X12 Clearinghouse Caucus. June 6, :00-6:15pm Hyatt Regency San Antonio Rio Grande East / Center

Transcription

1 X12 Clearinghouse Caucus June 6, :00-6:15pm Hyatt Regency San Antonio Rio Grande East / Center

2 Clearinghouse Caucus Sponsors

3 Overview of Cooperative Exchange (CE) 24 Clearinghouse Member Companies Represent over 90% 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

4 Our Members

5 Clearinghouse Caucus - ASC X12 Standing Meeting June 6, :00-6:15pm Hyatt Regency San Antonio / Rio Grande East / Center Welcome and Introduction Sherry Wilson, Board Chair, Cooperative Exchange and EVP/ CCO, Jopari Solutions ASC X12 Update - Stacey Barber, ASC X12N Chair Getting Started on Attachment Implementation for Claims and Prior Authorizations - Mary Lynn Bushman, Anthem; Durwin Day, HCSC and Bruce Bellefeuille, Aetna Moderator: Debbi Meisner, Board of Directors, Cooperative Exchange and Vice President Regulatory Compliance, Change Healthcare EDI Readiness - Present & Future - Debra Strickland, Education Chair, Cooperative Exchange and Project Manager, Conduent Open Floor

6 ASC X12 Update Stacy Barber, Chair, ASC X12N

7 Getting Started on Attachment Implementation for Claims and Prior Authorizations Mary Lynn Bushman, Anthem Durwin Day, HCSC Bruce Bellefeuille, Aetna Moderator: Debbi Meisner, Board of Directors, Cooperative Exchange and Vice President Regulatory Compliance, Change Healthcare

8 Cooperative Exchange National Clearinghouse Association Attachment Survey February 16, 2016 Over 49 Million Electronic Attachments Processed Annually Electronic Attachments by Healthcare Line of Business 55% Property and Casualty 15% Dental 15% Commercial 15% Government Electronic Attachment Utilization Business Process 83% Claims Adjudication i.e., high% unsolicited) 11% Post Adjudication (i.e., appeal/audit) 3% Referral/Notification 3% Prior Authorization Electronic Attachment Format Type 95% Unstructured (e.g., TIF, PDF, etc.) 5% Structured (C-CDA) Variety of Attachment Transport Methodology 53% Web Portal Upload (Single or Batch) 27% EDI using ASCX % EDI (e.g., SFTP with PGP Encrypted) 3% Secure Fax 1% Secure 1% IHE Profile (XDS, XDR) *Cooperative Exchange NCVHS Feb 2016 Attachment Testimony:

9 Background Electronic attachments span multiple standards development organizations. X12N and HL7 have worked together to ensure that their standards are compatible to meet the needs of the industry. Since the use of multiple standards in a single transaction is new to the industry, X12N, HL7 and WEDI collaborated on a project to provide an overview on how these standards work together with business processes. Status of the ACP Whitepaper In final development Expectation of sending to HL7, X12 and WEDI approval process Goal is Publication in Q3 Status of HL7 CDA R2 Attachment Implementation Guide:Exchange of C- CDA Based Documents Finalized the ballot process at the May meeting Moving forward for publication Goal is to publish within the next month

10 Recommendation for Standards Clinical Data Content HL7 Consolidated Clinical Documentation Architecture & Templates (C-CDA R2.1) HL7 Attachment Supplement Specification: Exchange Implementation Guide Release 1 HL7 Clinical Documents for Payers Set 1 (Optional) LOINC (subset HIPAA Panel) Administrative Standards ASC X12N 277 Health Care Claim Request for Additional Information (Required in Solicited Model) ASC X12N 275 Additional Information to Support a Health Care Claim or Encounter (minimal requirement) ASC X12N 275 Additional Information to Support a Health Care Services Review (minimal requirement) ASCX12 Healthcare Acknowledgement Reference Model (ARM)

11 What Version of X12 ACP White Paper is Version Agnostic Examples Version 6020 for the X12N 277 and X12N 275; Current 5010 HIPAA Version of the X12N transactions. HL7 C-CDA v2 These versions have been recommended to NCVHS by both HL7 and X12N for adoption under HIPAA. At this time, X12N recommended implementation specification for version at the NCVHS hearings in February 2016.

12 Scope of the ACP Paper Background on Why and What information is requested to support administrative transactions Current processes for requesting and responding to additional Today s challenges Benefits of Electronic Transactions Examples of implementation approaches in the industry Getting Started recommended Skills, Essential Resources, approaches to implementation A review of Electronic Attachment Business flows for Claims, Prior Authorizations and Notification Business flows, use cases and examples A guidance on how to embed additional information within an X12N transaction in the BDS Segment.

