An attachment, in the context of healthcare electronic data interchange, is an electronic rendition of medical documentation, such as an X-ray, lab report, or questionnaire, that supports a healthcare administrative transaction.
An attachment can be unstructured, such as an Adobe® PDF file, WORD, TEXT or images using jpg, or tiff. The standards development organization Health Level 7 International (HL7) has developed standards for the clinical data in both types of attachments. This standard is HL7 Clinical Document Architecture (CDA). HL7 has also developed an HL7 CDA® R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 - US Realm for using the C-CDA for Attachments.
Two ASC X12N transactions allow the receiver of a claim or Health Services Review to ask for supporting documentation:
The Health Care Claim Request for Additional Information (277RFAI) is used to request supporting documentation for a claim.
The Health Care Services Review – Request for Review and Response (278RR) is used to request documentation supporting a prior authorization, referral, or admission review.
Two ASC X12N 275 transactions allow attachments to be sent electronically, either unsolicited (without a request from the receiver) or in response to a request for supporting documentation:
The Additional Information to Support a Health Care Claim or Encounter (275) is used to send attachments related to a healthcare claim.
The Additional Information to Support a Health Care Services Review (275) is used to send attachments related to a health care services review or review notification.
The Administrative Simplification provisions under the Affordable Care Act of 2010 require the adoption of transaction standards and operating rules for Attachments.
On February 16, 2016, the National Committee on Vital and Health Statistics (NCVHS), advisory body to the Department of Health and Human Services (HHS), conducted hearings on the Attachment standards. The following recommendations were made by NCVH to the Secretary of Health and Human Services in a letter posted July 21, 2016.
Request for Attachments
- ASC X12N 277 Health Care Claim Request for Additional Information (for all claim-related attachment requests)
- ASC X12N 278 Health Care Service Review – Request for Review and Response (the response is used to request additional information for Health Care Service such as prior authorizations, referrals, and notifications).
Response – Submission of an Attachment Message Content/Format:
- HL7 C-CDA R2 – Consolidated Clinical Documentation Architecture Release 2
- HL7 CDA® R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 - US Realm
- ASC X12 Acknowledgment Reference Model (ARM)
- ASC X12C Implementation Acknowledgment for Health Care Insurance (999)
- ASC X12 TA1 Acknowledgment Segment (Appendix to the 999)
Attachment Type Value Set:
Logical Observation Identifier Names and Codes (LOINC) developed and maintained by the Regenstrief Institute, Inc., LOINC® c/o Center for Biomedical Informatics. HIPAA Panel Solicited and Unsolicited Lists.
- ASC X12N 275 Additional Information to Support a Health Care Claim or Encounter
- ASC X12N 275 Additional Information to Support a Health Care Services Review
To see the NCVHS recommendation, go to www.ncvhs.hhs.gov.
It is anticipated that the Department of Health and Human Services will issue a proposed rule adopting electronic Attachment standards in late 2016 or early 2017.
Change Healthcare continues to work with the Standards Development Organizations on the Implementation Guides for Attachments.
At this time, operating rules for Attachments have not yet been developed.
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