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6/7/2016 1 Clearinghouse Caucus Tuesday, June 7, 2016 5:00 - 6:15pm Intercontinental Dallas / Lalique I Thanks To Our Sponsors
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Clearinghouse Caucus
Tuesday, June 7, 2016 5:00 - 6:15pm
Intercontinental Dallas / Lalique I
Thanks To Our Sponsors
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The Cooperative Exchange is the recognized resource and representative of the clearinghouse industry for the media, governmental bodies and other outside interested parties.
We are committed to promote and advance electronic data exchange for the healthcare industry by improving efficiency, advocacy, and education to industry stakeholders and government entities.
The mission of the Cooperative Exchange is to promote and advance electronic data exchange for the healthcare industry by improving efficiency, advocacy, and education to industry stakeholders and government entities.
Overview of Cooperative Exchange (CE)• 28 Clearinghouse Member Companies
• Represent over 80% of the clearinghouse industry
• Over 750,000 submitting provider organizations
• Maintain over 8,000 Payer connections
• 1000 plus HIT vendor connections
• Process over 4 plus billion claims annually
• Value of transactions –over $1.1 Trillion
• Infrastructure framework supports BOTH administrative and clinical transactions
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Our Members
2015/2016 Executive Board
SecretaryDebbi Meisner
Change Healthcare
Vice PresidentJoe Bell
ClaimRemedi
Past President Joe Gonzalez
ClinXdata
President Sherry WilsonJopari Solutions
TreasurerKathy Sites
Availity
Executive DirectorLisa Beard
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Agenda Clearinghouse Caucus - ASC X12Tuesday, June 7, 2016 - 5:00 - 6:15pm
Intercontinental Dallas / Lalique I
1. Welcome and Introduction – Sherry Wilson, President, Cooperative Exchange and EVP/ CCO, Jopari Solutions
2. ASC X12 Update - Stacey Barber, ASC X12N Chair
3. Key MACRA Regulations Topics - Preparing for Change Medicare Social Security Number Change
- Open Item Questions- Potential Stakeholder Impact- What are the implementation considerations
Crystal Ewing, Senior Business Analyst and Manager, Regulatory Strategy, ZirmedModerator: Doreen Espinoza, Vice President of Regulatory Affairs and Privacy Officer, UHIN
4. Strategies to streamline the implementation process- Lessons learned New CMS ICD-10 Codes
- October 1, 2016 Implementation - Checklist Readiness Considerations
Betty Llengyel-Gomez, Compliance Director, Government Healthcare Solutions, Xerox Healthcare Moderator: Joe Bell, Standards & Compliance Officer, Claimremedi
5. Attachment Landscape Update – Durwin Day, Supervisor, Health Care Service CorporationModerator: Debbi Meisner, Vice President Regulatory Compliance, Change Healthcare
ASC X12 Update
Stacy Barber, Chair, ASC X12N
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Key MACRA Regulation TopicsSocial Security Number Removal Initiative
Crystal Ewing
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Social Security Number Removal Initiative (SSNRI) Security Number Removal Initiative (SSNRI)Background:
• Since the beginning of the Medicare program, the SSN‐based Health Insurance Claim Number (HICN) has been used as the beneficiary identifier for administering the Medicare program.
• The Centers for Medicare and Medicaid Services (CMS) uses the HICN with multiple parties, such as Social Security Administration (SSA), Railroad Retirement Board (RRB), States, Medicare providers, Medicare plans, etc.
• Given the risk of identity theft, Congress passed and the President signed into law, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, mandating the removal of the SSN‐based HICN from Medicare Cards.
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Timeline and Implementation
• In 2018, CMS will be generating new MBIs for all Medicare beneficiaries (both living and deceased/archived).
• All systems and business processes will need to be able to accept and process transactions using the new MBI by April 2018, when new Medicare cards will start being distributed.
• Current estimates show that over 60 million Medicare card with the MBI will be distributed to beneficiaries between April 2018 and April 2019.
• It is anticipated that CMS will have a transition period where either the HICN or MBI may be exchanged with CMS.
• The transition period is currently planned to begin April 2018 and end on December 31, 2019.
• After the 20-month transition period, CMS will no longer accept the HICN (with limited exceptions).
• In keeping with the intent of the legislation to protect Medicare beneficiaries from identity-theft, CMS will not provide the MBI to the provider. Health care providers will need to obtain the MBI from their patients.
• Analysis so far believes the new Member Identification number will have the same characters as the current HICN (11) but will be visibly distinguishable from the HICN, contain alpha and numeric characters throughout the 11 digit number and can occupy the same field as the HICN on transactions.
Questions to CMS on MBI Implementation
• Will this be a one time cutover vs. phased implementation by CMS?
