Standards and Operating Rules for Electronic Funds Transfer and Claims Payment/Remittance Advice. 2010, Data Interchange Standards Association

Transcription

1 Standards and Operating Rules for Electronic Funds Transfer and Claims Payment/Remittance Advice 2010, Data Interchange Standards Association

2 Overview Our Role and expertise in the Remittance Advice Transaction and Electronic Funds Transfer Build the standards for ERA (835) transaction Work closely with ASC X12F (Finance) Subcommittee to relate the remittance transaction to appropriate standard payment transactions. Allow for many different types of payments supported to remain flexible to the industry. ASC X12N (Insurance) Subcommittee does not create EFT standards ASC X12N does write business requirements regarding which EFT transaction is to be paired with a health care transaction which are selected and named with guidance from X12F 2010, Data Interchange Standards Association 2

3 ERA evolution and EFT selection ASC X12N Develops TR3 for ERA NACHA develops standard EFT transactions. CCD+ CTX PPD Etc. Working closely with ASC X12F, the appropriate EFT transactions are selected to be paired with the ERA transaction. This facilitates re-association and ensures consistency in the industry. The rules around how these paired transactions function together and re-associate in the Healthcare industry are made by ASC X12N in cooperation with ASC X12F and are located in the front matter of the TR3 implementation guide. 2010, Data Interchange Standards Association 3

4 What are the available EFT payment transactions The Electronic Remittance Advice (ERA) transaction allows for both the CCP which is CCD+ or CTX electronic payment transactions The Technical Reports developed by ASC X12N include what is called front matter which describes in detail the use of the transaction for various specific purposes or situations. The CCD+ format which is a NACHA standard format is referenced in the front matter and is to be used with the ERA transaction for electronic payment when sent separate from the ERA. When sending a separate ACH payment, the CCD+ ACH format is used. Using this method, the Re-association Key Segment in its entirety is contained in the ACH Addenda Record. Front matter 835 TR3 The CCD+ format has been used in the industry well before and including 4010, is also in Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N Health Care Claim Payment/Advice (835), X221 pg 20. Washington Publishing Company, Apr < 2010, Data Interchange Standards Association 4

5 Define the Activity Credit or Debit Credit is typically Used to add funds To the providers Account. Debit is used less, Allows an entity to Debit the account of the sender (additional transactions are required in this model.) Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N Health Care Claim Payment/Advice (835), X221 pg 71. Washington Publishing Company, Apr < 2010, Data Interchange Standards Association 5

6 Many payment types are accommodated in the 835 guide For the purposes of healthcare EFT Automated Payments ACH is used. Additional payment methods are available in the guide to meet business requirements. This information is defined in Coordination with X12F Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N Health Care Claim Payment/Advice (835), X221 pg 72. Washington Publishing Company, Apr < 2010, Data Interchange Standards Association 6

7 Definition of the EFT transaction being used to move the funds. Two different types of EFT transactions are supported in the 835. The Workgroup supports CCD+ as the format for EFT when traveling separate from the ERA. And CTX when there is a requirement for the ERA to travel with the EFT transaction through the banking network. Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N Health Care Claim Payment/Advice (835), X221 pg 72. Washington Publishing Company, Apr < 2010, Data Interchange Standards Association 7

8 Models of EFTs in the industry The previous slide shows two different EFT models that can be used - Why? Two different business uses: Payment and Remittance travel separately model CCD+ Payment and Remittance Travel together model CTX 2010, Data Interchange Standards Association 8

9 How CCD+ is used? The EFT transaction flows through the ACH network in the CCD+ format. EFT contains re-association information in the addenda Same TRN (Trace) segment as the ERA transaction. ie: TRN*1* * Trace segments are matched by the receiver and used widely by most of the largest commercial payers. Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N Health Care Claim Payment/Advice (835), X221 pg 9. Washington Publishing Company, Apr < , Data Interchange Standards Association 9

