Transcript Slide 1

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Copyright © 2014 TriZetto Corporation
Solutions for Federal
Regulatory and Compliance
Enablement
Susan Scardina – Sr QicLink Product Manager
Laura Gerling – Mgr of Product, Partner & Acct Mgmt
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Agenda
 5010 Modifications
 Billing PCORI and Transitional Reinsurance Fees
 Combined / Shared Accumulations
 Unique National Health Plan ID
 CAQH CORE IV
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5010 Transactions
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5010 Regulations
 Federal Register – January 16, 2009
 45 CFR Part 162
 Modifications to HIPAA Final Rule
 Effective date of final rule – March 17, 2009
 Mandatory compliance date – January 1, 2012
 Adopts updated versions of the standards for
electronic transactions
 ASC X12 Standards for Electronic Data Interchange Technical
Report Type 3
 Version 5010 enforcement discretion period ended
on June 30, 2012
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5010 Transactions – Purpose
 Enhanced business functions and content
 Added
 Improved
 Removed
 Supports ICD-10
 NPI implementation clarification
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5010 to 4010 Cross Reference
Transactions
 212 – Health Care Claim Status Request and
Response (276/277)
 217 – Health Care Services Review — Request for
Review and Response (278)
 218 – Payroll Deducted and Other Group Premium
Payment for Insurance Products (820)
 220 – Benefit Enrollment and Maintenance (834)
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5010 to 4010 Cross Reference (Cont’d)
Transactions
 221 – Health Care Claim Payment/Advice (835)
 222 – Health Care Claim: Professional (837)
 223 – Health Care Claim: Institutional (837)
 224 – Health Care Claim: Dental (837)
 279 – Health Care Eligibility Benefit Inquiry and
Response (270/271)
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220 Benefit Enrollment Maintenance
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Change Description
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5010 Additional Information
 Center for Medicare and Medicaid Services
 4010A to 5010 comparison PDF and Excel documents
 837 Professional Claim
 837 Institutional Claim
 835 Health Care Claim Payment Advice
 276/277 Health Care Claim Status Request and Response
 270/271 Health Care Eligibility Benefit Request and
Response
 http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp
 Workgroup for Electronic Data Interchange (WEDI)
 Strategic National Implementation Process (SNIP)
 Transactions and Code Sets Workgroup
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5010 Impact on QicLink
 5010 compatible versions of all HIPAA transaction
programs
 CBLD calls:
 CBLD1 for ECSIF
 CBLD2 for 4010 version 837 inbound transactions
 CBLD3 for 5010 version 837 inbound transactions
 GS control segment determines program overlay
 GS08 Version/Release/Industry Identifier Code
 004010X098 for 4010 version 837 Professional
 005010X222 for 5010 version 837 Professional
 Multiple GS control segments with different GS08
values in same batch not allowed
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System Name Maintenance (SN-5)
 HIPAA 4010 complnt date (was HIPAA Compliant Date)
 HIPAA 5010 complnt date
 Controls 835 transaction output version
 Default value is equal to zeroes
 5010 Compliant Date equal to zeroes
 All 835 transaction output in 4010 version format
 5010 Compliant Date entered
 835 transaction output controlled by new Version field in Provider
Maintenance (PM) if system date is prior to 5010 Compliant Date
 All 835 transaction output in 5010 version format if system date is
equal to or greater than 5010 Compliant Date
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837 Transaction Modifications
 Additional claim header diagnosis codes and pointer
codes
 Calculation of other carrier allowed amounts
 4010 Loop 2320 AMT data segments eliminated
 COB Approved Amount
 COB Allowed Amount
 COB Patient Responsibility
 Based upon two models of benefit coordination
 Provider-to-Payer-to-Payer
 Prior payer payment plus total of all patient responsible amounts (CAS
segments)
 Provider-to-Payer-to-Provider
 Prior payer payment plus remaining patient liability amount (AMT
segment)
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PPACA Billing PCORI
and Transitional
Reinsurance Fees
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PCORI Billing Fee
 Affordable Care Act (ACA) established the PatientCentered Outcomes Research Institute.
 Institute helps patients, clinicians, purchasers and
policy-makers make informed health decisions by
advancing clinical effectiveness research.
 Funded by the Patient-Centered Outcomes Research
Trust Fund.
 Funded in part by fees paid by issuers of certain
health insurance policies and sponsors of certain
self-insured health plans.
