Medicare System Project for Electronic Submission of Medical Documentation

MLN Matters®Number: SE1343

Provider Types Affected
This Special Edition (SE) MLN Matters® Article is intended for all Medicare Fee-For-Service (FFS) providers and suppliers who submit medical documentation to Medicare review contractors.

Provider Action Needed
This article is based on the utilization of the Electronic Submission of Medical Documentation (esMD) via Medicare's esMD Gateway to respond to review contractor's requests for medical documentation.

Background
The Centers for Medicare & Medicaid Services (CMS) uses several types of review contractors to measure, prevent, identify, and correct improper payments or identify potential fraud.
Review contractors find improper payments and potential fraud by reviewing a sample of claims. They request medical documentation from the provider or supplier and manually review the claims against the medical documentation to verify the providers' compliance with Medicare's rules.
As of September 2011, providers are able to respond to these requests for medical documentation electronically using the Electronic Submission of Medical Documentation (esMD) via Medicare's esMD Gateway. Since September 2011, CMS enhanced the esMD Gateway to support several new use cases, for example:

• In September 2012, CMS implemented a Prior Authorization (PA) process via the esMD Gateway for Power Mobility Devices (PMD) for FFS Medicare beneficiaries who reside in seven states with high populations of error prone providers (CA, IL, MI, NY, NC, FL and TX).
• In January 2013, CMS expanded the CMS esMD Gateway to allow Durable Medical Equipment (DME) suppliers and providers to send electronic PA Requests to Medicare review contractors.
• In June 2013, CMS enabled automated Prior Authorization Review Results Responses from Medicare review contractors to Health Information Handlers (HIHs) via the esMD Gateway.

Medicare's esMD system provides an alternative mechanism for submitting medical documentation, PMD PA requests, and PMD result code responses to review contractors. A list of review contractors that will accept esMD transactions, as well as receive PMD PA requests and send PMD PA review results can be found at http://go.cms.gov/RevCon  on the CMS website.
The primary intent of esMD is to reduce provider costs and cycle time by minimizing paper processing and mailing of medical documentation to review contractors.
The number of participants in the CMS esMD Program has grown steadily since its inception.
As of September 30, 2013:

• 449,460 Unique Medical Record Transactions have been submitted;
• 30,199 Medicare Providers are using esMD to respond to medical record requests;
•  55 Medicare Providers use esMD to submit Prior Authorization Requests;
• 24 HIHs are certified by CMS to offer esMD services;
• 27 Review Contractors are approved by CMS to accept medical records via esMD

Medicare providers, including physicians, hospitals, and suppliers must obtain access to a CONNECT-compatible gateway in order to send medical documentation electronically to review contractors.
For example:

• Larger providers, such as hospital chains, may choose to build their own gateway;
• Many providers may choose to obtain gateway services by entering into a contract or other arrangement with a HIH that offers esMD Gateway services.

HIHs contract with providers to supply them with esMD services much the same way that providers contract with claims clearinghouses to supply them with claims submission services.

A listing of the HIHs that have been approved by CMS to offer esMD services can be found at http://go.cms.gov/esmd-HIH  on the CMS website.

HIH's set the price of their esMD provider services. Providers are encouraged to contact one or more of the HIHs to determine what esMD services are available.

While esMD is not mandatory, many healthcare providers find that it reduces costs, increases efficiency, and shortens processing times for certain transactions. CMS has instructed review contractors to not target providers for medical review based on their use of esMD.

The esMD system accepts Portable Document Format (PDF) files, which enables providers to use esMD services as long as they have the proper scanning mechanism. Some HIHs may offer scanning services in addition to their esMD services.

Additional Information
If you have any questions, please contact the review contractor to whom you wish to send esMD transactions. The review contractor toll-free numbers can be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/provider-compliance-interactive-map/index.html  on the CMS website.

For more information, visit the esMD webpage at http://www.cms.gov/esmd  on the CMS website, or follow esMD on Twitter @CMSGov (#CMS_esMD).

For more information on the Medicare Recovery Audit program, see the MLN Matters® article SE1024 at http://www.cms.gov/MLNMattersArticles/downloads/SE1024.pdf  on the CMS website.

Contact information for your Recovery Auditor is available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/RAC-Contact-Information-AbbrState-Apr2013.pdf  on the CMS website.

Courtesy of Noridian/CMS https://med.noridianmedicare.com/web/jeb/article-detail/-/view/10525/medicare-system-project-for-electronic-submission-of-medical-documentation