Presenters. Today s Agenda. Claims Attachments Maximizing the Benefits. Attachments: Setting the stage. Architectures for Compliance

Transcription

1 Claims Maximizing the Benefits Steve Barr, First Consulting Group Chris Stahleck, BCBS Association Maria Ward, Pricewathouse Coops Wes Rishel, Gartn Maria Ward, First Consulting Group Presents Maria Ward PricewathouseCoops Co-Chair, HL7 SIG Incoming Chair, DSMO Steing Committee Memb, NUCC Executive Committee Steve Barr, First Consulting Group Chris Stahleck, BCBS Association Wes Rishel Gartn Chair-elect HL7 Memb of WEDI Board Maria Ward, First Consulting Group 2 Today s Agenda : Setting the stage * Brief history * X12 + HL7 = HIPAA stdard * Why LOINC Codes? Architectures for Complice 3 1

2 Background HIPAA d Claims Law allows for time between initial set of trsactions d claims attachments Mentioned in the Final Rule for EDI sactions d Code Sets Development work for claims attachment recommendation undway since 1996 workgroups in X12 d HL7 working closely with CMS d HHS 4 history of activity WEDI: Workgroup Report, 1994 NUCC: National Uniform Claim Committee (NUCC) Survey, 1996 Survey to Blues & Medicare contractors asking what attachments are utilized? COB, SNF, Thapies, DME, Surgy 54 responses - no follow-up conducted of HIPAA d NUCC need to focus on 1500 dataset CMS(formly HCFA) Surveys to Medicare Carris d Intmediaries, 1996 / 1997 Results led to funding 275 POC 5 history of activity CMS led Proof of Concept (POC) Team 5 Medicare contractors funded by CMS to develop Electronic Request for Information 1997 beg considing options for Claims as response to request August 1997 POC Team joined HL7 d helped to form ASIG ASIG solicited industry input before moving forward. Included groups such as CMS, AMA, AHA, BCBSA, X12, HL7 d oths 6 2

3 history of activity Industry outreach recommendations Detmine most frequently used Consid whe HL7 messages already exist / in development Need to Stdardize the questions pays ask - industry consensus required Form workgroups by soliciting help from all sectors of industry (e.g. pays, provids, National Associations) Use LOINC codes 7 - history of activity types ultimately selected for development d HIPAA recommendation: Ambulce Emgency Department Rehabilitative Svices Lab Results Medications Clinical Notes 8 Orgizations d Documents ASC X12 & Subcommittee X12N X12 s. Sets 277, 275 X12N Impl. Guides 277, 275 X saction Health Level Seven HL7 Vsion 2.4 HL7 Claims Impl. Guide X saction HL7 ORU Msg LOINC Consortium LOINC Codes LOINC Booklets

4 Claim saction Relationships sactions involved in Claims 837 (claim) + 275(patient info) + ORU 277(info request) + 275/ORU *997 (functional acknowledgment) * mutually agreed upon 10 Claim saction usage requirements Provid has choice to: Request 277 from pay Respond to request via 275/HL7 Pay has responsibility to: Create 277 when provid elects to receive it Receive & process a 275 / HL7 when provids elect to receive it Pay & provid mutually agree to use Key components of the trsaction What is LOINC? Logical Obsvation Identifi Names d Codes Why LOINC d not Health Care Claim Reason Codes as in the Claims Status Notification (277)? Coding comparison 12 4

5 Key components of the trsaction LOINC vs. Claim Status reason Codes POC pilot in 1996 revealed that Claim Status Reason Codes we not effective in requesting information from provids Using LOINC lets us be vy specific when needed LOINC already had my codes needed for Claims LOINC consortium was vy accommodating regarding special code requests 13 Key components of the trsaction If the request is for Rehab treatment, progress notes, d goals, d the LOINC codes are used, it is expressed STC * R4 : :: LOI~ 14 Key components of the trsaction With Reason Codes, must use 3 STCs STC*R4:310:3F~ STC*R4:436:3F~ STC*R4:437:3F~ 310=6 months prior 436=short tm goals 437=long tm goals 15 5

6 Key Issues Claim data vsus data LOINC vsus Reason Codes Imaging d X-ray capabilities request: pap d electronic 16 Premises: Healthcare orgizations will use these trsactions diffently, according to their level sophistication structured data vs. textual data document image vsus charact data When the provid d pay are mismatched on sophistication, it still works Benefits start immediately d grow with the sophistication of the orgizations 17 Provid Mapping d Provid Specialty Provid System that Includes Billing Claim Mapping Mapping d Clinical Information Clinical Systems (electronic d pap) Network (275) Pay Source: Gartn Research 18 6

7 Provid Function Provid Patient Accounting Claim Clinical Information Clinical Systems (electronic d pap) Mual function C be enhced by automated support Subject to the judgement of a pson Mapping software creates the combined 275-ORU message Revision for images fax-quality scned images portions of attachments that would othwise be sent as unstructured textual reports each scned portion of a document is in OBX with a specific LOINC code valuable for provids that have image-based electronic medical record systems valuable for small provids that have no online storage of medical record systems Source: Gartn Research 19 Pay Architecture: Level 1 Provid Network Pay Claims d Processing Electronic System Claim Pap pap Source: Gartn Research 20 Pay System: Level 1 System Claim Print Receive Pap pap print structured data to print image Notify adjudication system of receipt of requested attachment Source: Gartn Research 21 7

