HIPAA Transaction Testing

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2 HIPAA Transaction Testing October, 2002 Julie A. Thompson Alliance Partners

3 Agenda HIPAA Transaction Overview A whole new world Transaction Analysis The steps in the process Transaction Issues and solutions Test Planning Testing Methodologies Example Test Scenarios Other considerations Building Client Specific Test Data Certification/Testing Vendors Companion Documents The Implementation Process Contingency Plans Vendor Assessments Transaction Implementation

4 A True Paradigm Shift In Plato s famous analogy of the cave, describing a tribe of people have lived in a cave from their childhood. Their legs and necks chained so that they cannot move, and can only see before them. They cannot see above, or behind them. View from within the cave A whole new world Yet, if only they would stand up, turn around and face the mouth of the cave. A whole NEW world was waiting! Plato challenges all people to recognize that their perception of the world is limited and a simple stretch will open opportunities to visit new worlds.

5 Changing Technology-Where are we going? Healthcare Claims History EDI Outsourcing X12N-XML-eCommerce 2004 X12 Standard adopted by Healthcare 1996 HIPAA Internet First EDI Standard 1985 NSF electronic Standard UB First Uniform Institutional Paper Form 1975 HCFA 1500 Professional Claim Point to Point

6 Why X12N? How is the new world different? Previous Formats Claims only No Adjustments or Corrections Fixed Length Fields Fixed Length Records Fixed Number of Line Items Minimum fields No Payments X12N Format Claims, plus other standard healthcare transactions Allows for Payments, Adjustments, and Corrections Variable Length Fields Variable Length Records Variable Line Items 99 Lines on 837P 999 Lines on 837I Additional details such as provider taxonomy

7 The new transaction world Types of Covered Transactions Providers Eligibility Inquiry 270 Subscriber/ Patient Info. Eligibility Response 271 Request for Review 278 Referral/Auth/ Certification Claim 837 Attachments 275 Review Response 278 Claims Remittance Advice 835 Payment/Remit Processing Status Inquiry Claim Status Payors Subscriber Info. Enrollment 834 Premium Payment Premium Payment 820 Employers

8 Where do we begin? What are the steps? What problems can we anticipate? How do we solve those problems? How do we test the solutions? How do implement the solutions?

9 HIPAA Transaction Testing What are the steps?

10 Steps in Transaction Analysis 1. Define Transaction Strategy 2. Build System, Application Inventory 3. Build Maps based on the inventory 4. Define Transaction Issues and Solutions 5. Build a Document Library Trading Partner Business Rules Code Set Crosswalk 6. Reports Gaps, Solutions, Plans, Budget

11 How do we implement the transactions? CAP MAP Cohesion TpX Manager

12 Concio s Transaction Solutions Phases Transaction Specifications Test Planning Internal Testing Integration And Certification Trading Partner Mgmt. Transaction Analysis Test Scenarios Unit/ System Testing Testing/ Certification Trading Partner Specific Testing Activities Project Planning Budgeting Test Cases Test Data/ Files Level 1-6 Testing Integration Testing Trading Partner Testing Management Progress Monitoring HIPAA Compliant System Tools MAP Cohesion TpX Manager Resources Project Manager/ Transaction Testing Consultants/ Subject Matter Experts

13 HIPAA Transaction Testing What are the issues and solutions?

14 Remediation Solutions What is the impact? The Issue The Impact Repeating Loops, Segments, Elements Up to 999 claim lines Unlimited Pay to Providers Up to 8 Secondary Provider IDs Situational and Optional Elements Both Payers and providers must communicate how repeating loops, segments, and element will be created, processed, and accepted. Providers may submit all valid Provider Ids to assure payment Payers tend to focus on only the require elements and the elements used in previous standards like NSF, HCFA 1500, and the UB92. Providers must utilize the situational and optional elements for proper reimbursement.

15 Remediation Solutions What is the impact? The Issue The Impact Repeating Loops and Segments 1. Claims up to 999 lines 2. Unlimited Pay to Provider Loop Code Set Cross walks Maintaining the original line number order. Payers, Clearinghouses, and/or Repricers may change original line order. Payers may choose to split claims to resolve this kind of issue. Providers should consider the impact on reimbursement and 835 remittance. Trading Partners may want to share all code set crosswalks. Providers require all original lines to be returned on the 835 in the original order.

