All Payer DatabaseExcellus BlueCross BlueShield

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BIOGRAPHY

Benjamin Palmer Manager, Health Plan Risk Adjustment Excellus BlueCross BlueShield Responsibilities:

RAPS, EDPS, EDGE, Medicaid encounter, and All Payer Database data submission and cleanup

Contact Info:Phone: (315) 671 - 7270Email: benjamin.palmer@excellus.com

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BIOGRAPHY

Kirill Shebalin Solution Architect, Data Management and Integration Excellus BlueCross BlueShield Responsibilities:

PBM and Pharmacy claims, Enterprise Data Warehouse (EDW), All Payer Database Implementation and Support.

Contact Info:Phone: (585) 797 - 5145Email: kirill.shebalin@excellus.com

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New York State All Payer Database

Participation in New York State Exchange for the Affordable Care Act also required issuers to submit encounter data related to Exchange membership to New York, the format and system to be determined at a later date.

November 2013, New York released preliminary information on this system, which they named the All Payer Database (APD).

Regulation of this system falls under the NYS Department of Health.

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APD Mission

NYS Department of Health (NYSDOH) outlines the following potential uses of APD data:

• Risk Adjustment / Risk Based Payment / Payment Reform• Clinical Risk Evaluation• Quality measurement• Price and cost transparency• Care evaluation and longitudinal health services research

For the pre-cursor Medicaid Encounter Data System, NYS does data quality audits, risk adjustment and a variety of issuer comparisons.

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APD Timeline & Phase Approach

Phase 1: On Exchange QHP Individual and Small GroupGo live date of Q1 2015, 50% of 2014 Data due June 2015

Phase 2: Medicaid Managed Care & CHPGo live date of September 14th, 2015

Phase 3: Other Commercial Off Exchange QHP, Fully Insured large groupGo live date TBD 2016

Phase 4 and beyond: Federally regulated data Medicare Advantage and Self FundedNYS researching options on how to obtain this data

Other sources of data not submitted by Issuers that NYS could include in APD are Medicaid Fee For Service data and Institutional records via a legacy system that collects data from hospitals (SPARCS).

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QHP Issuer Metrics – Provided by NYS 6/24/2015

Issuer Name Issuer HIOS ID Estimated Enrollment Count 298 299 300 NCPDPAffinity 57165 4,085 2,285 0 0 456

CDPHP 92551 822 2,757 406   4,70694788 3,683 21,872 4,599   34,542

Delta Dental 10345 2014 Member ID File Not Submitted     0  Dentacare 30798 7,160     1,518  Dentegra 42750 2014 Member ID File Not Submitted     0  Emblem 88582 27,557 384,476 14,678 0 0

Empire 80519 45,660 0 0   044113 1,647     0  

Excellus 78124 21,047 155,603 34,199   215,366Fidelis 25303 66,875 163,096 258 98 7,320

Guardian 42640 927     0  HealthFirst 91237 11,736 84,919 11,574 0 86,232

HealthNow 36346 2,098 548 164 0 049526 6,120 21,992 2,824 0 0

HealthPlex 92786 17,315     2,781  Health Republic 71644 77,083 46,181 17,073   340,388

Independent Health 18029 5,313 43,557 2,540   0MetLife 78414 339     0  

MetroPlus 11177 54,932 30,697 7,069 1,031 87,350MVP 56184 34,108 256 158   0

North Shore 82483 5,883 0 0 26 31,171Oscar 74289 14,737 349 0   0

Solstice 85427 280     0  United Healthcare 54235 6,482 0 0 0 0

WellCare (2015 QHP) 39595 N/A 0 0 0 0Totals 958,588 95,542 5,454 807,531

5% covered lives in QHP market 16% 36% 27%

% of all accepted claims

Technology stack used in the solution• Backend/Database – Oracle DB.

• ETL Tool – Informatica.

• Middle Tear – IBM Message Broker and WTX type trees for X12 EDIs.

• sFTP, Unix Scripts to move files between the handoff points.

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Output Files

EDI formats:

Medical Professional Claims – 837P X298, aka PACR X12 for Professional Post Adjudication Claims. Version: 005010X298.

Medical Institutional Claims – 837I X299, aka PACR X12 for Institutional Post Adjudication Claims. Version: 005010X299.

Dental Claims - 837D X300, aka PACR X12 for Dental Post Adjudication Claims. Version: 005010X300.

Pharmacy Fixed Width Format

NCPDP 4.2, Post Adjudication History Layout.

