Basics of Medical Data Call Reporting Requirements Presented by: Grace Arrieche, Kristin Champagne, and Bob Vaughan 1 Objectives Review the basic business and reporting rules for reporting medical data as outlined in the Medical Data Call Reporting Guidebook. You will also become familiar with using the Medical Data Collection tool to monitor your data reporting. 2 1
Agenda Medical Data Call Overview General Rules and Call Structure Editing and Validation Medical Data Compliance Programs Medical Data Collection Additional Resources 3 Medical Data Call Overview 4 2
Driving Force of the Medical Call Legislative Analysis Recently, more than 30% of legislative activity is medical related States have been proposing and/or enacting more comprehensive cost controls in these areas: Physician fee schedules Inpatient/outpatient hospitals Ambulatory surgical centers Prescription drugs 5 Workers Compensation Medical Losses 2005 2014 1997 2001 1987 Indemnity Medical 54% 46% Indemnity 47% Medical 53% Indemnity 43% Medical 57% 6 3
Medical Data Call Usage Legislative pricing and proposed state legislation: 90 pricing analyses 38 effective changes priced 3 post-reform studies 7 Medical Data Call Usage Workers Compensation Prescription Drug Study: 2014 Update Price Impact of Workers Compensation Physician Fee Schedules Medical Services for Claims 20 or More Years Old 8 4
Medical Data Call Each medical service that occurs due to an employee s injury, including: Hospital Stay Office Visits Physical Therapy Prescription Drugs Workers Compensation Medical Payment Transactions Bill Line Detail 9 Medical Data Call General Rules 10 5
Core Resources Medical Data Call Reporting Guidebook contains the rules and requirements for reporting Medical Call data, including record layouts, data definitions, and the edit matrix. Electronic Transmission User s Guide contains the requirements for preparing and submitting test and production files for all NCCI data types. Medical Incentive Program (MIP) evaluates the completeness and accuracy of medical data in accordance with the program requirements. Medical Data Collection provides you with the ability to view the status of your Medical Call data submissions to NCCI. This tool also allows you to monitor the quality and completeness of your submissions through each level of editing as well as your Medical Incentive Program results. 11 Medical Data Call Reporting Guidebook The Medical Data Call Reporting Guidebook is your primary reference for the instructions needed to accurately complete your Medical Data Call reporting. Medical Data Call Reporting Guidebook 12 6
Accessing the Medical Data Call Reporting Guidebook 13 Accessing the Medical Data Call Reporting Guidebook 14 7
Medical Data Call Reporting Guidebook Table of Contents 15 Participating States WA ME CA OR NV ID UT MT WY CO ND SD NE KS MN WI IA IL MO MI OH IN KY WV VT NH NY CT PA NJ DE VA MD NC MA RI AZ NM OK AR MS TN AL GA SC TX LA FL Alaska Hawaii Participating NCCI States Participating Independent Bureaus Non-Participating Using WCMED Format Non-Participating 16 8
Participation/Eligibility Part 2 General Rules Single contract Includes individual coverage providers Affiliate Group Level Market Share 1% market share (three year average) in any one applicable state Data representing 15% or less of gross premium Exclusion Option Medical Data Call States Report for all Medical Data Call states in which they write Continue to report indefinitely 17 General Rules Report all medical transactions associated with workers compensation claims in any Medical Data Call state The Jurisdiction State is the state under whose workers compensation act the claimant s benefits are being paid 18 9
Vendor Business Partners Part 2 General Rules Companies differ in handling medical data: Carrier keeps all medical claim handling in-house Carrier uses business partners for various aspects of medical claim handling, including third party administrators (TPAs), medical bill review vendors, etc. Carrier retains some internal claim handling and uses business partners for some aspects 19 Reporting Responsibility Part 2 General Rules Submit Directly Authorize Vendor Combination of Both Regardless of who submits the data, the quality, timeliness, and completeness of the data is the responsibility of the carrier. 20 10