16 Remediation Solutions What is the impact? The Issue The Impact Handling fields not in core system 1. Add field to core system. For example: Provider s Claim ID (CLM01) is required on the 835 payment remittance Payers and providers will need to consider adding new fields to their systems. A Transaction Repository is a valid solution and is used by other industries such as banking. 10 types of providers on both the claim header and each line time: Billing, Rendering, Pay-to, Referring, Purchased, Supervising, Ordering, Attending, Operating, Other Trading Partners need to communicate the usage of each of the 10 different types of Providers. Both on the claim level and the line level.

17 Remediation Solutions What is the impact? The Issue Multiple references to line numbers 1. Provider line number 2. Payer line number The Impact All original lines must be returned to the provider in the original line number order on the 835 payment remittance. Providers may receive multiple trading partner companion documents for health plans. Companion documents may be necessary but they must adhere to the HIPAA Transaction Implementation Guides.

18 HIPAA Transaction Testing How do we test the solutions?

19 Facing the Testing Challenges How will your organization determine a Trading Partner has passed acceptance testing? High potential impact on corporate financials and market share Complex testing criteria multiple levels, systems Software changes in multiple systems and vendors High volume testing and numerous testing scenarios Multiplied by Large number of trading partners Potential delays in claim and eligibility processing Tight testing schedule begin by April 16, 2003 Severe penalties for non-compliance Education Assessment Remediation Testing Monitoring

20 Understanding the Basics Standard testing methodology terms: Unit Is a date in the right format? System Does a single system pass information correctly to another system? Integration Does both system process both the request and the response correctly?

21 Unit, System, and Integration Unit System Integration Compliance testing Types 1-7 Transaction Certification Trading Partner Business to Business testing

22 Test Plan Design Easy Isolation of error source using test phases Gradually increasing complexity Clear identification of issue solutions Comprehensive evaluation of all potential situations Expect the unexpected Work Load Testing for high volume

23 Test Phases Identifying source of errors Phase 1 Translator Only Phase 2 Single Pass System Testing Core Core System System Payer Provider Provider Payer Phase 3 Full System Integration Testing Core System Payer clearinghouse Provider Core System

24 Integration Testing includes: Testing System Components and Component Integration API and Middleware Testing Testing System Interfaces Testing the Integration of Front-Ends with Legacy Systems

25 HIPAA Transaction Testing Testing Consideration for Claims and Claim Payments

26 Integration Testing What is it? 837 Cohesion 835 X12N Covered Business Processes Results Match original claim to payment Validate bundling and unbundling Validate claim/payment corrections Validate repriced claims Validate split claim payments Verify Reissued claim handling comparison Monitor Statistical/Encounter or Capitated claims Validate Patient Payments Estimate Prompt Payment liabilities Validate COB Primary processing Validate COB Secondary processing Validate Dental Predetermination claims (estimated claims)

27 835 Test Scenario Overview The HIPAA Perspective Covered Business Processes Claim adjustments Original Claim Payments 837 Claim Corrections (Demographic/Line Item Adjustments) Payment Reversals and Corrections Incoming Provider Adjustments COB claims (Primary Payer Adjustments) Claim Splits Line Bundling and Line Deletion Claim Predetermination/Estimates Patient Payments Repriced Claims Statistical Encounters

28 Original Claim Payments Payer System Payment All original lines returned with Payments Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5 Paid Line 1 Paid Line 2 Paid Line 3 Gateway Service Line 1 Paid Service Line 2 Paid Service Line 3 Paid Service Line 4 Not Paid Service Line 5 Not Paid 837 HIPAA Transaction 835 Relationships Gateway Provider System 835 Processing Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5

29 837 Claim (Demographic/Line Item Adjustments) Corrections should be processed electronically by both payer and provider to assure 835 payment remittance can be processed by the provider. Payer System Original Claim X Phone corrections may not allow for proper posting of the 835 by the provider Original and/or Corrected Payments Demographic 1 Service Line 1 Service Line 2 Service Line 3 Service Line 4 Demographic 2 Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5 Corrected 837 Duplicate Claim Logic must consider resubmission as updated claims Gateway Demographic 2 Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line Claim Frequency Type Code (CLM05-3) 1 - ORIGINAL (Admit thru Discharge Claim) 6 - CORRECTED (Adjustment of Prior Claim) 7 - REPLACEMENT (Replacement of Prior Claim) 8 - VOID (Void/Cancel of Prior Claim) 835 Original Claim Corrected Claim Provider System 835 Processing Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5