8 Pay Architecture: Level 1+ Provid Network Pay Claims d Processing Electronic System Claim Link Pap Image Magement Source: Gartn Research 22 Pay System: Level 1+ System Claim Reformat Receive Pap Link Image Magement Convt structured data to print image Create various ID fields for image magement LOINC codes pmit vy specific matching with claim adjudication workflow Notify adjudication system of receipt of requested attachment Source: Gartn Research 23 Pay Architecture: Level 2 Provid Network Pay Auto Medical Magement Claims d Processing Medical Review Image Magement Warehouse Source: Gartn Research 24 8

9 Coordinator for Best Pay Benefits Routing d mapping of structured data Notification of arrival of claims data Auto Medical Magement Best possible hdling of unstructured text d image data because LOINC codes are still used Medical Review Image Magement Warehouse Source: Gartn Research 25 And they all work togeth... Provid Collect Structured for Specific Pay Print d Use Pap Sc or retrieve document images for textual documents Retrieve structured data from Electronic Medical Record Create image or copy from the attachment Auto-adjudicate, automate medical magement d review 26 And They Evolve Independently The NPRM approach to Claims is: a basis for dramatic long-tm upgrade in efficiency d intelligence of claims processing (d authorization, pre-ct) implementable in the short-tm with realizeable benefits Pays d Provids have individual options d incentives to upgrade their levels of implementation 27 9

10 More Information HL7 official Web site genal information/link to ASIG 28 More Information HHS - Administrative Simplification page Washington Publishing Compy (HIPAA Implementation Guides) includes all matials related to Claims 29 Questions or to participate: Maria Ward: Wes Rishel: wes.rishel@gartn.com 30 10

11 Refence Matial The following pages include refence matial not intended for use during the presentation. 31 X12 Enveloping Structures Communications Envelope Co m m un ic Int ati on ch s ge Co sp ntr ort ol Pr He ot ad oc ol Communications sport Protocol Intchge Control Head Fu nc tio na l Gr ou p He ad Functional Group Head Intchge Envelope Functional Group Functional Group Fu Fu nc nc tio tio na na l l Gr Gr sa for sa ou sa ou cti ex for sa cti p cti a p ex cti on De m on on He De a on Se tai ple Se ail Se ad tai m Se t, t t ple He l t Cl He l, ad Se ai ail ad Se Eli ail g m gib g Su ilit m b m y en mi en In t ssi qui t saction Set Head Detail Segments for example, Claim Submission saction Set ail Functional Group ail Functional Group Head saction Set Head Detail Segments example, Claims saction Set ail Fu nc tio na l Gr ou p ail Functional Group ail Int ch ge Co ntr ol ail Intchge Control ail Co m m un ic ati on s sp ort ail Communications sport ail 32 HIPAA Stdard sactions Provid Eligibility (270/271) Refral (278) Claim (837) d Remittce Advice (835) Claim Status (276/277) Claims (277/275 + HL7) Employ/ Purchas Enrollment/ Disenrollment (834) Premium Payment (820) Claim (837) COB (second pay) Source: Gartn Research Claim (837) COB (second pay) Pay 33 11

12 X12 + HL7 = Claims X12 (SDO) X12N Insurce TG2 Healthcare WG 9 saction Sets 275 segments fields HL7 (SDO) (HL7) Ords TC CA SIG Messages ORU segments fields 34 Full Documentation Suite X12 Implementation Guides 4 ASC X12N Implementation Guide for Use of the 275 saction (004020) Additional Information to Support a Health Care Claim or Encount 4 ASC X12N Implementation Guide for Use of the 277 saction (004020) Health Care Claim, Request for Additional Information HL7 Implementation Guide HL7 LOINC Code Booklets Oth 4 Modifi Codes in the ASC X12N Implementation Guide for the 277 Requests for Additional Information saction 4 LOINC Codes for the HL7 d X12 Additional Information to Support a Healthcare Claim or Encount sactions: Summary Listing 35 Linking the sactions same trsmission submitted with Claim ( ) ISA Intchge Control Head GS Functional Group Head ST 837 saction Set Head: Claim PWK contains provid s control numb SE saction Set ail GE Functional Group ail GS Functional Group Head ST 275 saction Set Head: Add l Info TRN contains provid s control numb SE saction Set ail GE Functional Group ail IEA Intchge Control ail 36 12

13 Linking the sactions separate trsmissions must be paired Request from the Pay Response from the Provid ISA Intchge Control Head ISA Intchge Control Head GS Functional Group Head GS Functional Group Head ST 277 saction Set Head: ST 275 saction Set Head: Request Response...TRN contains pay s control numb...trn contains pay s control numb STC specific data requested STC specific data requested...bin specific data response SE saction Set ail SE saction Set ail GE Functional Group ail GE Functional Group ail IEA Intchge Control ail IEA Intchge Control ail 37 - Past HL7 proposed for use in trsaction Only ANSI accredited stdard focusing on clinical processes X trsaction has BIN segment allowing for inclusion of oth stdards HL7 already had much of the work done (i.e relevt segments, codes, fields already existed) LOINC supported by HL Future ASIG proposed name d scope chge Chge to Special Intest Group Scope to expd beyond attachments for claims only X12 WG10 request for development of attachments for pre-ctification / authorization Joint development already undway Oth X12 workgroups envision possible need for same 39 13

14 - Future ASIG continues development of workgroups to stdardize new claims (d non-claims) attachments HL7 Role in the Designated Stdards Maintence Orgization (DSMO) process Parties are HL7, X12, NCPDP, NUCC, NUBC, DeCC (dental content committee) Work will filt through ASIG Process d workflow already developed 40 14