Electronic Determination of Coverage (eDoC) Workgroup

In January 2013 The Centers for Medicare and Medicaid Services (CMS), in conjunction with the Office of the National Coordinator for Health Information Technology (ONC) began a new Workgroup within the esMD Initiative called electronic Determination of Coverage (eDoC).

This workgroup will establish a cross-initiative work effort focused on giving practitioners access to payer approved tools such as:

• Structured templates for documentation,
• Decision support systems, and
• Standards-based exchange of information between providers and payers

These tools can assist in the creation and communication of documentation required for electronic coverage determination.  The Workgroup anticipates utilizing the existing or on-going community effort of several existing S&I Initiatives to address the development, deployment, and ongoing operation of use cases addressed by eDoC. These initiative efforts include all of the esMD workgroups (Provider Registration, electronic Medical Documentation Request and Author of Record), Structured Data Capture, Health eDecisions, Consolidated CDA, Provider Directories, Direct, and Automated Blue Button. The reuse of the standards selected and implementation guides developed by these initiatives will expedite eDoC efforts to facilitate provider documentation of a patient’s condition to enable rapid communication between providers, suppliers, and payers to determine coverage for specific procedures, referrals, services, and devices.

The first use case for eDoC is the Power Mobility Device (PMD).  PMDs are defined as covered items under a Durable Medical Equipment (DME) benefit that are in a class of wheelchairs that includes power wheelchairs (four-wheeled motorized vehicles whose steering is operated by an electronic device or joystick to control direction and turning) or POVs (three- or four-wheeled motorized scooters that are operated by a tiller) that a beneficiary uses in the home to assist with limitations and impairments of Mobility Related Activities of Daily Living (MRADL).

This use case focuses on giving practitioners (physicians, PTs, OTs, etc) access to payer approved tools that can assist in capturing required documentation during provider interaction with the patient.  Coordination of communication between provider, suppler, and payer entities will be addressed at length within the scope of eDoC and the PMD use case, including:

• Communication between providers contributing to a patient’s documentation to substantiate particular procedures or equipment (e.g.- between the physician and the Licensed Clinical Medical Professional (LCMP)),
• Communication of the order from the ordering practitioner to the Durable Medical Equipment (DME) supplier,
• Communication of the Detailed Product Description from the DME  signed by the ordering practitioner,
• Communications with the Payer for post-service payment or pre-authorization, and ultimately
• Communication to the patient.

Standard transport mechanisms for communication will be determined, and structured documentation capture and exchange will be established.

The eDoC Workgroup is asking for community input, participation, and support toward reaching a consensus on technical questions to enable a robust Provider-Services-Payer-Patient ecosystem. We plan to deploy and demonstrate a reference implementation for an end-to-end use-case. To register, click on the link "Register to join S&I esMD Initiative" in the 'Related Links' section below, then plan to participate in the workgroup meetings. To view presentation slides and recordings from past meetings, click on the link "Instructions for esMD eDoC Workgroup materials" in the 'Downloads' section below.

We look forward to your participation in this complex work effort!