Mergers and Acquisitions Part 2 General Rules Current participants Required to continue reporting data after any merger Nonparticipating companies that merge with participating companies Not required to report Medical Call data until a future participation evaluation deems it eligible The nonparticipating company would be allowed to report after it joins the participating company 21 Merger Example If And Then Carrier A currently reports the Call Carrier A does not currently report the Call Carrier A currently reports the Call as part of Reporting Group B Merges with Carrier B, which does not currently report the Call Merges with Carrier B, which currently reports the Call Leaves Group B Only Carrier A reports the Call unless a future participation deems AB eligible Only Carrier B reports the Call unless a future participation deems AB eligible Both Carrier A and Group B continue to report the Call 22 11
Due Dates Part 2 General Rules All medical transactions (existing claims and new claims) that occur within a specific quarter, based on Transaction Date, must be reported in that quarter s submission New Claim Existing Claim Transaction Date 1/1/2014 Transaction Date 2/15/2014 Include in Q1 Submission Due by End of Q2 23 Duration of Reporting Part 2 General Rules Transactions must continue to be reported until: Transactions no longer occur or 30 years from accident date 24 12
Medical Data Call Structure 25 28 Medical Data Elements Part 3 Call Structure Carrier Carrier Code Code Policy Policy Number Number Identifier Identifier Policy Policy Effective Effective Date Date Claim Claim Number Number Identifier Identifier Transaction Code Jurisdiction State Code Claimant Gender Code Birth Year Accident Date Transaction Date Bill ID Bill Number ID Number Line ID Line Number ID Number Service Date Service From Date Service To Date Paid Procedure Code Paid Procedure Code Modifier Amount Charged by Provider Paid Amount Primary ICD Diagnostic Code Secondary ICD Diagnostic Code Provider Taxonomy Code Provider ID Number Provider Postal (ZIP) Code Network Service Code Quantity/No. of Units Per Procedure Place of Service Code Secondary Procedure Code 26 13
Medical Data Call Record Layout Part 4 Record Layouts Report one Medical Data Call record for each medical transaction (line) of a bill For specific data element reporting instructions, refer to the Data Dictionary section (Part 5) of the Medical Data Call Reporting Guidebook. 27 Element Source 28 14
FORM CMS-1500 29 FORM CMS-1500 30 15
Data Dictionary Part 5 Data Dictionary 31 Data Dictionary Part 5 Data Dictionary 32 16
Data Dictionary Part 5 Data Dictionary 33 Medical Call Transactions Part 6 Reporting Rules Transaction Code Use Transaction Date 01 Original The first reporting of a medical transaction Only one may be submitted for a medical transaction The date the medical transaction was originally processed and paid by the administering entity not the date the record was sent to NCCI 02 Cancellation Used to delete or cancel record(s) Apply to prior record(s) or record(s) in same submission 03 Replacement Used to revise non key field values Apply to prior record(s) or record(s) in same submission The date the medical transaction was cancelled in the administering entities system not the the date the the cancellation record was sent to NCCI The date the medical transaction was revised in the administering entities system not the date the replacement record was sent to NCCI. Must be after the Transaction date of the record it is intended to replace. 34 17
Medical Call Transactions Part 6 Reporting Rules Transaction Code Use Transaction Date 01 Original The first reporting of a medical transaction Only one may be submitted for a medical transaction The date the medical transaction was originally processed and paid by the administering entity not the date the record was sent to NCCI 02 Cancellation Used to delete or cancel record(s) Apply to prior record(s) or record(s) in same submission 03 Replacement Used to revise non key field values Apply to prior record(s) or record(s) in same submission The date the medical transaction was cancelled in the administering entities system not the the date the the cancellation record was sent to NCCI The date the medical transaction was All revised previously in the reported administering fields entities must system be reported not the even date if the there replacement is no change record was sent to NCCI. Report Must current be after cumulative the Transaction date values, of the not record change it is intended in value to replace. 35 Replacement File Use Correct major systemic programming issues Remove all records from Original File and add records in Replacement File Delete a prior file Do not use for data entry issues use Replacement Records instead. 36 18
