Q1 2016 Update Published: February 12, 2016
Q2 2016 Update Available: No later than May 13, 2016
HIPAA and ACA Timeline
Change Healthcare Quarterly Updates
2.12.2016
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE 2
HIPAA and ACA Timeline: 2013 to 2018
ICD-10
ASC X12N Version 7030
Operating Rules
Attachments
Health Plan Identifier (HPID)
Health Plan Certification
Meaningful Use Stage 3 (MU3)
Table of Contents
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE 3
HIPAA and ACA Timeline
1/1/2014
EFT Standard and
EFT/ERA Operating Rules
Compliance
Enforcement Delay
Health Plan ID use in
Transactions
Compliance
TBD
Attachments Standard
and Operating Rules
Compliance
TBD
Attachments Standard
and Operating Rules
Effective
TBD
Claims, Enrollment,
Authorizations Premium
Payment, Operating Rules
Compliance
TBD
Claims, Enrollment,
Authorizations Premium
Payment, Operating Rules
Effective
2013 2014 2015
Jan
April
July
Oct
Meaningful Use Stage 1 and 2
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA
Certification
TBD
Health Plan Claims,
Enrollment, Attachments,
Premium Payment, Referral
Certification
1/1/2013
Eligibility & Claim
Status Operating Rules
Compliance
Enforcement Delay
Health Plans must
register for HPID
Compliance
Enforcement Delay
Small Health Plans must
register for HPID
Compliance
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA
Penalty Fees
2016 2017-2018
Regulations below have not been published at this time or have been delayed and the dates are to be determined.
These regulations may be effective sometime in 2016 with compliance dates in 2017- 2018.
Meaningful Use Stage 3
10/1/2015
ICD-10
Compliance
ASC X12N v7030 Staggered Public Comment
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
ICD-10
4
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
After much planning and anticipation, the October 1, 2015 ICD-10 transition deadline has
come and gone. In the few months since implementation, the ICD-10 code set has
become the accepted industry standard and all involved should be proud of the
role they played in this monumental accomplishment.
Change Healthcare is closely monitoring the transition to ICD-10 and, thus far, has seen
positive trends. Our observations and metrics reveal the following:
More than 95% percent of claims submitted to Change Healthcare at the beginning of
February 2016 were coded ICD-10.
Change Healthcare will continue to process ICD-9 for claims with dates of service or
discharge prior to October 1, 2015 to support run-out and amended claims.
Both providers and payers have demonstrated readiness to utilize ICD-10 codes.
A review of ICD-9 and ICD-10 claims to date reveals little variance in trends related to
average payer payment and denial rates.
While isolated issues continue to occur, these issues continue to diminish as
healthcare organizations tweak their systems and identify opportunities for process
improvement.
Please reference the article “ICD-10 So Far, So Good" in Advance Healthcare Network’s
ExecutiveInsight publication for more information.
5
ICD-10 in Retrospect
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
ASC X12N Version 7030
6
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
ASC X12N Version 7030 – Public Comment
7
ASC X12N Insurance Subcommittee is currently finalizing version 7030 of the health care
Technical Reports Type 3 (TR3’s). It is anticipated that ASC X12N will recommend to HHS
that version 7030 of the HIPAA-mandated transactions be adopted. Over the course of
2016, ASC X12N will be releasing the 7030 TR3’s for public comment. The public comment
schedule will be announced in Q1; watch www.x12.org for more information.
PUBLIC COMMENT PERIOD – KEY FACTS
Public comment periods for the TR3’s will be staggered, beginning in April 2016 and
ending in December 2016.
NOTE: Public comment periods will be held for all 7030 TR3’s, including those
transactions not mandated under HIPAA.
Each public comment period will extend for 60 days.
Staggered approach allows for more focused reviews and hopefully, increased
participation from the industry.
The intent of ASC X12N is to publish all TR3’s together when the public comment cycles
have been completed and all comments considered.
Change Healthcare is actively participating in the standards development process.
