Texas Children s Health Plan. HIPAA 5010 Compliancy Plan STAR & CHIP. January 4, Version 1.1

Transcription

1 Texas Children s Health Plan HIPAA 5010 Compliancy Plan STAR & CHIP January 4, 2010 Version 1.1 Exhibit U Page 1

2 Background: The Workgroup on Electronic Data Interchange (WEDI) released its specifications for the 5010 EDI standards on October 1, On January 16, 2009 the Department of Health and Human Services (DHHS) published two final rules under the Administrative Simplification providers of the Health Insurance Portability and Accountability Act (HIPAA). These rules impart changes to Title 45 Public Welfare, Code of Federal Regulations, Part 162 Administrative Requirements by mandating the following: Electronic Transaction Standards: ASC X12N with applicable errata National Council for Prescription Drug Programs (NCPDP) D.0/Batch 1.2 NCPDP Batch 3.0 for Medicaid Subrogation of Pharmacy Claims Code Sets: ICD-10-CM Diagnosis ICD-10-PCS Inpatient Hospital Procedure Code Sets The 5010 transaction sets will be implemented on January 1, 2012 and ICD-10 diagnosis coding, supported within the 5010 transaction sets, will be implemented on October 1, It is the intention of the Texas Health & Human Services Commission (HHSC) to follow the directions of the Center for Medicare and Medicaid Services (CMS) to implement the 5010 transaction sets on January 1, To this end, HHSC has requested health plans contracting for CHIP, STAR Medicaid, and other similar state health care programs, to develop a written compliancy plan to as a roadmap to implementing the new transaction and code sets. Under the current national timeline and for the period of March 17, 2009 through December 31, 2011, both transactions versions X A1/NCPDP and X /NCPDP D are permitted to passed among trading partners. Effective January 1, 2012, only X /NCPDP D (with applicable errata) are permitted to be exchanged among trading partners and HIPAA-covered entities. It is understood that the following timeline is to be followed: Jan 4, 2010 MCOs submit compliancy plans Jan 2010 HHSC Submits ADP to CMS Mar 2010 CMS Approves ADP Nov 2010 HHSC Begins External Testing (8 mo after ADP approval) Mar 2011 HHSC Begins Dual Processing (12 mo after ADP approval) Jan 2012 Full 5010 Implementation Cut-Over Apr 2012 NCTDP Implementation Cut-Over Oct 2013 ICD10 Implementation Cut-Over Exhibit U Page 2

3 The following table lists the current standards versions mandated in 2003 and the new standards versions by transaction type. Electronic Transaction Standards Transaction Type Current Version (2003) New Version (2012/2013) Professional, Dental, Institutional Claims/Encounters and COB X12N 4010 X098A1 (837P) X12N A1 (837D) X12N 4010 X096A1 (837I) X12N 5010 X222E1 (837P) X12N 5010 X224A1, E1 (837D) X12N 5010 X223A1, E1 (837I) Retail Pharmacy Drug Claim/Encounter and COB NCPDP 5.1 (interactive) NCPDP 1.1 (batch) NCPDP D.0 (interactive) NCPDP 1.2 (batch) Retail Pharmacy Supplies and Professional Services Claim, Encounter and COB Unspecified X12N 5010 X222E1 (837P) ***OR*** NCPDP 4.0 (interactive) NCPDP 1.2 (batch) Remittance Advise X12N 4010 X091A1 (835) X12N 5010 X221E1 (835) Eligibility Inquiry and Response (nonpharmacy) X12N 4010 X092A1 (270/271) X12N 5010 X279E1 (270/271) Eligibility Inquiry and Response (retail pharmacy) NCPDP 5.1 (interactive) NCPDP 1.1 (batch) NCPDP D.0 (interactive) NCPDP 1.2 (batch) Benefit Enrollment and Maintenance X12N 4010 X095A1 (834) X12N 5010 X220E1 (834) Premium Payment X12N 4010 X061A1 (820) X12N 5010 X218E1 (820) Authorization and Referral Request X12N 4010 X094A1 (278) X12N 5010 X217E1 (278) and Response (non-pharmacy) Authorization and Referral Request and Response (retail pharmacy) NCPDP 5.1 (interactive) NCPDP 1.1 (batch) NCPDP D.0 (interactive) NCPDP 1.2 (batch) Claim Status Inquiry and Response X12N 4010 X093A1 (276/277) X12N 5010 X212E1 (276/277) Medicaid Pharmacy Subrogation Not Mandated NCPDP Batch Standard Medicaid Subrogation 3.0 The following table shows very basic differences between ICD-9 and ICD-10 diagnosis code versions. ICD-9 and ICD-10 Basic Differences ICD-9 U.S. Version ICD-10 U.S. Version Diagnosis Codes Nomenclature ICD-9-CM Volumes 1 and 2 ICD-10-CM Number of Characters 3-5 alphanumeric 5-7 alphanumeric Number of Codes 13,500 68,000 The following table shows very basic differences between ICD-9 and ICD-10 inpatient hospital procedure code versions. ICD-9 and ICD-10 Basic Differences ICD-9 U.S. Version ICD-10 U.S. Version Inpatient Hospital Procedure Codes Nomenclature ICD-9-CM Volume 3 ICD-10-PCS Number of Characters 3-4 alphanumeric 7 alphanumeric Number of Codes 4,000 72,500 Exhibit U Page 3