30 Payment Corrections and Reversals Payer System Service Line 1 Service Line 2 Original Payment Line 1 paid Line 2 paid Line 3 paid 0.00 UPS Universal Payment System Gateway Service Line 3 Payment Correction Line 1 paid Line 2 paid Line 3 paid HIPAA Transaction 835 Relationships 835 Line 1 paid Original Line 2 paid Gateway 835 Processing Line 3 paid 0.00 Line 1 paid Correction (CAS01 = CR) Provider System Line 2 paid Line 3 paid 15.00

31 Incoming Provider Adjustments Payer System Service Line 1 Service Line 2 Service Line 3 Service Line 4 Provider Contractual Adjustment (CAS) Payment Service Line 1 Paid Service Line 2 Paid Service Line 3 Paid Service Line 4 Paid Provider Contractual Adjustment (CAS) UPS Gateway Original Lines with Payments Service Line 1 Paid Service Line 2 Paid Service Line 3 Paid Service Line 4 Paid Provider Contractual Adjustment (CAS) HIPAA Transaction Relationships Gateway Provider System 835 Processing Service Line 1 Paid Service Line 2 Paid Service Line 3 Paid Service Line 4 Paid Provider Contractual Adjustment (CAS)

32 COB Claim (One Scenario - Awaiting HHS NPRM ) Payer System Medicare Secondary COB ORIGINAL Provider Submitted Lines Original Charge Original Procedure Original Units UPS Payment ORIGINAL Provider Submitted Lines (Secondary Responsibility) Original Charge Original Procedure Original Units Adjudicated Charge Adjudicated Procedure Adjudicated Units All Original Lines ORIGINAL Provider Submitted Lines Original Charge Original Procedure Original Units Adjudicated Charge Adjudicated Procedure Adjudicated Units PRIMARY Payer Adjudicated Services PRIMARY Incoming Adjustments SECONDARY Payments SECONDARY Adjustments SECONDARY Payments SECONDARY Adjustments PRIMARY Payer Adjudicated Services PRIMARY Incoming Adjustments Transaction Repository PRIMARY Payer Adjudicated Services PRIMARY Incoming Adjustments 837 HIPAA Transaction 835 Relationships Provider System 835 Processing

33 Split Claims and the associated payments Payer System Week 2 Payment Service Line 1 Claim 1 Service Line 4 Service Line 5 Service Line 2 Service Line 3 Week 1 Payment Service Line 4 Service Line 5 Claim 2 Service Line 1 Service Line 2 Service Line HIPAA Transaction Relationships Provider System 835 Processing Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5 Week 1 Total Charges will differ from the original claim, first 835 and second 835. Week 2

34 Line Bundling and Line Deletion Payer System Original Lines with Payments Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5 Line Bundling Service Line 1 -or- Service Line 2 Lines Deleted Service Line 3 Transaction Repository or Remediated Core System Gateway Service Line 4 Service Line 5 Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line HIPAA Transaction 835 Relationships Provider System 835 Processing Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5 False aging may occur without all the original lines on the 835 claim payment

35 Predetermination Claim Estimates (Dental) Payer System Date of Service = Blank Service Line 1 Date of Service filled Service Line 1 Dental Predetermination Claim Processing, No Payment for Predetermination Gateway Completed Service Lines with Payments Service Line 1 Service Line 2 Service Line 2 Service Line 2 Service Line 3 Service Line 3 Service Line 3 Service Line 4 Service Line 4 Service Line 4 Service Line 5 Service Line 5 Service Line 5 837D 837D HIPAA Transaction 835 Relationships Services Rendered Predetermination Claim (CLM19 = PB) Provider System 835 Processing Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5

36 Repriced 837 Claim Payer System Original Claim Return all Original lines in the original order Service Line 1 Service Line 2 Gateway Service Line 1 Service Line 2 Service Line 3 Service Line 3 Service Line 4 Service Line 5 Service Line 3 Service Line 4 Service Line 4 Service Line 5 Claim Repricing Service Line 5 Service Line 2 Service Line HIPAA Transaction 835 Relationships Service Line 1 Provider System 835 Processing Service Line 2 Service Line 3 Service Line 4 Service Line 5 Repriced References (REF01=9A,9C)