ASC X12N v7030 Staggered Public Comment
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Operating Rules
8
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Change Healthcare Operating Rules Readiness
9
CAQH certifies and awards CORE Certification Seals to entities that create, transmit or use
the administrative transactions addressed by applicable Operating Rules.
CORE Certification means an entity has demonstrated that its IT system or product is
operating in conformance with a specific phase(s) of the Operating Rules.
Change Healthcare is CORE Phase I, Phase II, and Phase III certified, as evidenced by
our Phase III seal.
Link to Change Healthcare’s CORE Phase III Seal.
Link to our CORE Voluntary Certification (Clearinghouses tab).
Link to the Change Healthcare Press Release announcing our certification.
Additional information regarding the Change Healthcare Operating Rules program can be
found on www.HIPAASimplified.com.
Change Healthcare is CORE Phase III Certified which is one of the two
options proposed in the Health Plan Certification NPRM. To become
CORE Phase III certified entities must be CORE-certified on the earlier
phases. Our CORE Phase III certification serves as Change Healthcare’s
exhibit of readiness.
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Enforcement Delay
Health Plan ID use in
Transactions
Compliance
TBD
Attachments Standard
and Operating Rules Compliance
TBD
Attachments Standard
and Operating Rules Effective
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Compliance
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Effective
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA Certification
TBD
Health Plan Claims,
Enrollment, Attachments, Premium Payment, Referral
Certification
Enforcement Delay
Health Plans must
register for HPID
Compliance
Enforcement Delay
Small Health Plans must
register for HPIDCompliance
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA
Penalty Fees
2016 2017-2018
Regulations below have not been published at this time or have been delayed and the dates are to be determined.
These regulations may be effective sometime in 2016 with compliance dates in 2017- 2018.
10
• Operating Rules build on applicable HIPAA and other related standards to make adopted
electronic transactions more predictable and consistent.
• Change Healthcare participated with the industry in defining and preparing for the CORE
Phase IV operating rules.
• Phase IV rules did not address Health Claim Attachments, as prescribed under the ACA,
because attachment transaction standards have not yet been established.
Operating Rules – HIPAA and ACA Timeline
Phase IV Operating Rules anticipated in 2016
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Regulatory Roadmap – Phase IV Operating Rules
11
In September 2015, CAQH CORE via their voting process, approved the Phase IV
Operating Rules for voluntary certification.
The Phase IV rules define infrastructure, connectivity, and companion guide
requirements for Health Care Claims (837), Health Care Services Review – Request for
Review and Response (278), Benefit Enrollment and Maintenance (834), and Premium
Payment (820) transactions.
The Department of Health and Human Services (HHS) will determine if the new
Phase IV CAQH CORE Operating Rules will be included in any regulatory
mandates.
NEXT STEPS
In February 2016 the National Committee on Vital and Health Statistics (NCVHS),
advisory body to HHS, will conduct a hearing relating to the adoption of the Phase IV
rules.
NCVHS will make a recommendation to the HHS Secretary as appropriate.
HHS is expected to publish a proposed rule with comment period in 2016.
The Change Healthcare Regulatory Program team will begin to flesh out impact areas
and key resources to build out our enterprise Phase IV Operating Rules program
which will inventory, assess gaps, and remediate all impacted products & services
following the published final rule.
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Attachments
12
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Enforcement Delay
Health Plan ID use in
Transactions
Compliance
TBD
Attachments Standard
and Operating Rules Compliance
TBD
Attachments Standard
and Operating Rules Effective
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Compliance
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Effective
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA Certification
TBD
Health Plan Claims,
Enrollment, Attachments, Premium Payment, Referral
Certification
Enforcement Delay
Health Plans must
register for HPID
Compliance
Enforcement Delay
Small Health Plans must
register for HPIDCompliance
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA
Penalty Fees
2016 2017-2018
Regulations below have not been published at this time or have been delayed and the dates are to be determined.
These regulations may be effective sometime in 2016 with compliance dates in 2017- 2018.
