Debbi Meisner, VP Regulatory Strategy

Transcription

1 Jan April July Oct Jan April July Oct Jan April July Oct Jan April July Oct Debbi Meisner, VP Regulatory Strategy HIPAA and ACA Timeline /1/2013 Eligibility & Claim Status Operating Rules Compliance ~1/1/2014 Claims Attachments Standard and Operating Rules Effective 1500 Claim Form (version 02/12). ~1/1/2016 Claims Attachments Standard and Operating Rules Compliance ~1/1/2014 Claims, Enrollment, Authorizations Premium Payment, Operating Rules Effective ~1/1/2016 Claims, Enrollment, Authorizations Premium Payment, Operating Rules Compliance 1/1/2014 ERA/EFT Standard and Operating Rule Compliance 1/1/14: Payers begin receiving 1/6 3/31: Dual use period 4/1: Payers receive only 5/6/2013 Prescriber Modifications to NPI Compliance ~4/1/2014 Health Plan Eligibility, Claim Status, EFT, ERA Penalty Fees 10/1/2014 ICD-10 Implementation 11/5/2015 Small Health Plans must register for HPID Compliance 11/7/2016 Health Plan ID Compliance ~12/31/2013 Health Plan Eligibility, Claim Status, EFT, ERA Certification 11/ 5/2014 Health Plans must register for HPID Compliance ~12/31/2015 Health Plan Claims, Enrollment, Attachments, Premium Payment, Referral Certification Meaningful Use Stage 1 and 2 ~indicates estimated date. All other dates are as specified in the regulation. 1

2 The Secretary shall adopt a single set of operating rules for each transaction referred to under subsection (a)(1) with the goal of creating as much uniformity in the implementation of the electronic standards as possible. Such operating rules shall be consensus-based and reflect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of Publication Date Publication Date Effective Date Compliance Date National Plan Identifier (HPID) Other Entity Identifier (OEID) NPI Modifications for Prescribers Standards for: Electronic Funds Transfers Remittance Advice Standards and Operating Rules for Claims Attachments Operating Rules for: Eligibility Claim Status Operating Rules for: Electronic Funds Transfers Remittance Advice Operating Rules for: Claims Enrollment Premium Payments Referrals and Authorizations Certification by Health Plans for: Electronic Funds Transfers Remittance Advice Eligibility Claim Status Certification by Health Plans for: Claims Enrollment Premium Payments Referrals and Authorizations Claims Attachments Final Rule September 5, 2012 Final Rule September 5, 2012 November 5, 2012 November 7, 2016 November 5, 2012 May 6, 2013 IFC January 5, 2012 January 10, 2012 January 1, 2014 ~January 1, 2014 ~January 1, 2016 IFC July 8, 2011 June 30, 2011 January 1, 2013 IFC August 10, 2012 August 10, 2012 January 1, 2014 ~July 1, 2014 ~January 1, 2016 ~December 31, 2013 ~December 31, 2015 ~indicates estimated date 2

3 The term operating rules means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part. In adopting operating rules under this subsection, the Secretary shall consider recommendations for operating rules developed by a qualified nonprofit entity that meets the following requirements: (A) The entity focuses its mission on administrative simplification. (B) The entity demonstrates a multi-stakeholder and consensus-based process for development of operating rules, including representation by or participation from health plans, health care providers, vendors, relevant Federal agencies, and other standard development organizations. (C) The entity has a public set of guiding principles that ensure the operating rules and process are open and transparent, and supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. (D) The entity builds on the transaction standards issued under Health Insurance Portability and Accountability Act of (E) The entity allows for public review and updates of the operating rules. 3

4 First Set of mandates: Adopted Phase I and II of the Rules Health Care Claim Status Request and Response (276/277) Health Care Eligibility Benefit Inquiry and Response (270/271) Second Set of mandates: Adopted Phase III of the Core Rules Health Care Claim Payment/Advice (835) Third Set of mandates: Health Care Claims (837) Benefit Enrollment and Maintenance (834) Payroll Deducted and Other Group Premium Payment for Insurance Products (820) Health Care Services Review Request for Review and Response (278) Claims Attachments (TBD) Not including Acknowledgments Not including Core Certification The operating rules adopted by HHS were developed by CAQH CORE to establish the criteria for exchanging transactions in a consistent manner. 3 Phase III Rules: 382: ERA Enrollment Data Rule 380: EFT Enrollment Data Rule 370: EFT & ERA Reassociation (CCD+/835) Rule 360: Uniform Use of CARCS and RARCS (835) Rule 350: Health Care Claim Payment/Advice (835 Infrastructure Rule) Phase II Rules: 250: Claim Status Rule 258: Eligibility and Benefits Normalizing Patient Last Name Rule 259: Eligibility and Benefits AAA Error Code Reporting Rule 260: Eligibility and Benefits Data Content Rule 270: Connectivity Rule Phase I Rules: 152: Eligibility and Benefits Real Time Companion Guide Rule 153: Eligibility and Benefits Connectivity Rule 154: Eligibility and Benefits Data Content Rule 155: Eligibility and Benefits Batch Response Time Rule 156: Eligibility and Benefits Real Time Response Time Rule 157: Eligibility and Benefits System Availability Rule Phase I was the first set; Phase II built on Phase I; Phase III built on Phase I and II. 4