Replacements 1. All of the Transaction Dates in the file show the date the records were submitted to NCCI not the date the transactions occurred 2. Data provider reported units, instead of minutes, for all anesthesia transactions, which is a relatively small subset of the total number of transactions submitted 3. Need to replace any data greater than 24 months old When in doubt, contact your Medical Data Call validator. 37 Submitting Medical Data Files Part 4 Record Layouts Data files are transmitted in specific record layouts: File Naming Convention: Production Medical.30characters.txt Certification Medical.30characters.tst Submission File Type Code (located on the Submission Control Record) O = Original R = Replacement 38 19
Certification/Testing Edits Ensures that test data files meet minimum formatting and quality requirements prior to production reporting Applied to each certification file as if it were received in production Requirements Medical data providers must pass certification for each carrier group Certify all new medical data providers and whenever system changes are made 39 Certification Process Three-Step Process Setup Testing Approval Required forms are completed and submitted Test file is created and submitted The quality of the data is acceptable 40 20
Electronic Transmission User s Guide Provides the necessary requirements, forms, and instructions for preparing and submitting test and production files 41 Data Provider Profile Form 42 21
Data Provider Profile Form Provides authorization to submit electronic data files Provides user information Identifies data types to be reported electronically Required for each data provider within each carrier or affiliate group (includes TPAs, vendors, etc.) 43 TPA Requirement For each TPA/vendor/outside data provider: Data Provider Profile Form Service Provider Agreement Service Provider Data Tool Access Addendum Data Provider Profile Form Service Provider Agreement (if applicable) Service Provider Data Tool Access Addendum (if applicable) Contact NCCI s Customer Service Center at 800 NCCI 123 to verify that appropriate authorization is on file. 44 22
Test Submission Test file must contain medical transactions representing production data Data can be live data or a set of historical data from the medical data provider s system Reporting year must be within the past two years Transaction dates must be within the reporting quarter A Submission Control Record must be included 45 Pre-Edit Submit files using file identifier Medical.30characters.tst (certification) Edits applied to the file as if it were in production Does not include Quarter End Validation Results are displayed in the Medical Data Collection tool 46 23
Editing and Validation 47 Edit Types Part 7 Editing and Other Validation Procedures Each edit is classified as a specific edit type: 48 24
Submission Edits Can we process the file? File naming convention is correct Record length is correct and contains only valid characters Data provider information is valid Contains a Submission Control Record with valid values Record count balances Key fields are populated 49 Field Edits Are the formats and values acceptable? Formatting is correct by field class Date fields are formatted YYYYMMDD Data is reported and values are valid Alpha fields are only A through Z or blank spaces Numeric fields are only 0 through 9 50 25
Logical Edits Does the data make sense compared to other fields in the record? Dates are in logical order Conditional fields are reported when condition exists Paid fields align with charged fields Primary field is reported when its associated secondary field is reported 51 Relational Edits Does the data make sense compared to previously submitted records? Original, replacement, and cancellation transactions occur in a logical order Transactions are reported in chronological order by transaction date 52 26
Edit Categories Part 7 Editing and Other Validation Procedures Critical (C) Elements necessary for a transaction to have value Priority (P) Elements needed for legislative analysis Supplemental/ Low (L) Elements used in specialized studies 53 Elements by Category Part 7 Editing and Other Validation Procedures Critical Priority Supplemental/Low Accident Date Network Service Code Birth Year Amount Charged by Provider Identification Provider Number Claimant Gender Code Jurisdiction State Code Provider Postal Zip Code Second Paid Procedure Code Modifier Paid Amount Quantity Secondary ICD Diagnostic Code Service Dates Paid Procedure Code Secondary Procedure Code Place of Service Code Provider Taxonomy Code Primary ICD Diagnostic Code First Paid Procedure Code Modifier 54 27