4 Scope / Constraints / Assumptions: At this time, specific instruction / guidance regarding timing, details, testing, modifications to standard HIPAA 5010 transactions sets (to meet local need) or overall communication program has not yet been made available from HHSC or TMHP / Maximus. The impact of that missing information on this draft plan cannot be exaggerated or overstated. TCHP does plan to follow such instructions when provided and will, of course, develop a final implementation plan that fits around that and the guidance which is given to providers in Texas. We do understand the need to begin planning now and have done so. Further, we understand that this is in the process of being developed. However, all TCHP implementation plans are tentative, at best, until such information begins to become available. For the sake of brevity, this statement of concern will not be repeated throughout the document, but we ask that you understand that the entire document is subject to revision based on additional information being made available. Additionally, Implementation of the 5010 transaction sets is a multi-track process. Numerous agencies, including CMS, WEDI, State Medicaid agencies, healthcare trade organizations, insurance trade organizations, and insurers, are working on aspects of the 5010 implementation, but are also dependent on one another s direction to achieve a common goal. TCHP 5010 Compliancy Plan is an attempt to narrow the focus from a national stage to this individual health plan s needs. Once sufficient information is at hand to create such documents, it is expected that this plan will be modified. Substantial modifications may be required. The focus of this document in on the HIPAA 5010 transaction set and TCHP ability to receive and send such transactions. While it is understood that 5010 makes ICD10 information available, the document will not focus on the substantial effort required to implement ICD10. Instead the focus will be applied specifically to the 5010 transaction sets. TCHP used the same suite of applications to support both the STAR and CHIP products. As a result a single version of this document has been prepared to address both products. As per guidance from HHSC, this document will be embedded with the STAR nomenclature, but covers both. This document represents Version 1.0 of TCHP s 5010 Implementation Plan and is subject to likely substantial revision. Exhibit U Page 4

5 Transactions: TCHP s use of all HIPAA 5010 transactions is detailed below: ASC X Eligibility request Not currently used by TCHP ASC X Eligibility response Not currently used by TCHP ASC X Claim status inquiry Not currently used by TCHP ASC X Claim status response Not currently used by TCHP ASC X Referral certification and authorization (request and response) Not currently used by TCHP ASC X Health plan premium payment Not currently used by TCHP ASC X Health plan enrollment TCHP does use. Detail Follows. ASC X Health care claim payment/remittance advice TCHP does use. Detail Follows. ASC X Institutional health care claims TCHP does use. Detail Follows. ASC X Professional health care claims TCHP does use. Detail Follows. ASC X Dental health care claims Not currently used by TCHP ASC X Institutional encounters TCHP does use. Detail Follows. ASC X Professional encounters TCHP does use. Detail Follows. ASC X Dental encounters Not currently used by TCHP B1 Pharmacy Billing Request and Response Not currently used by TCHP B2 Pharmacy Billing Reversal Request and Response Not currently used by TCHP E1 Pharmacy Eligibility Verification Request and Response Not currently used by TCHP Based on the above, our review of HIPAA 5010 transaction sets indicates that we will focus on: 834 enrollment, 835 payment / remittance advice, 837 I and P claims, and 837 I and P encounters. Contingency Options: HHSC has indicated that no contingency option is available for this effort. As such, TCHP will ensure that we can meet all required deadlines and timing as that becomes available from HHSC and TMHP/Maximus. TCHP understands that HHSC and TMHP/Maximus will follow a dual strategy. Our current plan is to follow that same approach. Exhibit U Page 5

