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Solicited and Unsolicited Attachments

The following page is DRAFT. It has not yet undergone HL7 balloting.

Currently claims typically come through X12 transactions or portal submissions. Payers may need additional information from a Provider to determine if the service being billed (claim) or requested (prior authorization) is supported by medical benefits or by policy benefits. In this guide, the use of the term “attachments” is limited to a subset of additional information which are defined by the LOINC Document Ontology and data elements presented in document form. Attachments for claims or prior authorization can be divided into solicited and unsolicited workflows. The sections below document the differences and similarities between these workflows and the CDex transactions that can be used for each.

Unsolicited Attachments

For an unsolicited attachment the Provider will submit additional documentation to support a claim or prior authorization based on Payer predefined rules without any type of request. The attachments may be submitted before, at the same time as, or after the claim or pre-authorization has been supplied to the Payer. Following submission, the attachment is then associated with the claim or prior authorization.

Example Scenarios

1. A set of pre-defined rules, made by the Payer or State Mandates, necessitates that additional information is provided without a specific request.
2. A Provider believes the Payer will need additional information to process a claim.
3. A Provider is under review and required to provide additional documentation for all claims.

In all of these cases, the Payer will require a trading partner agreement for sending attachments based on predefined rules.

The flow diagram for this transaction is shown in the figure below:

See the Sending Attachments page for how CDex transactions can be used to support unsolicited attachment transactions.

Solicited Attachments

For a solicited attachment the Provider will submit additional documentation, to support a claim or prior authorization, in response to a Payer’s request for additional documentation. The submitted attachments are then associated with the claim or prior authorization. The flow diagram for this transaction is shown in the figures below:

Attachments may be requested via a non-CDex-FHIR-based request such as an X12 transaction, fax, portal, or other platform or they may be requested using CDex. See the Requesting Attachments page and Sending Attachments page for how CDex transactions can be used to support solicited attachment transactions.