13 Activities Requiring Attachments Claims Prior Authorizations Claim Submission Professional Institutional Dental Request for Authorization Referrals Notifications Post Payment Audits

14 Structured vs. Unstructured Codified Content C-CDA Non-codified 1. Care Plan 2. Consultation Note 3. Continuity of Care Document 4. Diagnostic Imaging Report 5. Discharge Summary 6. History and Physical 7. Operative Note 8. Procedure Note 9. Progress Note 10. Referral Note 11. Transfer Summary MSWORD PDF Plain Text RTF Text HTML Text GIF Image TIF Image JPEG Image PNG Image

15 Solicited vs. Unsolicited Requested PreDefined The act of requesting and/or responding with information which was requested after a healthcare entity determines a need for additional information to complete the healthcare administrative activity. The act of providing additional information that conforms to a set of rules-based criteria. These guidelines are defined by the payer through trading partner agreements or published criteria (i.e., policies, websites).

16 Solicited vs. Unsolicited Payer Provider The entity creating (payer) the request for additional information would assign an Attachment Control Number used to reassociate the Attachment response to the original Attachment request. This Attachment Control Number must be returned with the Attachment response. The provider would assign an Attachment Control Number. This identifier must be provided with the Attachment to be reassociated with the healthcare administrative activity.

17 LOINC (Logical Observation Identifiers Name and Codes) LOINC Document Type: Identify an electronic Attachment (e.g., Discharge Summary Report) LOINC Document Template Modifier code: Identify the specific implementation guide version of a document being requested (e.g., C-CDA R2.1 Operative Note versus the CDP1 Enhanced Operative Note) LOINC Time Window Modifier code: Identify the explicit scope of a requested activity (e.g., to modify a request for information to a period 30 days prior to treatment).

18 LOINC Attachment Page The LOINC website maintains an Attachments Page documenting three methods to identify LOINC codes that are valid for attachments: 1. The LOINC Table the master database that associates codes with their component parameters (type, provider type, etc.) 2. The RELMA application a browsing and mapping application with a special form for attachment codes 3. The online LOINC search application search.loinc.org All three methods access the same sets of codes. New users should become familiar with the organization of the codes using the RELMA graphical user interface, used here to illustrate the key concepts.

19 LOINC Mapping Assistant

20 Attachment Control Number When the Attachment is solicited, the Attachment Control Number is used in both the request and the response and is assigned by the payer. When the Attachment is unsolicited, the Attachment Control Number is on both the associated transaction and the Attachment and is assigned by the Provider. 20

21 Attachment Control Number in X12 Transactions Location Industry Name Version 5010 (Required under HIPAA) X222 Professional Claim (837) X223 Institutional Claim (837) X224 Dental Claim (837) X217 Services Review (278) Loop 2300 & 2400 PWK05 Loop 2300 & 2400 PWK06 Loop 2000E & 2000F PWK05 Loop 2000E & 2000F PWK06 Version 6020 (Recommended for adoption under HIPAA) Code AC Attachment Control Number Attachment Control Number Code AC Attachment Control Number Attachment Control Number X313 Request for Additional Information (277) 2200D TRN02 Payer Claim Control Number X314 Additional Information to Support a Claim (275) 2000A TRN02 Payer Claim Control Number or Provider Attachment Control Number X315 Healthcare Services Review (278) Loop 2000E & 2000F PWK05 Code AC Attachment Control Number X316 Additional Information to Support Health Services Review (275) 2000A TRN02 Attachment Control Trace Number

22 Technical Requirements Information in the BDS Segment of the 275 MUST be Base64 Encoded following the IETF RFC 4648 Guidelines Conformance Statements for Attachments are in the HL7 CDA R2 Attachment Implementation Guide: Exchange of C-CDA Based Documents, Release 1 Release 1 (Universal Realm) in Section 7 specific to the use of C-CDA for attachments. 22

23 US Realm Header All documents (both structured and unstructured ) must have a valid US Realm Header for consistent description of the following document attributes : Patient Provider organization Author(s) Legal authenticator and Authenticators Other relevant participants Encounter date(s) Purpose (in Fulfillment Of and documentation of) Authorization Document SetId and Version Number 23

24 AIGEX Identifiers The AIGEX conformance identifiers in front of each conformance statements are unique error codes and should be used, where appropriate, in the validator when the document fails to meet the requirements of the conformance statement. 24

25 Example of Conformance for Unstructured Documents AIGEX-UD1: All unstructured documents SHALL conform to the HL7 Unstructured Document, templateid with no extension or with a valid extension. AIGEX-UD2: The US Realm Header for all unstructured documents SHALL contain exactly one LOINC code where SHALL be selected from the LOINC document ontology and accurately represents the content of the unstructured body. AIGEX-UD3: If the unstructured content is the same as content for a defined structured document (e.g., both are a Discharge Summary), then the LOINC code for the equivalent structured document SHOULD be used. AIGEX-UD4 :An unstructured document SHALL NOT contain a reference to a document file unless there is a trading partner agreement. AIGEX-UD5: An unstructured document SHALL contain exactly (e.g., MIME type) selected from the value set defined in Table 1. AIGEX-UD6: The unstructured content SHALL be Base64 Encoded using the method defined in RFC AIGEX-UD7: If unstructured content is compressed, it SHALL be compressed using the method in RFC 1951 prior to being Base64 Encoded and the compression attribute SHALL be present and it SHALL have the value of DF. 25