• How will MBIs be assigned to members or validated with CMS?
• Will both HICN & MBI ever be used simultaneously for the same member/transaction?
• Define “new beneficiaries” (newly eligible to Medicare, new to plan, etc.)?
• How will transition to MBI from HICN be communicated?
• Will existing members require validation with health plans or will a file be provided with mapping?
• Will support tools be provided for plan operators to identify or search for members?
• Is there a contingency/workaround if link between HICN & MBI fails?
• How is CMS identifying non-active (e.g., deceased) members?
• What is the criteria for changing MBIs, how will this be communicated to plans and will it be mapped to HICNs?
• How will dual eligibility be impacted/managed with Medicaid, etc.?
• How will premium payment deduction from social security checks be handled through the transition?
• Does this change effect the use of SSN in other functions for member identification/verification processes for commercial or government plans?
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Questions from CMS to the CE
Question 1
What systems would need to be updated? PM Systems
HIS Systems
Clearinghouse Systems
Third Party Vendors Systems
Payer Systems
HIE Systems
EHR
Questions from CMS to the CE
Question 2
Impacts to Industry?
Rules and Edits
Secondary Crossover Claims and COB Claims
Claim Status
Eligibility Verification
Claim Rejection and Denials
Authorization and CMN’s
Registries for Meaningful Use and PQRS
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Questions from CMS to the CE
Question 3
How long would the industry need to
implement the change?
At least two to three years
Need adequate system remediation and testing
time
Would recommend end to end testing
opportunities
If dual use period would need system testing for
both MBIs
Questions from CMS to the CE
Question 4
How would the industry expect to obtain information about this change?
Recommend an education campaign
Dedicated Webpage such as the Road to 10
Webinar’s
Dedicated Email distribution and Phone number for implementation and transition questions
Eligibility verification should return new MBI if SSNbased MBI is submitted
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Questions & Comments
Feedback or Questions can be sent directly to CMS at
Strategies to streamline the implementation process-Lessons learned New CMS ICD-10 Codes
Betty Lengyel-Gomez, Compliance Director, Government Healthcare Solutions, Xerox Healthcare
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Two ICD-10 Items
• Grace period for specificity
• 12 months after ICD‐10 implementation ends October 1, 2016
• New Codes for FY17
• PCS codes just published on CMS website
• Diagnosis (Approx. 1900) not out yet but expect them soon
• DRG Grouper v34 not out yet
New ICD-10 PCS Codes Summary
CMS 2017-ICD-10-PCS-and-GEMs codes
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Lessons Learned
• Early Communication
• Can’t do all the testing for your customers they need to test internal as well
• Test business processes and customization
• It’s not just IT testing
• WEDI-CMS Issue Reporting System
• Over 600 entries
• Many questions on coding
• Some questions on specialties
• In other words, how do I pick the right code?
Strategies to streamline implementation
• Early communication
• Opportunity to validate your code set maintenance process
• Ensure all new codes are incorporated into your system
• Providers – do you have the documentation needed to support the new codes
• Do your business processes support the workflow to get the new codes to where they’re supposed to be
• Apply any applicable edits (code or payer specific)
• Watch your KPI metrics
• Product support – supplying or requesting
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Attachment Landscape Update
Durwin Day, Supervisor, Health Care Service Corporation
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NCVHS Letter of Recommendations for the Electronic Health Care
Attachment Standard
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SUMMARY - ACTIONS
Adopt one standard definition of the “Attachment” transaction, and establish the scope of the transaction.
Adopt a set of mature, implementable electronic standards for the health care industry to execute the Attachments transaction.
Define a series of transaction process requirements, including consistency with adopted privacy laws and regulations.
Take an incremental, flexible implementation approach in no less than five years. Broadening the testing, education, outreach and compliance efforts.
Ensure alignment of the Attachment standard’s regulatory requirements with those adopted for use with Electronic Health Records under the Office of the National Coordinator (ONC) for Health Information Technology’s 2015 Edition Certification of Health Information Technology program (i.e. Meaningful Use) and the Medicare Access CHIP Reauthorization Act of 2015 (MACRA)/Merit-Based Incentive Payment System (MIPS).
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ATTACHMENT DEFINITION
NCVHS recommends that the definition of “attachment” to be
adopted in regulations should be the definition proposed in
previous NCVHS recommendations as the “any supplemental
documentation needed about a patient(s) to support a specific
health care-related event (such as a claim, eligibility, prior
authorization, referrals, and others) using a standardized format.