 Rate multiplied by the average number of lives
covered under the policy for that policy year.
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Transitional Reinsurance Fee
 Affordable Care Act (ACA) established the
Transitional Reinsurance Program as a riskspreading program.
 Provide payments to health insurance issuers that
cover higher-risk populations.
 Spread the financial risk more evenly carried by
issuers.
 This program will impose a fee on health insurance
issuers and self-insured group health plans.
 For 2014, HHS announced a national contribution
rate of $5.25 per month ($63 per year).
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QicLink™ Modifications in 2014
 Billing Rate Maintenance
 2 New Calculation Types
 All Enrollees/Spouses/Members
 Check Enrollment (Enr/Sp/Mem)
 Enrollment Listing
 Option to include or exclude terminated spouses/members
 Option to enter up to six benefit types
 Sort by benefit type
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Combined / Shared
Accumulators
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Combined / Shared Accumulators
 Public Health Service (PHS) Act section 2707(b)
 Added by the Affordable Care Act
 Provides that a group health plan shall ensure that
any annual cost-sharing imposed under the plan
does not exceed the limitations provided for under
section 1302(c)(1) and (c)(2) of the Affordable Care
Act. Section 1302(c)(1) limits out-of-pocket
maximums for employer-sponsored plans
 No guidance provided by ACA as to ‘how’ to
administer (no formal Operating Rules similar to CAQH
CORE Phase I, II, and III)
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Current QicLink Data Solutions
Inbound
 History Accumulator Load – HCMLOAD
 20 different history accumulator record types overall
 Data submitter to populate various required fields
 Claim History Load – CLMLOAD
 Data submitter to populate up to 24 required data elements
 Detail Accumulator Load – ACCLOAD
 Update history accumulators
Outbound
 Ad-hoc enrollment data extract query
 Ad-hoc history accumulator data extract query
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QicLink Standard Modification
 Create a history accumulator data extract for
defined history accumulator types and history
accumulator codes
 Provide the ability for User to define history
accumulator types and codes to extract by
group/plan
 Create history accumulator types and codes
 Delete history accumulator types and codes
 List history accumulator types and codes
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Proposed Funded Development Solution
- First Phase
 Vendor interface functionality
 Multiple interface vendors can be assigned to
employer group/plan
 Pre-defined required data elements maintenance
 Ability to store and cross-reference interface vendor
ID for employer group to QicLink™ group ID
 Inbound claims data with minimally required data
elements to be provided by data submitter
 Automatic assignment of claim/worksheet numbers
for inbound claims
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Proposed Funded Development Solution
- First Phase
 PBM claims-based prescription drug history data
element storage
 Drug Quality, Days Supply, Brand/Generic Flag, Formulary Flag,
Dispensed As Written Code, Drug Name/Description,
Preventative Flag
 History accumulator update for inbound interface
vendor claims
 Premier Partnership Program data extracts expanded
for PBM drug history data elements
 Generate HIPAA-formatted outbound enrollment
 5010 ASC X12 834 (220A1) Benefit and Enrollment Transactions
 Create health coverage enrollment crosswalk data elements
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Proposed Funded Development Solution
- Second Phase
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Display of drug history data elements
Accumulator Over Limit Report
Accumulator Reconciliation Report
Manual check payment/reimbursement to a third-party
vendor from passed flag claims data load records
 Process outbound 5010 ASC X12 834 (220A1) Benefit
and Enrollment transactions through QicLink™ HIPAA
Gateway
 Inbound interface vendor proprietary-formatted claims
translation function
 Outbound interface vendor proprietary-formatted
history translation function
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Unique National
Health Plan ID
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Unique National Health Plan Identifier
 HHS published proposed rule April 17, 2012
 Department of Health and Human Services (HHS)
establishes a unique health plan identifier (HPID)
under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) standards for
electronic health care transactions.
 The rule also proposes a data element that will serve
as an “other entity” identifier (OEID) for entities that
are not health plans, health care providers, or
individuals, but that need to be identified in standard
transactions.
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CAQH CORE
(QicLink™ Phase IV)
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CAQH CORE (QicLink™ Phase IV)
 7/1/2014 Final Rule will be published
 1/1/2016 Compliance Date of operating rules for:
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Health claim or equivalent encounter information
Enrollment and disenrollment in a health plan
Health plan premium payments
Referral certification and authorizations
 1/1/2016 Compliance Date of standard operating
rules for:
 Health claim attachments
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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Thank You!
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