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Electronic Clinical Attachments: The Long Road to Standardization


Electronic Clinical Attachments

Addressing the Growing Demand for a Standardized Mechanism
to Exchange Clinical Data

By the American Medical Association

In order to successfully receive payment for patient services, healthcare providers often must provide clinical documentation to support claims sent to payors. To help improve the efficiency of this process, the Health Insurance Portability and Accountability Act (HIPAA) called for the creation of a standardized electronic attachment for use throughout the health care industry. Establishing this standard has proven difficult, as the industry has been unable to settle on an appropriate method in the 20 years since HIPAA was signed into law.

The Department of Health and Human Services (HHS) issued a Notice of Proposed Rulemaking on attachment standardization in 2006, but no final action was taken on the proposed rule.

Following the unsuccessful effort in 2006 to standardize the attachment format, the healthcare industry has remained in limbo while waiting for guidance on this issue. During this time, the number of clinical attachments necessary for claims adjudication has increased. Without a standardized electronic attachment format, health plans have utilized a wide variety of methods, including faxes, U.S. mail, direct email, health plan portals, and the Accredited Standards Committee X12 (ASC X12) 275 transaction to collect supporting clinical documentation from providers. Not only do certain methods take significant time and energy (for example, manually completing and faxing paper forms), but the dynamic variation from plan-to-plan presents significant administrative burdens for providers.

The growing demand for a standardized mechanism to exchange clinical data has spurred recent increased industry interest and activity on attachments. The National Committee on Vital and Health Statistics (NCVHS) issued a letter to the HHS Secretary on July 5, 2016, recommending the establishment of an electronic standard for attachments. The full text of the letter is available on the NCVHS website (

In this letter, NCVHS recommended that HHS prioritize the establishment and implementation of an electronic attachment standard to streamline how clinical information is transmitted in the industry. This recommendation is an important step to eliminating the burdens and achieving administrative simplification in the provision of healthcare. In order to fully achieve the administrative simplification objectives of HIPAA, however, it is critical that the adopted standard enables true automation of a single format across the industry. From this standpoint, NCVHS falls short of true simplification, recommending a standard that enables clinical documents to be formatted using two different options.

NCVHS Attachment Standard Recommendations
In order to standardize sending clinical information for administrative purposes, an attachment solution must establish formats for both the transport of the clinical document (often called the "envelope") and the clinical information itself. ASC X12 has established the 275 transaction as the standard "envelope" format for administrative uses. Additionally, HealthLevel7 (HL7), the standards designation organization for clinical data, has created the Consolidated Clinical Document Architecture Release 2.1 (C-CDA R2) and the Clinical Documents for Payors – Set 1(CDP1) for the formatting of clinical information. While both of these formats can carry the relevant information, the CDP1 format requires providers to complete additional steps as compared to the C-CDA R2.

In its July 2016 letter, NCVHS recommended that HHS mandate adoption of the ASC X12 275 while allowing usage of either the C-CDA R2 or the CDP1. This proposed allowance of two different HL7 formats for attachments creates a potential for continued administrative burdens for providers, as some health plans may require providers to send clinical attachments using the CDP1 format, while others would require C-CDA R2. As a result, providers would once again be responsible for changing the ways in which they transmit information based on payor preferences.

AMA Concerns and Advocacy
According to HHS, the HIPAA Administrative Simplification provisions were enacted in order to enable providers "to submit the same transaction to any health plan in the United States" when conducting it electronically.1 A standardized attachment that allows multiple ways of sending clinical information fails to meet this legislative purpose and is effectively not a standard. Therefore, in order to promote efficiency and meet the goals of the HIPAA legislation, the industry needs a single, standard, defined way of transmitting clinical information from providers to health plans and other providers.

To minimize provider burdens and ensure that the attachment standard meets the stated provisions of HIPAA Administrative Simplification, the AMA strongly advocates for the adoption of a single format for clinical information. In testimony before NCVHS in February 2016, the AMA stressed the need for consistency between payors in any mandated attachment
standard. More details on the AMA's testimony are available on the NCVHS website.

The industry movement towards a standardized attachment transaction presents an exciting opportunity to greatly diminish administrative inefficiencies throughout the industry, especially as usage of attachment data becomes increasingly important to health plans. The AMA strongly supports a mandated standard for electronic attachments to facilitate the automated exchange of clinical data. However, in order to truly achieve administrative simplification, the standard must fully streamline the transactional process so that payor-specific idiosyncrasies do not bog down provider workflows. For additional information on the AMA's advocacy related to the electronic attachment standard and other administrative simplification initiatives, please visit