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RECOMMENDED STANDARDS
Query (Request) for Attachments:
• X12 277 Health Care Claim Request for Additional Information (for all claim related
attachment requests)
• X12 278 Health Care Service Review – Request (for non-claim-related attachment
requests)
Response – Submission of an Attachment: Message
Content/Format:
• HL7 CDA R2 – Consolidated CDA Templates for Clinical Notes R2.1
• HL7 Attachment Supplement Specification Request and Response Implementation
Guide R1
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RECOMMENDED STANDARDS
Acknowledgment:
• X12 Acknowledgment Reference Model (ARM) o X12 TA1 and 999
Acknowledgment standard (ACK)
Attachment Type Value Set: Logical Observation Identifier Names
and Codes (LOINC) developed and maintained by the Regenstrief
Institute, Inc., LOINC® c/o Center for Biomedical Informatics.
HIPAA Panel Solicited and Unsolicited Lists.
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STANDARDS FOR ROUTING/ ENVELOPE
NCVHS recommends that the Secretary adopt the following standards to
support the electronic routing of attachment transactions. These
standards should be the ones to be used by trading partner covered
entities when a routing or envelop method is needed, and as agreed upon
by trading partners. Not all attachment queries may need these
routing/envelope standards, thus, they should not be required to be used
in all exchanges.
Routing/Envelope:
• X12 275 Additional Information to Support Health Care Claim
• X12 275 Additional Information to Support Health Care Service Review
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PHARMACY STANDARDS
…. in the pharmacy industry attachments are used for prior
authorization and not for claims: Pharmacy Prior Authorization: o
Pharmacist initiated prior authorization for drugs/biologics:
• NCPDP Telecommunication Standard o Prescriber initiated prior
authorization for drugs/biologics:
• NCPDP Script X12 278 Health Care Services Review
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DENTAL STANDARDS
We recommend the adoption of the American National
Standard/American Dental Association Standard No. 1079 for
Standard Content of Electronic Attachments for Dental Claims.
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SUPPORT SOLICITED AND UNSOLICITED
We recommend that the transaction process support both
solicited and unsolicited models for attachment
request/submission.
The specific situations for which unsolicited attachments are
expected by payers should be clearly identified in trading partner
agreements (TPAs) and, in the future, in operating rules.
Supporting TPA pre-defined unsolicited attachments avoids
uncertainty
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FLEXIBLE, INCREMENTAL IMPLEMENTATION
An effective implementation date of no less than two years from
the publication of the Attachment Standard Final Rule
Utilizing a staggered approach for implementing the attachment
standard including publishing each implementation date
Publishing a the Notice of Proposed Rulemaking (NPRM) and the
subsequent final rule in a timely manner and are not delayed or
prolonged resulting in regulations that are outdated or ineffective
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TESTING, COMMUNICATION, EDUCATION & OUTREACH
HHS work with the industry to implement additional
implementation testing for attachments, to ensure a successful
transition prior to the compliance data.
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PUBLICATION OF A NOTICE OF PROPOSED RULE
We recommend that the Secretary consider publishing an
expedited Notice of Proposed Rule Making (NPRM) adopting the
recommended standards, rather than an Interim Final Rule, or a
Final Rule, considering the length of time that has elapsed since
the previous NPRM was published and the technology advances
made since then.
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ALIGN WITH EHRS AND MACRA
Ensure alignment with the Electronic Health Record (EHR)
Incentive Program and the Medicare Access CHIP
Reauthorization Act of 2015 (MACRA)/Merit-Based Incentive
Payment System (MIPS)
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UPDATE!
Feb 2016 NCVHS Hearing on Attachments
• Letter of Recommendation (draft out today!)
May WEDI National Conference
• Think Tank and CMS Listening Sessions on Prior Authorizations and
Attachment
CMS development of rule (NPRM or IFC?)
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HEALTH LEVEL 7 INTERNATIONAL (HL7)
MM/DD/2016
Major Activities
• Attachments (cont.)
• Demo of CDA Validation Tools• Lisa Nelson arranged panel with Trifolia, Art-Décor, MDHT• Diameter Health to demo on HL7 AWG call, June 14
• Project Scope Statements approved• Periodontal Attachment – sponsored by ADA and DOD
• Development Calls to be scheduled for Thursdays• FHIR Repository
• LOINC Codes• Introduction to the HL7 LOINC Ontology Document• Review how to access LOINC Database • Changes/Updates to HIPAA Panel • New code requests (~50)
• Ballot Reconciliation – 470 comments• DSTU Supplemental Guide with Conformance Statements• Continued on AWG weekly calls - Tuesdays
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Thank You
Cooperative Exchange Contact Information
Lisa Beard, Executive Director, Cooperative [email protected]://www.cooperativeexchange.org/
Sherry Wilson, President Cooperative ExchangeEVP and Chief Compliance Officer Jopari [email protected]
