of an agreed-on data model for these, and subsequently for all forms. The data models will be encoded and transferred in a hybrid syntax composed of X12, where pre-defined X12 transactions apply, and HL7, where HL7 messages apply, or a hybrid of X12 and HL7 (an X12 envelop with HL7-encoded data in a segment.) The X12N transaction that will serve as the envelop is the 275 -- a transaction type for clinical data that was defined, but never implemented. The 275 includes a BIN segment which can be any binary data segment. The CAP segment which precedes the BIN will identify the data type of the BIN. Long term requirements include not only send, receive, and acknowledgment, but real-time notification of reimbursement. Opportunities for Technical Demonstrations We see several opportunities to demonstrate how SGML encoded data and SGML-based technology can address these requirements. Much of the information requested in attachments is clinical data that exists in notes (narrative) and is not defined by either X12 or HL7. There may be substantial advantages to use of SGML or XML to describe this data and send it in the BIN segment within an X12 or HL7 attachment envelop. This can be demonstrated for each type of attachment. Where the requested attachment does not conform to an existing document or form, there is a significant opportunity for demonstration of the advantage of SGML-based attachments. Consider that even in the first case, where a single attachment form is well-defined, the number of attachments is very difficult to ascertain and is constantly shifting, changing, and increasing. Listing and defining all attachment forms, creating separate, but overlapping data models for each, and standardizing these through X12N or HL7 balloting will be a long and cumbersome process. A standard query and link mechanisms can accommodate widely varying requests even where no agreed-upon forms exists as long as there are standards for SGML encoded medical data. Today, lacking such a standard, send and receive by link or query mechanisms can illustrate the direction that ultimate solutions will take once such a standard is in place and can generate support for this standard. Public and private insurers and providers will be receptive to and interested in demonstrations that meet the immediate POC requirement for known attachment forms including: 1. Creation of SGML-encoded documents with structured editors database extraction 2. transmitting and receiving these documents within message segments. 3. payor processing such as: import and display in a desktop browser, import and insertion into a database, transformation and reformatting of data, standard queries performed on XML data. 4. demonstration of flexible query and link mechanisms that can operate between distributed, secure systems such that payors can request and received all three types of attachments: pre-defined data collections, single data elements, entire medical records. Participants in the HL7 SGML Mixer are invited to address these government requirements for electronic attachments or other requirements for medical record creation, distribution, and processing unrelated to claims attachments. For those specifically interested in addressing the claims attachment requirements, we invite forward-looking solutions that meet or exceed the immediate proof of concept requirements and that illustrate the application of sgml-based tools and technology for these difficult questions. We will post examples of attachments on the web sites of the three sponsor organizations or you can request a copy by fax from Marion Elledge at GCA (703) 519-8193 FOR MORE INFORMATION: Contact the organizations co-sponsoring the event * GCARI (Graphic Communications Association Research Institute; * HL7 SGML SIG (Health Level 7, SGML Special Interest Group; * SGMLOpen ( or Liora Alschuler, HL7 SGML Mixer Program Chair or 802/785-2623