13
The Administrative Simplification provisions under the ACA include adoption of
transaction standards and operating rules for Attachments.
Attachments are electronic documents that support the following transactions:
• Health Care Claims/Encounters (837)
• Health Care Services Review-Request for Review and Response (278)
• Health Care Services Review Notification and Acknowledgment (278).
A proposed rule establishing Attachment standards is anticipated in late 2016.
CAQH CORE has indicated that development of operating rules for attachments will be
started once HHS establishes transaction standards.
Attachments – HIPAA and ACA Timeline
Proposed Rule for Attachment standards
anticipated in 2016
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE 14
Two Standards Development Organizations, Health Level 7 (HL7) and
ASC X12, have been collaborating on the development of Attachments
standards.
HL7 is finalizing the Supplemental Specification for Attachments, which
describes the use of the HL7 Consolidated CDA R2.1 document type
specification for Health Claim Attachments.
Change Healthcare continues to work with the Standards Development
Organizations on the Implementation Guides for these transactions.
The Standards Development Organizations, together with other
industry groups such as WEDI and CAQH CORE, are currently
preparing their testimonies to the National Committee on Vital and
Health Statistics (NCVHS), advisory body to HHS, in a hearing to be
held in February 2016.
ASC X12, HL7, and WEDI are developing a “How To” white paper to
help implementers understand how the ASC X12 and HL7 Attachment
standards work together.
Attachments – Current Activities
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE 15
Testimonies to NCVHS are expected to recommend that HHS establish the following
Attachment standards:
Attachments Envelope
- ASC X12N Additional Information to Support a Health Care Claim or Encounter (275)
- ASC X12N Additional Information to Support a Health Care Services Review (275)
- Allow other methods by trading partner agreement
ASC X12N Health Care Claim Request for Additional Information (277RFAI)
- To request additional information to support a health care claim or encounter
HL7 Consolidated CDA (C-CDA) Specification R2.1
- Unstructured Document Type (mandatory support)
- Structured Document Types (optional or phased support)
HL7 Supplemental Specification for Attachments
- Describes use of the C-CDA R2.1 document type specification for Attachments
HL7 Clinical Documents for Payers Set 1 (optional)
Logical Observation Identifiers Names and Codes (LOINC)
- To identify Attachment types and data content.
Acknowledgments
Attachments – Recommendations
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE 16
The HL7 Supplemental Specification For Attachments due to be published in
Q2 2016.
Conformance Version of the Supplemental Specifications for Attachments
balloted by HL7 in early May 2016.
NCVHS Hearings to be held on February 16, 2016.
NCVHS Letter of Recommendation expected Q2 2016.
Proposed rule expected Q3 2016.
Final Rule may be issued as early as Q4 2016 with an implementation period
and compliance date of up to two years following final rule publication.
Attachments – Regulatory Roadmap
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Health Plan Identifier
(HPID)
17
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Enforcement Delay
Health Plan ID use in
Transactions
Compliance
TBD
Attachments Standard
and Operating Rules Compliance
TBD
Attachments Standard
and Operating Rules Effective
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Compliance
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Effective
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA Certification
TBD
Health Plan Claims,
Enrollment, Attachments, Premium Payment, Referral
Certification
Enforcement Delay
Health Plans must
register for HPID
Compliance
Enforcement Delay
Small Health Plans must
register for HPIDCompliance
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA
Penalty Fees
2016 2017-2018
Regulations below have not been published at this time or have been delayed and the dates are to be determined.
These regulations may be effective sometime in 2016 with compliance dates in 2017- 2018.
18
• On 10/31/14 CMS announced an HPID enforcement discretion delay until further notice.
• With clarification that HPID does not replace PayerID, the impact of implementing HPID
has been significantly reduced.
• Change Healthcare has enabled “dual use” support of HPID data content in claim
transactions.
• Industry dialog continues with regard to removing HPID/OEID in healthcare
transactions.
Health Plan ID – HIPAA and ACA Timeline
Regulatory clarifications/revisions
expected in 2016.