10 How do they re-associate the ERA with EFT in CCD+ format? ST*835*0001~ BPR*I*187.50*C*ACH************ ~ TRN*1* * ~ REF*EV* ~ DTM*405* ~ N1*PR*YOUR TAX DOLLARS AT WORK~ N3*481A00 DEER RUN ROAD~ N4*WEST PALM BCH*FL*11114~ N1*PE*ACME MEDICAL CENTER*FI* ~ N3*PO BOX ~ N4*ORLANDO*FL*55115~ REF*PQ*10488~ LX*1~ ERA 835 Transaction CLP* *3*1766.5*187.50**12* ~ NM1*QC*1*ISLAND*ELLIS*E****MI* ~ NM1*82*2*JONES ASSOCIATES*****BS*AB34U~ DTM*232* ~ SVC*HC*24599*1766.5*187.50**1~ DTM*472* ~ CAS*OA*23*1579~ REF*1B*44280~ AMT*AU*1700~ SE*38*0001~ EFT CCD+ Transaction Re-association occurs in both The ERA and the CCD+ The provider uses this to link The Remit and the Payment 2010, Data Interchange Standards Association 10

11 Challenges / Solutions CCD+ CCD+ Pros This has been the format in the ASCX Implementation guides for EFT when done separately from the ERA. As such the industry has adopted this as the payment transaction when performing an EFT. Cons Some payers are not doing the plus portion of the CCD NACHA transaction. This is record 7 in the CCD NACHA transaction. Without this reassociation reconciliation is impossible as the connection to the remittance is broken. Solution : EDUCATION - If this NACHA transaction is done as it should be done all information that is necessary to tie the two transactions is readily available. Banks can help in the education when taking CCD+ transactions from the payers and could insist the appropriate record 7 data is in the file. Cons Transaction travels separate from the Remittance and needs to be reassociated however some feel that this is a check and balance between the Practice management system and the bank records. 2010, Data Interchange Standards Association 11

12 How is CTX Used? Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N Health Care Claim Payment/Advice (835), X221 pg 8. Washington Publishing Company, Apr < 2010, Data Interchange Standards Association 12

13 How the CTX re-associates to the remittance detail ERA 835 Transaction ST*835*0001~ BPR*I*187.50*C*ACH************ ~ TRN*1* * ~ REF*EV* ~ DTM*405* ~ N1*PR*YOUR TAX DOLLARS AT WORK~ N3*481A00 DEER RUN ROAD~ N4*WEST PALM BCH*FL*11114~ N1*PE*ACME MEDICAL CENTER*FI* ~ N3*PO BOX ~ N4*ORLANDO*FL*55115~ REF*PQ*10488~ LX*1~ CLP* *3*1766.5*187.50**12* ~ NM1*QC*1*ISLAND*ELLIS*E****MI* ~ NM1*82*2*JONES ASSOCIATES*****BS*AB34U~ DTM*232* ~ SVC*HC*24599*1766.5*187.50**1~ DTM*472* ~ CAS*OA*23*1579~ REF*1B*44280~ AMT*AU*1700~ SE*38*0001~ 2010, Data Interchange Standards Association 13

14 Challenges / Solutions CTX CTX Pro The CTX transaction allows for the Remit and EFT to transmit together so there is no latency between the two transactions. Con The CTX transaction utilizes addenda records each at 80 bytes to populate the ERA detail data. At this time there is a 9,999 addenda record limit, which would support approximately 800,000 bytes of data. This could be a limiting factor with some of the larger plans that generate large transactions. Con - The Remittance data contains PHI and banks are not covered entities. At a minimum, detailed business associate agreements need to be developed and used in this context. Con The pricing for this format may be too high vs the value add. At this time the usage of this transaction is limited in the industry due to some of these factors but it does not mean there is not a business need for this transaction type. 2010, Data Interchange Standards Association 14

15 CTX flow and the PHI Payer ACH network Hospital PHI OK PHI not OK PHI OK The data flowing from the payer to the bank is covered by their BAA The data flowing from the payer bank into the ACH and through the ACH is not protected. The data from the provider bank to the provider would be protected by the bank provider BAA 2010, Data Interchange Standards Association 15

16 Comments from the Industry when asked what format is used today We use the CCD+ format. We will not honor any requests for CTX as our business rule is to use CCD+. When our Finance department researched this possibility, they determined that it was cost prohibitive to do the Remittance detail through the ACH network. We do not receive it, and do not see a need for this. We never had a request for CTX. 2010, Data Interchange Standards Association 16