5 The eligibility and claim status operating rules adopted by HHS were developed by CAQH CORE as two separate sets, Phase I and Phase II, to establish the criteria for their voluntary Phase I and Phase II certification program. Phase II Rules: 250: Claim Status Rule 258: Eligibility and Benefits Normalizing Patient Last Name Rule 259: Eligibility and Benefits AAA Error Code Reporting Rule 260: Eligibility and Benefits Data Content Rule 270: Connectivity Rule Phase I Rules: 152: Eligibility and Benefit Real Time Companion Guide Rule 153: Eligibility and Benefits Connectivity Rule 154: Eligibility and Benefits Data Content Rule 155: Eligibility and Benefits Batch Response Time Rule 156: Eligibility and Benefits Real Time Response Time Rule 157: Eligibility and Benefits System Availability Rule Phase II Rules build upon Phase I Rules CORE Rules: Phase I Rule 153: Eligibility and Benefits Connectivity Phase II Rule 270: Connectivity Phase II Rule 250: Claim Status Communications level requirements: Use HTTP/S over the public internet for transport Request and response handling Security and authentication Audit-Logging Capacity HTTP error handling Response timeout, retransmission Transaction packaging 5

6 CORE Rules: Phase I Rule 155: Eligibility and Benefits Batch Response Time Phase I Rule 156: Eligibility and Benefits Real Time Response Time Phase II Rule 250: Claim Status Real-time: Round trip of 20 seconds or less For 90% of transactions handled per month Batch: If dropped off by 9:00 PM Eastern, return by 7:00 AM Eastern next business day Business day defined by health plan/information source. CORE Rules: Phase I Rule 157: Eligibility and Benefits System Availability Phase II Rule 250: Claim Status Available no less than 86% of a calendar week. Maximum regularly scheduled downtime of 24 hours per calendar week Reporting requirements for Scheduled downtimes Non-Routine downtimes Unscheduled/emergency downtimes 6

7 CORE Rules: Phase I Rule 154: Eligibility and Benefits 270/271 Data Content Phase II Rule 260: Eligibility and Benefits 270/271 Data Content Phase II Rule 259: Eligibility and Benefits 270/271 AAA Error Code Reporting Phase II Rule 258: Eligibility and Benefits 270/271 Normalizing Patient Last Name Health plans: Detailed reporting of patient financials (base and remaining deductibles, co-pays, co-insurance) plan name out-of-network and coverage level variances Support for 50+ service types Standardized AAA reporting Enhanced patient identification through name normalization Vendors: Detect and display context of response elements Detect errors and display text uniquely describing the error CORE Rules: Phase I Rule 152: Eligibility and Benefit Real Time Companion Guide Phase II Rule 250: Claim Status Follow required format and flow Template provided 7

8 The ERA/EFT operating rules adopted by HHS were developed by CAQH CORE to establish the criteria for Phase III Operating Rules. 3 Phase III Rules: 382: ERA Enrollment Data Rule 380: EFT Enrollment Data Rule 370: EFT & ERA Reassociation (CCD+/835) Rule 360: Uniform Use of CARCS and RARCS (835) Rule 350: Health Care Claim Payment/Advice (835 Infrastructure Rule) Phase II Rules: 250: Claim Status Rule 258: Eligibility and Benefits Normalizing Patient Last Name Rule 259: Eligibility and Benefits AAA Error Code Reporting Rule 260: Eligibility and Benefits Data Content Rule 270: Connectivity Rule Phase I Rules: 152: Eligibility and Benefit Real Time Companion Guide Rule 153: Eligibility and Benefits Connectivity Rule 154: Eligibility and Benefits Data Content Rule 155: Eligibility and Benefits Batch Response Time Rule 156: Eligibility and Benefits Real Time Response Time Rule 157: Eligibility and Benefits System Availability Rule Phase I was the first set; Phase II built on Phase I; Phase III built on Phase I and II. CORE Rule: Phase III Rule 350 Claim Payment/Advice (835) Infrastructure Applies safe harbor requirements defined in CORE Phase I Rule 153 and Phase II Rule 270 to the ERA. (Retail pharmacies are exempt because they use NCPDP D.0 specifications.) Requires health plans that issue proprietary paper claim remittance advices to continue to offer paper remittance advice for a minimum of 31 days from the implementation of ERA Requires use of standard Companion Guide template for ERA Companion Guides. Excludes ASC X Acknowledgement requirements defined in the Rule. 8