Editing Flow Notified of reject via email Medical Data Provider File rejected or records returned File Acceptance File processed successfully Quality Tracking Summarized group results Quarter End Validation 55 File Acceptance Three Stages of Editing Quality Tracking Quarter End Validation Part 7 Editing and Other Validation Procedures Submission, field, relational edits Pass or reject and return file/records Field, logical, relational edits Count occurrences Results available for viewing in Medical Data Collection tool Logical and relational edits, distributions Count occurrences are aggregated Results available for viewing in Medical Data Collection tool 56 28
Edit Matrix Part 7 Editing and Other Validation Procedures 57 Reporting Issue Linking Inconsistent Reporting of Key Fields Policy Number, Policy Effective Date, and/or Claim Number Most common cause for this issue is: Multiple data providers Resubmission of prior quarters to resolve may be required 58 29
Reporting Issue Missing Data Missing Portions of Data Pharmacy and/or Large Loss Claims Pharmacy Pharmacy transactions are often handled by a separate vendor Large Loss Claims Often a specialty TPA takes over management of these claims 59 Reporting Issue Duplicates Duplicate claims are reported Often caused by: Changing systems Changing vendors Discussed further in the Complex Medical Data Call Reporting Concepts class 60 30
Medical Data Call Compliance 61 Compliance Programs Medical Incentive Program Applies monetary assessments for failure to meet minimum expectations Alabama Florida Kentucky Nebraska South Carolina Alaska Georgia Louisiana Nevada South Dakota Arizona Hawaii Maine New Hampshire Tennessee Arkansas Idaho Maryland New Mexico Utah Colorado Illinois Mississippi Oklahoma Vermont Connecticut Iowa Missouri Oregon Virginia District of Columbia Kansas Montana Rhode Island West Virginia Carrier Data Quality Report Program (Report Card) Medical Addendum Criterion utilizes the Medical Incentive Program Completeness and Quality components 62 31
Compliance Objectives Ensure full scope of submissions are sent by due date Medical Incentive Program Meet or exceed quality tracking Ensure data meets criteria or exceeds quality tracking criteria Identify extreme outliers of reporting behavior 63 Medical Data Incentive Program 1 2 3 Insufficient Data Completeness Quality 64 32
Medical Data Incentive Program 1 Insufficient Data No medical data is reported to NCCI by the due date. 65 Medical Data Incentive Program 2 Completeness Insufficient data is submitted for one or more of the five Completeness categories: State Coverage Provider Medical Data Provider Service Date Distribution Medical Service 66 33
Medical Data Incentive Program 3 Quality Medical data is edited at the data element level and compared to Medical Incentive Program editing thresholds. Refer to the Medical Incentive Program on ncci.com for additional information. 67 Compliance Resources Data Quality page on ncci.com contains the Medical Incentive Program 68 34
Medical Data Incentive Program Applicability for Participants Identified in 2012 Q3 2012 Q1 2014 Q1 2015 August 2015 New participants identified and contacted 1st Quarter 2014 transactions due to NCCI by 6/30/2014 Insufficient Data, Completeness, and Quality go into effect First billing (Q1 2015 transaction dates) 69 Carrier Data Quality Report Medical Data Addendum Two categories built on Medical Incentive Program results 4Q 1Q 2013 2014 1Q 2Q 2014 3Q 2014 4Q 2014 6/30/2014 9/30/2014 12/31/2014 3/31/2015 Annual review of results for data due in the prior year 70 35
Carrier Data Quality Report Medical Data Addendum A quarter passes if all categories are completed 71 Carrier Data Quality Report Medical Data Addendum A quarter passes if: No Critical elements and No more than two Priority or Low elements were assessed Three or more passing quarters = Passing grade for the category 72 36
Independent Bureaus Annual or Semiannual Completeness: State Coverage Providers Medical Service (Pharmacy) Service Dates Distribution Quality: Critical Elements Priority Elements 73 Medical Data Collection Tool 74 37
Usage Benefits Medical Data Collection allows you to monitor the status and completeness of your submissions throughout the editing process Enables you to manage your medical data reporting quality more efficiently Targets areas that need improvement 75 Submitter/Vendor Workflow Prepare Data and Submit File Submission Tracking Quality Tracking Per the Medical Data Call Reporting Guidebook and the Electronic Transmission User s Guide Upload your data file through Data Transfer via the Internet (DTVI) Review the Submission Tracking Results through the Medical Data Collection tool Ensure that the submission status of all files is marked as Completed Review the Quality Tracking Results at the individual file or aggregate level Compare edit results to expected thresholds for each data element Receive Status Email Notification Review Rejected Records/Files View Validation Results 76 38