37 Statistical Encounter (Managed Care) Payer System No Payment to be made Service Line 1 Service Line 2 Service Line Paid Service Line 3 Service Line Paid Service Line 4 Service Line Paid Service Line 5 Service Line Paid Service Line Paid Related transaction 276/277 Claim Status Claim Status Processing Entire batch is capitated 837 BHT06 = RP Provider System HIPAA Transaction Relationships 278 Claim Status Processing Claim Status = 105, Claim captiated.

38 HIPAA Transaction Testing Testing Consideration for Eligibility

39 Eligibility (270/271) Batch.vs. Real Time HHS FAQ: What level of service is required to be provided under HIPAA when an entity implements batch and/or real time submission of a standard transaction? 45 CFR states "a health plan may not delay or reject a transaction, or attempt to adversely affect the other entity or the transaction, because the transaction is a standard transaction." If the standard transaction (e.g., ASC X12N 270/271) is offered in a batch (non-interactive) mode, the health plan has to offer the same or higher level of service as it did for a batch mode of transaction before the standards were implemented by the plan. If a health plan offers the transaction in a real time (interactive) mode, the level of service has to be at least equal to the previously offered level for a real time mode of transaction. If a transaction is offered through Direct Data Entry (DDE), the level of service, again, has to be at least equal to the level offered for the DDE transaction before implementation of the HIPAA standard.

40 Patient Eligibility Real Time.vs. Batch Current response time must be maintained Payer System Real Time (GS02) Currently providing real time, 271 must provided real time Batch (GS02) Gateway GS03 (real time/batch) Real Time Linkage: BHT03 TRN 2000C, 2000D 270 Information Source, a provider a provider, payer, employer, 271 Provider System or payer, not a clearinghouse or van (2100A loop NM1) 835 Processing Information Receiver not a clearinghouse or van (2100B loop NM1) Service Line 1 Service Line 2 Service Line 3 Service Line 4 Service Line 5 See clearinghouse discussion page 19

41 Eligibility (270/271) Levels The 270/271 may convey the following information regarding a patient s eligibility: 1. Eligibility to receive health care under the health plan. 2. Coverage of health care under the health plan. 3. Specific benefits associated with the benefit plan.

42 Eligibility - Types of Requests 1. General Request - All Providers, all benefits 2. Categorical Request All Benefits for a provider type 3. Specific Request Detailed Benefits for a specific submitter

43 Eligibility - General Request Request: For All Provider Types and All Medical/Surgical Benefits and Coverage Segment: EQ01 = 60 General Benefits Response: eligibility status (i.e., active or not active in the plan) maximum benefits (policy limits) exclusions in-plan/out-of-plan benefits C.O.B information deductible co-pays

44 Eligibility - Categorical Request Request: For a Specific Provider type All Benefits Pertinent to Provider Type Segment: PRV01 Type of Provider Code EQ01 = 60 General Benefits Response: eligibility status (i.e., active or not active in the plan) maximum benefits (policy limits) exclusions in-plan/out-of-plan benefits C.O.B information deductible co-pays

45 Eligibility - Specific Request Segment : EQ01 not equal to 60 General Hospital Psychiatric Treatment Hospital O.P. Surgery Nursing Home Physical Therapy Services Other Allied Health Providers Occupational Therapy Pharmacy Prescription Drugs Physician Well Baby Coverage Physician Hospital Visits Ambulatory Surgery Center Hernia Repair D.M.E Wheelchair Rental Dentist Bonding Free Standing Lab Diagnostic Lab Service Home Health Nursing Visits Hospital Pre-Admission Testing Hospital Detoxification Services

46 Eligibility - Specific Response Segment : EB procedure coverage dates procedure coverage maximum amount(s) allowed deductible amount(s) remaining deductible amount(s) co-insurance amount(s) co-pay amount(s) coverage limitation percentage patient responsibility amount(s) non-covered amount(s)

47 HIPAA Transaction Testing Additional Considerations: Test Data, Certification, Companion Documents

48 Creating Client Specific Test Data NSF HCFA 1500 Valid Partner Specific 837 UB92

49 Certification Options Claredi Certification Portal Concio Cohesion In Line, All the time Hipaatesting.com Foresightcorp.com HCCO HIPAA Conformance and Certification organization

