ESMD FHIR Implementation Guide - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Notifications Metadata

PickUp Success

This notification is generated to indicate pickup success when the RC attempts to retrieve a package delivered by esMD. A successful pickup response indicates no issues were encountered by the RC.
Below are the list of metadata elements for the following Lines of Business (LOBs):

Additional Documentation Request (ADR) (CTC 1) ADR submissions are used by Medicare Administrative Contractors (MACs) to request additional documentation from healthcare providers to support a claim. This metadata set ensures that the requested information is electronically submitted and accurately reflects the needs of the request.

Unsolicited PWK Documentation (CTC 7)

Prior Authorization/Pre-Certification Requests (PA/PCR) Submissions (CTC 8.1, 8.3,8.4, 8.5 and 8.6) PA/PCR submissions, which include specific programs such as Ambulance, HHPCR (Home Health Prior Authorization Requests), DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies), HOPD (Hospital Outpatient Department), and IRF (Inpatient Rehabilitation Facility), are used to submit documentation for prior authorization or pre-certification of services and procedures before they are performed.

First Level Appeal Requests (CTC 9) First Level Appeal Requests (CTC 9) are initiated by healthcare providers when they wish to appeal an adverse decision or claim denial by a Medicare contractor. This submission set facilitates the submission of documentation to support the appeal and ensures it is tracked in accordance with the esMD standards.

Second Level Appeal Requests (CTC 9.1) Second Level Appeal Requests (CTC 9.1) are filed when the First Level Appeal has been denied, and the provider seeks further review of the decision. This submission set includes metadata attributes to ensure that the appeal documentation is appropriately processed and accurately reviewed at the second level.

Advance Determination of Medicare Coverage (ADMC) Submissions (CTC 10) The ADMC submissions (CTC 10) are used by healthcare providers to request an advance determination from Medicare on whether a service or item is covered before it is provided. This submission set allows the provider to submit necessary documentation to receive a preemptive coverage decision. The metadata attributes ensure accurate processing and tracking of these requests within the esMD system.

Recovery Audit Contractor (RAC) Discussion Request (CTC 11) RAC Discussion Requests are initiated when a provider wishes to discuss or appeal a finding made by a Recovery Audit Contractor, typically relating to claims or payment discrepancies. This submission set contains metadata that facilitates proper documentation exchange and discussion with the contractor.

Durable Medical Equipment (DME) Phone Discussion Request (CTC 11.1) DME Phone Discussion Requests are specific to Durable Medical Equipment and provide a platform for providers to discuss issues or clarification with contractors regarding DME claims. This metadata includes submission attributes that allow for accurate record-keeping and response tracking during the phone discussion process.

ID	Data Element	Element Description	Validation Rule	Length and Format	Usage
1	esMDTransactionId	esMD TransactionID is generated by the esMD when a PA request is received from the HIH	Valid transaction ID	15 Alphanumeric	R
2	esMDClaimId	The Claim Identifier is the identifier used by the provider to submit the medical claim to the esMD system. It can be submitted in either Standard or Composite Format.	Claim ID submitted in the request to the RC	1. Claim ID length must be 1-23 character for either standard or composite format. 2. Claim ID in Standard Format: - 8 numeric characters (must not be all zeroes) - 13–15 numeric characters (must not be all zeroes) - 17–23 alphanumeric characters, including hyphens, spaces, and underscores (must not be all spaces, all zeroes, or all a single special character). 3. Composite Claim ID Format Ex: [Claim ID^^^&RC OID&ISO]	O
3	esMDCaseId	The Case Identifier is generated by the Review Contractor (RC) to open a claim-specific case. The Case ID can be submitted in either Standard or Composite Format, depending on the requirements of the Line of Business (LOB).	Case ID submitted in the request to the RC	1. Case ID length must be 1-23 character for either standard or composite format. 2. Length must be 0–32 characters if it is optional. 3. Case ID can be sent in Composite format Ex: "CaseID^^^&RC OID&ISO" 4. Format check (No check is performed up to the "CaseID"; the only format check starts from the "^^^&RC OID&ISO".	O
4	contentTypeCode	The Content Type Code identifies the specific line of business for which the provider or Health Information Handler (HIH) is submitting the request.	1. Content Type Code or Line of Business ID must be part of esMD and in active status	1) Length 1 -16 2. Format must be numeric with period Ex: ""1 or 1.1or 11""	R
5	HIHToESMDDeliveryTimeStamp	The time at which the request is sent to esMD from HIH		YYYYMMDDHHMMSS	R
6	ESMDClaimReviewerPickUpTimeStamp	The time at which the RC picked up the file		YYYYMMDDHHMMSS	R
7	ESMDPickedUpClaimReviewer	The Intended Recipient refers to the organization (RC) that will receive the message from the sender (HIH) containing the esMD Claim supporting documents. This Intended Recipient will be uniquely identified using an OID (Object Identifier) issued by HL7.		Format must be as stated: "urn:oid:1.3.6.1.4.1.101420.6.1"	R