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Regulatory Roadmap – Health Plan ID
19
Since the HPID final rule was issued in 2012, there have been growing industry concerns
surrounding the regulation, including (1) lack of clarity of the purpose and function of the
HPID, (2) the requirement to use the HPID in HIPAA transactions, and (3) the definition
of health plan versus payer.
Additionally, the National Committee on Vital and Health Statistics (NCVHS), a
governmental advisory body to the Department of Health and Human Services (HHS),
recommended that the HPID not be used in HIPAA transactions.
On May 29, 2015, HHS issued a Request for Information soliciting public comments on
the requirements set forth in the HPID final rule.
The public comment period ended July 28, 2015.
Change Healthcare participated and submitted comments in response to the RFI.
HHS has not yet communicated further regulatory action based on the feedback.
Related Materials
ASC X12 updated errata in HIPAA transactions
WEDI Issue Brief clarifying Payer vs. Health Plan
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Health Plan Certification
20
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Enforcement Delay
Health Plan ID use in
Transactions
Compliance
TBD
Attachments Standard
and Operating Rules Compliance
TBD
Attachments Standard
and Operating Rules Effective
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Compliance
TBD
Claims, Enrollment,
Authorizations Premium Payment, Operating Rules
Effective
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA Certification
TBD
Health Plan Claims,
Enrollment, Attachments, Premium Payment, Referral
Certification
Enforcement Delay
Health Plans must
register for HPID
Compliance
Enforcement Delay
Small Health Plans must
register for HPIDCompliance
TBD
Health Plan Eligibility,
Claim Status, EFT, ERA
Penalty Fees
2016 2017-2018
Regulations below have not been published at this time or have been delayed and the dates are to be determined.
These regulations may be effective sometime in 2016 with compliance dates in 2017- 2018.
Would require Health Plans to certify data and information systems are in
compliance with applicable standards and operating rules.
Dependent on Health Plan ID regulatory clarifications and revisions.
CAQH CORE is proposed as the certifying entity and there are 2 methods proposed by
which a Health Plan can certify:
1. CORE Certification Seal – existing CORE certification process.
2. HIPAA Credential – under development.
Health Plan Certification – HIPAA and ACA
Timeline
21
Health Plan Certification regulatory clarifications / revisions
expected in 2016.
CHANGE HEALTHCARE IS CORE PHASE I, II, AND III CERTIFIED
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Regulatory Roadmap – Health Plan Certification
22
Proposed Rule
Outlines Health Plan definitions and requirements for Controlling Health Plans (CHPs)
and Sub Health Plans (SHPs).
Outlines applicable penalties and fees based on covered lives.
Controlling Health Plans are required to certify compliance.
CAQH CORE has been proposed as the certifying entity.
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Meaningful Use Stage 3
23
PROPRIETARY & CONFIDENTIALCHANGE HEALTHCARE
Meaningful Use Stage 3 – Regulatory Roadmap
24
On October 16, 2015 a final rule with comment period was published that establishes
modifications to meaningful use in 2015 through 2017 and specifies the requirements that
eligible entities must meet in order to qualify for Medicare and Medicaid Electronic Health
Record (EHR) incentive payments. The final rule with comment can be viewed here.
On April 14, 2015, President Obama signed the Medicare Access and CHIP
Reauthorization Act (MACRA) into law. The MACRA makes three important changes to
how Medicare pays those who give care to Medicare beneficiaries. These changes
include:
- Ending the Sustainable Growth Rate (SGR) formula for determining Medicare
payments for health care providers’ services.
- Making a new framework for rewarding health care providers for giving better care not
just more care.
- Combining existing quality reporting programs into one new system.
Proposed regulations under MACRA are expected to be published in March 2016. The
CMS blog post “EHR Incentive Programs: Where We Go Next” by Andy Slavitt (CMS Acting
Administrator) and Karen DeSalvo (HHS Acting Assistant Secretary for Health) can be found
here.
Meaningful Use Stage 3