9 CORE Rules: Phase III Rule 360 Uniform Use of CARCS and RARCS (835) Includes CORE-required Code Combinations for CORE-defined Business Scenarios: 1. Additional Information required Missing/Invalid/Incomplete Documentation 2. Additional Information Required Missing/Invalid/Incomplete Data from Submitted Claim 3. Billed Service Not Covered by Health Plan. 4. Benefit for Billed Service Not Separately Payable Identifies four business scenarios representing the minimum set to be used in conveying details of claim denial or payment adjustment (see left). Defines a maximum set of CARC 1, RARC 2, CAGC 3, and NCPDP Reject 4 code combinations to be used within each scenario. Addresses adjustments arising from code committees who own the code sets. Requires vendors to render the meaning of the codes as well as the description of scenario to which the codes belong. 1 Claim Adjustment Reason Code 2 Remittance Advice Remark Codes 3 Claim Adjustment Group Codes 4 Used by Pharmacy CORE Rule: Phase III Rule 370 EFT & ERA Reassociation (CCD+/835) Defines the data elements required for reassociation with the ERA: Effective Entry Date Amount EFT Trace Number * Originating Company Identifer * Situationally, Originating Company Supplemental Code * Requires providers to notify their financial institution to receive the reassociation data. Establishes maximum elapsed time between release of ERA and EFT. Three days for health plan For Pharmacy, ERA any time before the EFT but within three days after the EFT Defines requirements for resolving late or missing EFT and ERA transmissions. * From the TRN segment of the ERA, transmitted in the addenda portion of the CCD+. 9

10 CORE Rule: Phase III Rule 380 EFT Enrollment Data Includes Master Template for Paper Enrollment Forms Applies a controlled vocabulary when referring to enrollment data elements. Requires standard data elements to appear on paper enrollment forms in a standard format and flow. Requires health plans to: Give instruction to providers to assist in paper-based enrollment. Offer electronic EFT enrollment. (It does not require discontinuation of paper-based enrollment.) Convert all paper-based enrollment forms to comply with this rule no later than six months after the compliance date in this IFC. CORE Rule: Phase III Rule 382 ERA Enrollment Data Includes Master Template for Paper Enrollment Forms Applies a controlled vocabulary when referring to enrollment data elements. Requires standard data elements to appear on paper enrollment forms in a standard format and flow. Requires health plans to: Give instruction to providers to assist in paper-based enrollment. Offer electronic EFT enrollment. (It does not require discontinuation of paper-based enrollment.) Convert all paper-based enrollment forms to comply with this rule no later than six months after the compliance date in this IFC. 10

11 Effective Date January 1, 2016 Health Care Claims (837) Benefit Enrollment and Maintenance (834) Payroll Deducted and Other Group Premium Payment for Insurance Products (820) Health Care Services Review Request for Review and Response (278) Claims Attachments (TBD) Core is starting the process of looking at the remaining ACA-drive operating rules Next 3 Next Phase Rules Survey: Build on the current structures Phase III Rules: 382: ERA Enrollment Data Rule 380: EFT Enrollment Data Rule 370: EFT & ERA Reassociation (CCD+/835) Rule 360: Uniform Use of CARCS and RARCS (835) Rule 350: Health Care Claim Payment/Advice (835 Infrastructure Rule) Phase II Rules: 250: Claim Status Rule 258: Eligibility and Benefits Normalizing Patient Last Name Rule 259: Eligibility and Benefits AAA Error Code Reporting Rule 260: Eligibility and Benefits Data Content Rule 270: Connectivity Rule Phase I Rules: 152: Eligibility and Benefit Real Time Companion Guide Rule 153: Eligibility and Benefits Connectivity Rule 154: Eligibility and Benefits Data Content Rule 155: Eligibility and Benefits Batch Response Time Rule 156: Eligibility and Benefits Real Time Response Time Rule 157: Eligibility and Benefits System Availability Rule Next Phase will continue to build on Phase I, II and III 11