26 Claim Use Cases A request might ask for an Operative Note or Procedure Note for unlisted procedures or a CPT having: Modifier 22 (increased procedure), Modifier 52 (reduced services); or Modifier 62 (2 surgeons). A request may also ask for Progress Notes or Consultation Notes for high level Evaluation and Management Codes.

27 Solicited Claim Flow 1. The claim submitted by provider to a payer is the triggering event. 2. The request for additional information by payer to provider using X12N 277 Health Care Claim Request for Additional Information. 3. The provider responses with an Attachment using X12N 275 Additional Information to Support a Health Care Claim or Encounter.

28 Unsolicited Claim Flow 1. The claim submitted by provider to a payer. 2. Provider submits additional information previously agreed to between payer and provider as an Attachment using ASC X12N 275 Additional Information to Support a Health Care Claim or Encounter.

29 Prior Authorization Use Case When a provider submits a request for prior authorization, a payer may determine that additional information is needed to complete review. The payer initiates a request for that additional information. The provider receives that request, and responds to the payer with the Attachment requested.

30 Prior Authorization Solicited 1. The Prior Authorization Request by a provider using the X12N 278 Health Care Services Review - Request for Review and Response as the triggering event for requesting an attachment. 2. A Request for Additional Information in support of a Prior Authorization requested by payer to the provider using X12N 278 Health Care Services Review - Request for Review and Response. 3. The provider s response with an Attachment using ASC X12N 275 Additional Information to Support a Health Care Services Review.

31 Prior Authorization Unsolicited 1. Prior Authorization Request or Notification from a provider to a payer using ASC X12N 278 Health Care Services Review - Request for Review and Response. 2. Provider submits additional information previously agreed to between payer and provider as an Attachment using ASC X12N 275 Additional Information to Support a Health Care Services Review.

32 PWK Use in the X Workarounds PWK01 (Attachment Report Type Code) is required when using the PWK and indicates the type of report, document or supporting information. The 5010 does not have a value for LOINC in the PWK01. When sending a LOINC always use a PWK01 value 77 - Support Data for Verification. The next ASC X12N 278 version will have a value UL - Other Type of Report. This code will have a code note of Use when type of report is being identified in an HI segment using a LOINC Code. PWK02 (Report Transmission Code) is required when using the PWK and indicates the method by which the additional information is being sent. When using the Response, there is not a value to support the situation where the submitter can obtain the forms at a specific URL and/or website. When submitting a URL use a PWK02 value EM as a workaround along with adding the actual URL versus the in the PWK07 (Attachment Description). Since this is a common workflow for UMO s, a value of OL - On- Line has been added to the code list in the next version. Since the PWK02 is required in the 5010 TR3, but is not needed if LOINC codes are being returned in the HI Segments in the ASC X12N 278 Response, use EL - Electronically Only - until the next version of the ASC X12N 278 makes the element situational. The situational rule will only require the PWK02 when the UMO is sending the requesting entity specific documentation requirements, formats or forms.

33 Next Steps Industry needs education Overview of Attachments (101) Getting Started What do you need to think about before you get started? Use the resources section Implementation Approach to Attachments some real life experiences Use of LOINCs in Attachments Use of OIDS in C-CDA and Attachments Validating the Attachment Transaction Technical Requirements

34 Next Steps We NEED the regulation to get everyone on the same page Develop the implementation roadmap Real life implementation experiences Gathering of ROI from production experiences for all stakeholders

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36 EDI Readiness Present & Future Moderator: Debra Strickland, Education Chair, Cooperative Exchange and Project Manager, Conduent

37 What to focus on? Gap Analysis High level should already be started during public comment period Example Database structure changes CARC/RARC to RAS Segment Identify partners that will be affected by these changes Level of Risk Their steps to implementation Identify legacy formats and resolutions Identify what systems will be affected Plan / Budget for IT resources

38 Moving Forward Question for next Clearinghouse Caucus What do we need to do to prepare? Roll out options? Other Concerns / Issues? The Cooperative Exchange will be planning on a variety of industry stakeholders education and communication forums including: Webinars Deep Dives Surveys

39 Open Floor

40 Clearinghouse Caucus Sponsors

41 Thank You Cooperative Exchange Contact Information Lisa Beard, Executive Director, Cooperative Exchange Sherry Wilson, Board Chair Cooperative Exchange EVP and Chief Compliance Officer Jopari Solutions