HL7 CDA R2 AIS Implementation Guide

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HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0303.3 General Compliance StatementsThe following compliance statements apply to all CDA documents proffered as attachments.[Make the following head-3 and ensure style agreement with all other compliance statements]1) CDA Compliant. The document shall be compliant with Health Level Seven (HL7)Clinical Document Architecture, Release 2.0, April 2005 (ANSI/HL7 CDA R2-2005).2) CDA Namespace. The document shall use a namespace with the Uniform ResourceIdentifier (URI) "urn:hl7-org:v3" for elements in the CDA schema.3) Self-Contained Package. Unless a specific Additional Information Specificationspecifically overrides this provision, the interpretation of the attachment shall not dependon any information that is not included in the attachment package.This statement means that a compliant health plan need not perform documentmanagement with respect to revisions of the submitted document. Decisions will be madeon the basis of the transmitted document without regard to whether it is an updated oramended version of a prior document. This does not preclude a payer from requestinganother attachment once an attachment has already been requested and received. TheHIPAA federal regulations (i.e., the "final rule") for claims attachments will define therules regarding when it is appropriate to request more supporting documentation.It also means that if a submitted document contains a URL that references informationotherwise not included in the attachment package (e.g., available only through theinternet), a compliant health plan does not need to retrieve and render the referencedinformation in order to make a decision based on the document. This is consistent withthe CDA rule that the information referred to by such URLs are not part of the attestablecontent of the CDA document.At publication date no Additional Information Specifications will override thiscompliance statement. We are holding out the option that the use case of a specificAdditional Information Specification in the future might justify something like Internetaccess to related data.4) Deprecate and Limit Recipient Obligations for Confidentiality Elements. Providersshould not include any of the following elements anywhere in a compliant CDAattachment document:section/confidentialityCode,structuredBody/confidentialityCode, andnonXMLBody/confidentialityCode.If, however, a provider transmits an attachment document that includes these elements,the health plan is not obligated to give the document any special handling beyond itsnormal policies for dealing with personally identifiable health information.Page 40March 2007Copyright © 1998-2007Health Level Seven, Inc. All rights reserved.Release 3.0 Draft Standard
HL7 Additional Information Specification Implementation GuideCDAR2AIS0000R0303.4 Header Compliance StatementsThe following compliance statements apply to elements in the header of all CDA documentsproffered as attachments.Relative XPaths in this section are derived from the base location of /ClinicalDocument. Forexample, a reference to "code/@code" would be a reference to the code attribute of the element within the element of the document.3.4.1 General Header Compliance Statements1) Document Type. The ./title element will contain the name of the document type in naturallanguage that has been identified as the subject of an attachment in natural language.This name will be understood by a human reader to be equivalent to the name of adocument that has been identified as the subject of an attachment in an AdditionalInformation Specification. There is no requirement that the name be repeated letter byletter from the Additional Information Specification, only that it be understood by aknowledgeable person to have the same meaning.2) Coded Document Type. The element code/@code (value) attribute will contain a LOINCcode for the document.3) Required Header Elements. Certain header elements that are required in the headermay be redundant with questions specified in individual Additional InformationSpecifications. In such cases the provider shall provide the information in the header,and should provide it in the body.4) Optional Header Elements. Certain header elements that are optional in the header maybe redundant with questions specified in individual Additional InformationSpecifications. In such cases the provider shall provide the information in the body of thedocument and should redundantly include that information in the header.Comment: the reason that such information should appear in the header is to allow copiesof the document to be processed by software that is built to the CDA standard but notspecific to attachments.5) Format of LOINC Codes. LOINC codes must always be transmitted without leadingzeroes with a hyphen before the check digit (e.g., "8709-8" or "10154-3").6) Signing. Documents that are signed by a person but not legally authenticated shall usethe element. Documents that are legally authenticated shall use the element.3.4.2 Recording the Attachment Control Number (ACN)In order to ensure appropriate linkage to the associated healthcare transactions such as the ASCX12 837 claim or the ASC X12 278 services review, the header shall contain aninFulfillmentOf/order/id element to convey an attachment control number. TheinFulfillmentOf/order/id/@extension attribute shall contain the value that is specified in thecorresponding loop position of the related administrative transaction. TheinFulfillmentOf/order/id/@root attribute shall contain the OID of the assigning authority of thatidentifier.Example: a claim identified in ASC X12 275 Additional Information to Support a Health CareClaim or Encounter, contains the value XA728302 in data element TRN02-Attachment ControlCopyright © 1998-2007 Health Level Seven, Inc. All rights reserved.Release 3.0 Draft StandardPage 41March 2007
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HL7 CDA R2 AIS Implementation Guide

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