Manager/Carrier Workflow Submission Tracking Quarter End Validation Incentive Program Review the submission results through the Medical Data Collection tool Ensure that all medical data providers have submitted for the quarter Review the Completeness and Quality results for NCCI compliance states and applicable independent bureau states Incentive Fines are displayed based on the Completeness and Quality results for NCCI compliance states only Follow up on rejected files Review Quality Tracking results at group/provider level Invoices are issued the 2nd month after each quarter 77 ncci.com My Preferences 78 39
Medical Data Collection 79 Medical Data Collection 80 40
Medical Data Collection 81 Submission Tracking 82 41
Quality Tracking 83 Quarter End Validation 84 42
Incentive Program 85 Additional Resources 86 43
Additional Resources NCCI offers a number of resources to provide you with reporting requirements and information for the Medical Data Call. These resources can be found at ncci.com. Data Reporting tab contains the following Web sections: Medical Data houses Web articles, guides, and additional references. Data Quality provides you with information about NCCI s Data Quality Compliance Programs. Circulars/FYI Plus Releases address topics that are especially time-sensitive. These documents may include a call for action and/or announce important information necessary for reporting timely and quality data. 87 Additional Resources 88 44
Training Opportunities Webinars on Demand NCCI s Webinars on Demand are online training modules that you can view and listen to at your convenience Data Educational Program NCCI s training event provides education and instruction on the latest data reporting requirements and tools 89 Additional Resources 90 45
Medical Data Education 91 Medical Data Call Webinars Medical Data Collection Tool Webinar on Demand Medical Data Call General Reporting Rules Medical Data Call Record Data Elements Medical Data Call Editing and Validation Medical Data Call File Submissions Medical Data Call Certification Medical Data Call Webinar on Demand Training Schedule Medical Data Call Tools and Resources Guide 92 46
Medical Data Call Webinars 93 Contact Us Visit our kiosk Contact your assigned validator directly Call our Customer Service Center at 800-NCCI-123 (800-622-4123) We re here to assist you Monday Friday, 8:00 a.m. 8:00 p.m. ET Visit ncci.com and choose Contact Us Customer Service will respond to your request within 24 hours of receipt 94 47
Questions 95 48
Supplemental Information
Presenter Biographies Bob Vaughan has worked at NCCI for 16 years. He is the manager of the Data Services Department in NCCI s Data Resources Division. Bob leads the business team that is responsible for data reporting communications and manuals, including rule interpretation and item filings. He is also involved in several trade associations and industry committees, focusing on data reporting. Grace Arrieche joined the Medical and DCI Operations Department as a data analyst in 2013. Prior to that, Grace worked as an analyst in the Assigned Risk Department, where she processed residual market applications ensuring coverage eligibility and binder quality. She also participated in several operational review projects and process improvement initiatives. She began her NCCI career in 2008 as a customer service specialist in Classification. Before joining NCCI, Grace was a mortgage professional, specializing in residential lending. She has held various operational positions including residential due diligence contract underwriter, quality control underwriter, and account manager. Kristin Champagne joined the Medical Data Validation Department as a senior data analyst in 2012. Her primary responsibilities include identifying, developing, and implementing solutions to data quality issues impacting data used for NCCI s core products, research, and legislative analyses. Prior to joining the Medical Data Team, she worked for two years on the Proof of Coverage team, where she primarily lead the resolution of complex POC data issues in addition to providing support to system changes. She began her career in workers compensation eight years ago, starting as an experience rating analyst. Kristin holds a bachelor of finance degree from Florida Atlantic University.