12 Outreach and Education Existing ORs ACA Goals Core Guiding Principles Environmental assessments Research Scope of items Public Surveys and Whitepapers Subgroups to develop Rules Q Draft Operating Rules Q Q Q First Survey went out this spring on Claims 1. Support for adoption of enhanced infrastructure rules for claims 999 Acknowledgments 277 CA Use and standardized error codes 2. Connectivity both RT and Batch Submission 3. Response Times 4. Companion Guides 5. Real Time Adjudication 12

13 6. Uniform use of data content rules Address ejects by claim type Clarity on Claim Frequency Codes Clarity on use of NPI at Billing and Rendering Levels Clarity around member identification Address the number of diagnosis codes and prevent rejections 7. Clarity on COB Requirements Standardize claim types (professional vs. institutional Ensure all payers accept secondary claims Promote use of CAS segments in COB Clarity between Medicare Supplemental and other types of COB 8. Clarity on pre-determinations 9. Identify data in the claim that could reduce the need for attachments. 13

14 WEDI has Workgroups looking at Operating Rules and making recommendations to CORE HL7 is discussing the Operating Rules around the attachment transactions NUBC and NUCC are discussing where Operating Rules can help The CAQH website, is your primary resource for the operating rules. The website includes: Phase I and II Eligibility and Claim Status Operating Rules Phase III ERA and EFT Operating Rules Educational Presentations, Town Halls and Webinars Tools Frequently Asked Questions To request clarification: Free of charge from the CAQH website. CAQH frequently presents educational webinars on the operating rules. Check the link below for a list of upcoming events: Past presentations are also available. The following presentations are recommended: Overview of Mandated CAQH CORE Eligibility & Claim Status Operating Rules, March 28, 2012 Public Town Hall Call, April 24, 2012 Public Town Hall Call, September 11, 2012 CAQH has many useful tools to assist in implementation of the operating rules. See: CAQH CORE Analysis and Planning Guide CAQH maintains a thorough list of FAQ s on the operating rules. core@caqh.org 14

15 The website for the Centers for Medicare & Medicaid Services (CMS) provides Frequently Asked Questions on the operating rules from their CMS FAQ page. See the subtopic Affordable Care Act under HIPAA Administrative Simplification. The Secretary shall promulgate a final rule to establish a transaction standard and a single set of associated operating rules for health claims attachments (as described in section 1173(a)(2)(B) of the Social Security Act (42 U.S.C. 1320d 2(a)(2)(B))) that is consistent with the X12 Version 5010 transaction standards. The Secretary may do so on an interim final basis and shall adopt a transaction standard and a single set of associated operating rules not later than January 1, 2014, in a manner ensuring that such standard is effective not later than January 1,

16 Include the ASC X and 275 as Envelope ASC X Health Care Claim Request for Additional Information version 6020 ASC X Additional Information to Support a Health Care Claim or Encounter version 6020 ASC X Additional Information to Support a Health Care Services Review version 6020 Acknowledgment TA1 and 999 used to validate syntax of the X12 transactions SDO s still discussing solutions for the application/business levels Recommendations Consolidated Clinical Document Architecture (C-CDA) Based on CDA release 2 HL7 Attachment Supplement Guide Logical Observation Identifiers Names and Codes (LOINC) as the code set to be used for Attachments Includes structured and unstructured clinical data 16

17 Code Set Recommended for the Attachment Updated twice per year in June and December Currently 21,000 users in 150 countries Three Main Purposes Identify the specific kind of information in the request and response Specify variables that modify the parameters used Identify the attachment type, section and entries RELMA is the tool for accessing the LOINC database STRUCTURED DOCUMENTS in the C-CDA Continuity of Care Document (CCD) Consultation Note Diagnostic Imaging Report (DIR) Discharge Summary History and Physical Operative Note Procedure Note Progress Note UNSTRUCTURED DOCUMENTS Other clinical information not listed above may be also exchanged using C-CDA by taking advantage of the Unstructured Document 17

18 Solicited only sent when requested from the health plan Unsolicited Other Uses Authorizations Referrals, Post Payment Audit Solicited versus Unsolicited Attachments Mandate Solicited Trading Partner Agreement for Unsolicited Rule Type NPRM IFR has limited ability to amend and industry needs to identify critical concerns WEDI is willing to hold Policy Advisor Group (PAG) to gather input Education and Outreach Encouraged HHS to work with WEDI to facilitate industry implementation Acknowledgments Support the use of a named standard Attachment Rule should not address at this time 18

19 Questions? Debbi Meisner 19