6 Detailed Gap Analysis: Please refer to Attachment A for a detailed analysis of HIPAA 5010 transactions used by TCHP and the critical differences between the HIPAA 4010 and 5010 versions. Separate tabs have been created for the 834, 835, 837 I and 837 P transactions. TCHP uses packaged software for transaction processing. TCHP s core claims system is QNXT and the vendor is Trizetto. Our vendor is required to support HIPAA standard transactions, has completed a detailed gap analysis regarding changes between HIPAA 4010 transaction sets and HIPAA 5010 transactions sets and has developed an updated version of the software that we will use to meet this requirement. A significant core claims system upgrade will be necessary in order to meet these requirements. System Impacts for each Transaction Set: 834 Eligibility Processing: o TCHP receives monthly inbound STAR and CHIP eligibility files in 834 format. Additionally, we receive daily STAR eligibility files in 834 format (and expect at some point that we may also receive daily CHIP eligibility files). o These files contain numerous Texas specific CHIP and STAR items and we expect that, when published, the 5010 Companion guide will also contain may Texas specific items some replicating current functionality and some new / additional items. o Our monthly and daily eligibility load processes will need to be modified to accommodate the updated 5010 format and any existing and new State specific items. o It is expected that there will be some changes to existing codes. Upon publication of the Companion Guides, these will need to be carefully reviewed to make certain that they are properly accommodated in our core claims processing system. o Additionally, TCHP will need to review eligibility files that we pass within our internal systems to make sure the new codes are properly accommodated. o TCHP does not generate any outbound 834 files although we do pass the 834 files we receive to our vision provider (BlockVision) 835 Health Care Claim Payment / Remittance Advice: o TCHP passes 835 files to a limited number of providers to facilitate claims processing. o Our existing 835 file generation processes will need to be modified to facilitate creation of these same files in the new format. o It is expected that there will be some changes to existing codes. These will need to be carefully reviewed to make certain that they are properly accommodated in our core claims processing system. Exhibit U Page 6

7 837 I and P Inbound Claim Processing: o TCHP uses a claim clearing house (Emdeon) to collect institutional and professional 837s from the many providers we work with. o Additionally, paper claims are scanned and converted to 837 institutional and professional transactions. o These files are loaded daily into our core claims processing system for adjudication. o These files contain numerous Texas specific CHIP and STAR items and we expect that, when published, the 5010 Companion guide will also contain may Texas specific items some replicating current functionality and some new / additional items. o Our daily claims load processes will need to be modified to accommodate the updated 5010 format and any existing and new State specific items. o It is expected that there will be some changes to existing codes. Upon publication of the Companion Guides, these will need to be carefully reviewed to make certain that they are properly accommodated in our core claims processing system. 837 I and P Outbound Encounter Processing: o TCHP passes many both 837 I and P transaction files weekly to the State s Data Warehouse. o These files contain numerous Texas specific items and we expect that, when published, the 5010 Companion guide will also contain may Texas specific items some replicating current functionality and some new / additional items. o Our file generation processes will need to be modified to accommodate the updated 5010 format and any existing and new State specific items. o It is expected that there will be some changes to existing codes. Upon publication of the Companion Guides, these will need to be carefully reviewed to make certain that they are properly accommodated in our core claims processing system and passed appropriately in the weekly files. o Finally, our Vision provider creates 837 encounter files that we then, in turn, submit to the Data Warehouse. These too will need to be modified. Business Process Impacts for each Transaction Set: 834 Eligibility Processing: o While extensive work will be required, business impact from changes to the 834 transaction will be limited to HHSC and TMHP/Maximus. o It is anticipated that much testing will be required to effectively implement this change o Several key internal reports will need to be modified to reflect new codes available. o Similarly, coordinated testing will be necessary with our Vision provider Exhibit U Page 7

8 o We do not expect that a coordinated communication program will be necessary here due the small number of parties coordinating changes. 835 Health Care Claim Payment / Remittance Advice: o While extensive work will be required, business impact from changes to the 834 transaction will be limited to a few (but likely increasing over time) number of providers o It is anticipated that much testing will be required to effectively implement this change o We do not expect that a coordinated communication program will be necessary here due the small number of parties coordinating changes. Coordination will be handled one by one with the provider with whom we exchange 835 files. 837 I and P Inbound Claim Processing: o Business impact from changes here will impact ALL providers TCHP works with. Business impact here cannot be overstated. This will be a much more complicated change to coordinate than either TPI or NPI and it immediately precedes a complex ICD10 implementation process to be created. o This will likely be the most complicated change area from a business / operations perspective. o This will impact both inbound EDI and paper claims. o It is anticipated that a State-wide communication program will be developed. Upon publication, TCHP plans to develop a TCHP communication strategy that builds upon state-wide provider education and communication. o It is anticipated that much testing and communication coordination will be required to implement this change o Additionally, TCHP will need to carefully coordinate with our claims clearing house -- Emdeon. o These files contain numerous Texas specific CHIP and STAR items and we expect that, when published, the 5010 Companion guide will also contain may Texas specific items some replicating current functionality and some new / additional items. o Several key internal reports will need to be modified to reflect new codes available. 837 I and P Outbound Encounter Processing: o While extensive work will be required, business impact from changes to the 837 transaction will be limited to files submitted to the State s Data Warehouse. o It is anticipated that much testing will be required to implement this change o Similarly, coordinated testing will be necessary with our Vision provider regarding the 837 files they create (and we submit). o We do not expect that a coordinated communication program will be necessary here due the small number of parties coordinating changes. Exhibit U Page 8

