esMD+Phase+I+-+Administrative+Transactions

=**Introduction**=

For 2009 the Medicare fee-for-service (FFS) program made an estimated $24.1 billion in improper payments.Medicare review contractors compare the claims submitted by Medicare providers against entries in medical records to measure, prevent and correct improper payments.


 * RACs identify and correct improper payments. **Recovery Audit Contractors (RACs) conduct post-payment review by comparing information from medical records to Medicare claims.The Centers for Medicaid & Medicare Services (CMS) estimates that RACs will request over 1 million medical records from providers each year.


 * MACs prevent improper payments. **Medicare Administrative Contractors (MACs) conduct pre-payment and post-payment reviews of Medicare FFS claims.CMS estimates that MACs will request several thousand medical records per year.

Prior to the Electronic Submission of Medical Documentation (esMD) pilot, the provider had three choices when responding to these documentation requests:mail paper, mail a CD containing a Portable Document Format (PDF) or Tag Image File Format (TIF) file, or transmit a fax. The esMD pilot will give providers an additional option for responding to these requests for medical documentation:electronic transmission via the Nationwide Health Information Network.

=Problem Statement=
 * The problem of || Inability to request and accept standardized transactions for additional documentation requests in support of program administration activities. ||
 * affects || organization's ability to conduct review of medical records for determining proper payment. It would also diminish the organizations ability to coduct pre-approval activities should that be implimented. ||
 * the impact of which is || the organization conducts fewer medical reviews. It is also required to request and manage large amounts of printed paper documentation which is expensive and cumbersome. ||
 * A successful solution would be || standards and services that will allow organizations to deliver simple, direct, secure and scalable transport of additional documentation requests and responses to those requests. ||

=**Stakeholders**=


 * **Organization Name** || Medicare Providers (physicians, hospitals, labs, DME facilities, ambulance companies, SNFS, CORFs, IRFs, etc) ||
 * **Division or Program** || CMS/OFM/Provider Compliance Group ||
 * **Address** || Various ||
 * **City, state, ZIP Code** || Various ||
 * **Phone number** || Various ||
 * **Fax number** || Various ||
 * **Web site address** || Various ||


 * **Organization Name** || CMS ||
 * **Division or Program** || OFM/Provider Compliance Group ||
 * **Address** || 7500 Security Blvd ||
 * **City, state, ZIP Code** || Baltimore, MD21244-1850 ||
 * **Phone number** || 410-786-7683 ||
 * **Fax number** || n/a ||
 * **Web site address** || Various ||

=**Solution Overview**=

=**Solution Features**=

=Solution Constraints=


 * __Supporting References:__**

**HITSP CAP 140** : From their site "This Capability addresses interoperability requirements that support electronic inquiry and response about a patient’s eligibility for health insurance benefits." This is an implementation of the X12 270/271 transactions.


 * __Use Cases:__**
 * **Use Case Name** || **Use Case Description** || Actors || Actor Description ||