17 What is the Rate of use of EFT in the industry? Commercial Payer A 10.5 million EFTs just in October 2010 CCD+ format. 65% of the total claims are paid with EFT. Commercial Payer B 9 Million CCD+ EFT transactions Jan 2010-Oct 2010 Commercial Payer C 64,000 per month approximately 768,000 CCD+ EFTs per year. Provider A receives their EFTs from their payers approximately 75,000 plus per year and have automated posting they require ERA and EFT via CCD+ and are at 90% EDI processing! 2010, Data Interchange Standards Association 17

18 Operating Rules Claims Payment/Remittance Advice 2010, Data Interchange Standards Association 18

19 Health Care Claim Payment/Remittance Advice (835) ASC X12 formally requests to be named as an operating rules entity for the Health Care Claim Payment/Remittance Advice, fulfilling the criteria established in HR (2) OPERATING RULES DEVELOPMENT. 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. ASC X12 is a not-for-profit entity ASC X12 standards and implementation guides have been developed based on business requirements for over 30 years. (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. ASC X12 is an ANSI-accredited standards development organization representing a balance of providers (physicians, hospitals, dentist, pharmacies, etc.), health plans (commercial, BCBS, government), vendors, clearinghouses, Medicare, VA, DOD, Medicaid, etc. ASC X12 collaborates with numerous other organizations. ASC X12 is a standards development organization that follows the requirements of ANSI which promotes openness, consensus, balance, etc ASC X12 participates in the DSMO. ASC X12 standards and implementation guides have been named in HIPAA. ASC X12 s process allows for public review, comments, an informational forum to review adjudication of comments and final consensus voting at multiple levels. 2010, Data Interchange Standards Association 19

20 Definition of Operating Rules (1) DEFINITION OF OPERATING RULES. Section 1171 of the Social Security Act (42 U.S.C. 1320d) is amended by adding at the end the following: (9) OPERATING RULES. 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. Points from the regulation: Recognized that business rules and guidelines may already be present in the implementation specifications. Operating rules may cover exchanges not already defined in the implementation specifications. SDOs govern the data content of the transmissions and the business rules and reference documents required to support the data content. Operating Rules cannot add, modify or remove requirements defined in the implementation specifications. 2010, Data Interchange Standards Association 20

21 Operating Rules Recommendations Health Care Claim Payment/Remittance Advice (835) X221A1 Section Data Use by Business Use contains Operating Rules Balancing Reassociation of Dollars and Data Remittance Tracking Claim Adjustment and Service Adjustment Segment Theory Advance Payments and Reconciliation Reversals and Corrections Procedure Code Bundling and Unbundling Interest and Prompt Pay Discounts Capitation and Related Payments or Adjustments Claim Splitting Balance Forward Processing Secondary Payment Reporting Considerations Service Line Issues PPOs, Network and Contract Types Post Payment Recovery Claim Overpayment Recovery Totals Reporting Encounters 2010, Data Interchange Standards Association 21

22 Operating Rules Recommendations WEDI/ASC X12 Joint Companion Guide Principles Document and the associated Companion Guide Template 120 people representing providers, health plans, vendors, clearinghouses, and other interested entities participated in the development Reviewed through ASC X12 and WEDI procedure Incorporates ASC X12 s Fair Use Policy and Copyright Supports the Implementation Guide Situational Note structure Implementation Acknowledgment For Health Care Insurance (999) X231A1 Includes the TA1 DSMO approved and presented to NCVHS the adoption of acknowledgments 2010, Data Interchange Standards Association 22

23 Operating Rules Recommendations ASC X12 Real-Time Claim Processing Model Provides guidance on communicating adjudication results using a real-time 835 transaction as a response to a real-time 837 transaction Explains the real-time usage of fields that reside in the 835 transaction only when different from the batch implementation. It also defines specific claim adjustment reason codes and remittance advice remark codes for the real-time , Data Interchange Standards Association 23

24 Thank You Margaret Weiker Debra Strickland , Data Interchange Standards Association 24