50 HCCO At-a-Glance Launched July 2002 Over 100 Members and Covered Entities Aligned with NIST, SQE, ISO, UCC Transactions, Privacy and Security Best practices organization Accreditation and Certification

51 HCCO Certification Interoperability Testing Covered Entity Certification IT Products Certification IT Services Certification

52 Transaction certification observations Further educational awareness on transactions Upgrade the use of proper testing processes Upgrade quality assurance methodologies 3 rd party testing efforts must be portable Clear definitive interpretation of the guides are needed IG ambiguities must be identified and resolved Software interoperability concerns must be solved Clear certification guidelines must be published Time and money saving initiatives must be implemented

53 Companion Documents Some trading partner relationships may require specific content Some Health Plans have prepared companion documents for their trading partners HHS requires that companion documents adhere to the HIPAA Implementation Guidelines without exceptions, limitations, or other restrictions.

54 Trading Partner Companion Documents Providers

55 HHS FAQ: Should health plans publish companion documents that augment the information in the standard implementation guides for electronic transactions? Additional information may be provided within certain limits. Electronic transactions must go through two levels of scrutiny: 1. Compliance with the HIPAA standard. The requirements for compliance must be completely described in the HIPAA implementation guides and may not be modified by the health plans or by the health care providers using the particular transaction. 2. Specific processing or adjudication by the particular system reading or writing the standard transaction. Specific processing systems will vary from health plan to health plan, and additional information regarding the processing or adjudication policies of a particular health plan may be helpful to providers.

56 Companion Document Guidelines Such additional information may not be used to modify the standard and may not include: Instructions to modify the definition, condition, or use of a data element or segment in the HIPAA standard implementation guide. Requests for data elements or segments that are not stipulated in the HIPAA standard implementation guide. Requests for codes or data values that are not valid based on the HIPAA standard implementation guide. Such codes or values could be invalid because they are marked not used in the implementation guide or because they are simply not mentioned in the guide. Change the meaning or intent of a HIPAA standard implementation guide.

57 HIPAA Transaction Testing How do we implement the solutions?

58 Riding the wave. Payers Providers Small Plans Oct, 2003

59 Assure Compliance Establish a contingency plan 1) Vendor / clearinghouse compliance assessment 2) Develop a backup plan. Some options are: Choose a new vendor Choose a new clearinghouse Choose a transaction translator If plans are satisfactory, assure plans can be executed within budget and time frames. If plans NOT satisfactory, consider implementation of the backup plan.

60 Decide on a course of actions Vendor Implementation Trading Partner Go Live Assessment Testing Upgrade New Installation Unit & System Testing Integration Testing Define a date April, 2003 October, 2003

61 HIPAA Compliant Vendor Assessment 1. Software Compliance Assessment Services 2. HIPAA Tools are available for assessment: a) Mapping Tools b) Testing Tools c) Certification 5. Issues Reporting 6. QA Strategy and Test Planning 7. Supporting Document Library

62 Vendor Assessment Objectives Develop Overall Project Plans for the Assessment Develop Contingencies Plans Establishment of Process Flows for Standard EDI Transactions Electronic Transaction Code Set Remediation Convert and Certify Key Trading Partner Electronic Data Exchanges (Unit and System only) Review and Validate HIPAA Ready Version Develop New Policies/Procedures Develop New Training Program Evaluate/Design Modifications for Standard Identifiers Trading Partner Readiness Survey (in multiple phases) Develop a Comprehensive Quality Assurance (QA) Approach and Testing Strategy (Integration Testing)

63 The Implementation Process Legal Agreements Trading Partner Specifics Security Compliance Privacy Compliance Testing Process Instructions Test Result Reporting Implementation and Sign off

64 Summary HIPAA Transaction Overview Transaction Analysis Transaction Issues and solutions Test Planning Testing Methodologies Example Test Scenarios Other considerations Building Client Specific Test Data Certification/Testing Vendors Companion Documents The Implementation Process Contingency Plans Vendor Assessments Transaction Implementation

65 Questions? THANK YOU

66 Select HIPAA Clients

67 Comprehensive HIPAA Solutions Minimize the Hurdles