9 Supporting Documentation: Please refer to Exhibit U.1 (5010 Compliancy Plan-1) for a detailed analysis of HIPAA 5010 transactions used by TCHP and the critical differences between the HIPAA 4010 and 5010 versions. Separate tabs have been created for the 834, 835, 837 I and 837 P transactions. This analysis makes clear the specific changes, additions and deletions between 4010 and 5010 for these transaction types. Please refer to Exhibit U.2 (5010 Compliancy Plan-2) for detail on key system changes that will be part of version 4.7: 837 I and P Exhibit U.2 (5010 Compliancy Plan-2) - Pages Exhibit U.2 (5010 Compliancy Plan-2) Pages Exhibit U.2 (5010 Compliancy Plan-2) Pages Please refer to Exhibit U.3 (5010 Compliancy Plan-3) for detail on timing and testing related to inbound 837 I and P transactions from Emdeon (TCHP s Claim Clearing House Provider). Timeline for Implementation and Remaining Analysis: Please refer to Exhibit U.4 (5010 Compliancy Plan-4), TCHP Timeline for an overview of TCHP planned timing related to the 5010 Implementation. Test Approaches: Testing will be a critical part of this initiative. We have planned that testing will be divided into two sets of activities; those tests that TCHP (and all MCOs) follow a dictated path and timing for and those other tests that TCHP (and all other MCOs) take an individual lead on. We anticipate the testing activities falling into the we follow your lead include: 834 Eligibility Load Processing 837 I and P Encounter Submission Testing activities that we anticipate we will take the lead on include: 837 I and P Claim Submissions from TCHP s Claim Clearing House (Emdeon) Paper claim conversion into 837 I and P transaction (TCHP task) Confirmation the our vision provider (BlockVision) can process and 834 file Confirmation that our vision provider can generate 837 Encounters Confirmation that the limited number of providers that process 835 files from us can do so with the new format Exhibit U Page 9

10 Testing is a key milestone in our overall implementation plan and will be completed prior to the upgrade and again prior to the implementation of dual processing. Dual Processing Strategy: It is understood that HHSC would like to follow a dual processing strategy to accommodate a mix of providers who will, over time, migrate from 4010 transactions to 5010 transactions. While TCHP looks forward to the publication of HHSC planned strategy and timing we do anticipate that we will follow a similar approach. We think this will best support our mix of providers who will likely implement 5010 on their own individual timelines (although necessarily greatly influenced by any HHSC mandates and required timing). We plan that will be able to accommodate dual processing over the course of the last half of It is assumed, however, that we will not be dual processing 834 files and that there will be a hard cut-over date for that. One important point which is not yet clear is in regard to encounters submitted by TCHP to the State s Data Warehouse. We look forward to some guidance on whether / how we will be submitting encounters in the dual processing period. Options include submitting only 4010 transactions (regardless of how we get them or 5010), submitting only 5010 transactions (regardless of how we get them or 5010), or submitting a mix (based on how we get them from the provider). Implementation of Dual Processing is a key milestone in the overall implementation plan. Provider Outreach Strategy: As with a better understanding of the State s dual processing approach, TCHP looks forward to future communication from the State regarding any intended provider communication program. Just as we did with the deployment of NPI, we plan to develop and communicate with our providers as consistently and in the same timing as we can with any state-wide communication programs. The earlier we obtain access to plans in this area, the better able we will be to create and deploy complimentary materials. Following this approach has the added benefit of keeping messaging from many MCOs all following a similar track. TCHP has developed a comprehensive Provider Representative approach that teams a TCHP provider representative with all networked providers in a given geography. We have used this group to facilitate communication and change of many other initiatives and plan to use them here as part of our communication strategy. Development and deployment of a communication program are key milestones in our overall implementation timeline. Exhibit U Page 10