PickUp Failure

This notification is generated to indicate pickup success when the RC attempts to retrieve a package delivered by esMD. A failure response will identify issues that prevented the RC from successfully picking up the package.

Additional Documentation Request (ADR) (CTC 1) ADR submissions are used by Medicare Administrative Contractors (MACs) to request additional documentation from healthcare providers to support a claim. This metadata set ensures that the requested information is electronically submitted and accurately reflects the needs of the request.

Unsolicited PWK Documentation (CTC 7)

Prior Authorization/Pre-Certification Requests (PA/PCR) Submissions (CTC 8.1, 8.3,8.4, 8.5 and 8.6) PA/PCR submissions, which include specific programs such as Ambulance, HHPCR (Home Health Prior Authorization Requests), DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies), HOPD (Hospital Outpatient Department), and IRF (Inpatient Rehabilitation Facility), are used to submit documentation for prior authorization or pre-certification of services and procedures before they are performed.

First Level Appeal Requests (CTC 9) First Level Appeal Requests (CTC 9) are initiated by healthcare providers when they wish to appeal an adverse decision or claim denial by a Medicare contractor. This submission set facilitates the submission of documentation to support the appeal and ensures it is tracked in accordance with the esMD standards.

Second Level Appeal Requests (CTC 9.1) Second Level Appeal Requests (CTC 9.1) are filed when the First Level Appeal has been denied, and the provider seeks further review of the decision. This submission set includes metadata attributes to ensure that the appeal documentation is appropriately processed and accurately reviewed at the second level.

Advance Determination of Medicare Coverage (ADMC) Submissions (CTC 10) The ADMC submissions (CTC 10) are used by healthcare providers to request an advance determination from Medicare on whether a service or item is covered before it is provided. This submission set allows the provider to submit necessary documentation to receive a preemptive coverage decision. The metadata attributes ensure accurate processing and tracking of these requests within the esMD system.

Recovery Audit Contractor (RAC) Discussion Request (CTC 11) RAC Discussion Requests are initiated when a provider wishes to discuss or appeal a finding made by a Recovery Audit Contractor, typically relating to claims or payment discrepancies. This submission set contains metadata that facilitates proper documentation exchange and discussion with the contractor.

Durable Medical Equipment (DME) Phone Discussion Request (CTC 11.1) DME Phone Discussion Requests are specific to Durable Medical Equipment and provide a platform for providers to discuss issues or clarification with contractors regarding DME claims. This metadata includes submission attributes that allow for accurate record-keeping and response tracking during the phone discussion process.

ID	Data Element	Element Description	Validation Rule	Length and Format	Usage
1	esMDTransactionId	esMD TransactionID is generated by the esMD when a PA request is received from the HIH	Valid transaction ID	15 Alphanumeric	R
2	HIHToESMDDeliveryTimeStamp	The time at which the request is sent to esMD from HIH		YYYYMMDDHHMMSS	R
3	ESMDClaimReviewerPickUpTimeStamp	The time at which the request is sent to esMD from HIH		YYYYMMDDHHMMSS	R
4	ESMDPickedUpClaimReviewer	The Intended Recipient refers to the organization (RC) that will receive the message from the sender (HIH) containing the esMD Claim supporting documents. This Intended Recipient will be uniquely identified using an OID (Object Identifier) issued by HL7.		Format must be as stated: "urn:oid:1.3.6.1.4.1.101420.6.1"	R
5	Severity	Severity describes the type of error		Error is the severity	R
6	codeContext	Code Context lists the type of error for which the validation error has failed.			R
7	errorCode				R