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Solution Design

• Tasked with creating 3 industry standard EDI files for Medical and Dental. • Tasked with creating industry standard NCPDP file for Pharmacy claims.• We are sending over 500 data elements to NYS!• NYS has very elaborate response mechanisms to validate our data

submissions. We fully automated response file intake from NYS. When issues arise we can react and interpret them very quickly.

Response Files – Medical and DentalTransaction Type File Purpose File Name Example

RJ File Rejection

Reject file. Generated when the X12 envelope is unreadable, the entire batch is rejected. End of the process, no other files will show up. RJ.NYHBE.837PQ.M.130430135202.001.DAT

TA1 Response

Transaction acknowledgment file. Can be Reject or Accept. If Reject, error code is returned, the entire batch is rejected. For the rejection, it is the end of the process; no other files will show up. IA.NYHBE.837PQ.M.130430135202.001.DAT

999 Acknowledgments

Reject file. Tier 1 edits failed, entire batch is rejected. End of the process, no other files will show up. FA.NYHBE.837PQ.M.130430135202.001.DAT

277CA Acknowledgment

Reports the status of each submitted claim. Tier II editing provides Accepted, Soft Edit (warnings), Hard Edit (rejection) statuses. HN.NYHBE.837PQ.M.130430135202.001.DAT

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• Response data is integrated with the submitted claims information within minutes after the receipt of the response files.

• This allows our team to react quickly to any issues. • Business team can easily identify claim level rejections, and root causes for

them.

Response Files – PharmacyTransaction Type File Purpose File Name Example

RJ File Rejection

Reject file. Generated when the file is unreadable, the entire batch is rejected. End of the process, no other files will show up. RJ.NYHBE. PDPQ.W.130430135202.001.DAT

RxFA Acknowledgment

Transaction acknowledgment file. Can be Reject or Accept. If REJECT, error code is returned, the entire batch is rejected. For the rejection, it is the end of the process, no other files will show up. IA.NYHBE.PDPQ.W.130430135202.001.DAT

RxTA Acknowledgment

Reject file. Tier 1 edits failed, entire batch is rejected. End of the process, no other files will show up. FA.NYHBE.PDPQ.W.130430135202.001.DAT

RxCA Acknowledgment

Reports the status of each submitted claim. Tier II editing provides Accepted, Soft Edit (warnings), Hard Edit (rejection) statuses. HN.NYHBE.PDPQ.W.130430135202.001.DAT

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• Pharmacy response files are in different format than Medical/Dental files.• We re-used the same solution pattern as for Medical/Dental responses. • Storing all of the responses identically to allow business users one “look

and feel” point regardless of the claim types/formats.

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Business and Financial Impacts

Medicaid Risk Adjustment

Medicaid is fully risk adjusted in New York and sourced from APD going forward. Medicaid represents a major portion of Excellus’s total revenue and APD data quality will heavily influence this.

Reporting and Audit

NY has historically used Medicaid encounter data to perform detailed audits, and can do so now with APD. Medicaid encounter had also been used to balance and check issuer submitted state reporting, and as APD expands the data NY has such balances is expect to increase.

Commercial Risk Adjustment

NY may have an interest in replacing the federal Commercial Risk Adjustment model (via the EDGE server) with their own state run program in the future. APD is the likely data source for any such program once Phase 3 is complete.

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Data Quality – Manual ModificationsAs claims data moves from Provider to ClearingHouse to Claims System to Warehouse, some elements may get lost in the process, New York can issue new requirements or change edits, resulting in rejected data.

Data rejections have a direct impact for Risk Adjustment and audits, so the ability to correct these errors was a Business Requirement of our project.

Our method for doing this is called Manual Modifications, which allows business analysts to research errors, find the correct data and resubmit rejected claims with changes, without needing an update to ETL or claims to be reprocessed. The process also creates an internal audit trail to track the changed data.

The general concept had been previously implemented and proven on the pre-cursor Medicaid encounter system and also the federal EDGE system. The increased number of fields and 5010 format of APD added additional complexity to this process.

Team Management and Approach

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• Complex project with many moving parts and complex requirements.

• We decided not to use a traditional waterfall approach, but rather an iterative approach.

• Iterative development is characterized by small mini-projects (iterations) designed with a clear set of objectives producing a measurable executable objectively assessed that incrementally advances a product of increasing business value. • It allowed us to focus on delivering business benefits with each release.

• Fully integrated business and technical team members, and made sure key team members stayed with the project. This allowed us to be on the same page and prioritize deliverables accordingly.