Clinical Laboratory Improvement Amendments (CLIA) ID ... · - All laboratory services subject to the CLIA submitted on either a CMS 1500 claim form or HIPAA 5010 837P claim file •Requires

Clinical Laboratory Improvement Amendments (CLIA) ID Requirement Policy UpdateSpring 2018

Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.Doc3: PCA-1-010717-05092018_XXXX2018

© 2018 United HealthCare Services, Inc.

Agenda

• Overview

• Requirements

• Claims Submission Process

• Compliance

• Summary

• Reference and Contacts

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Overview

What is CLIA?

A set of laboratory regulations introduced in 1988 by the Centers for

Disease Control and Prevention (CDC), Food and Drug Administration

(FDA) and The Centers for Medicare & Medicaid Services (CMS).

• Clinical laboratories performing a test for the purpose of diagnosis or

treatment are required to be certified.

• Certified laboratories receive a CLIA ID.

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Requirements

UnitedHealthcare’s CLIA policy:

• Applies to:

- All laboratory services subject to the CLIA submitted on either a CMS

1500 claim form or HIPAA 5010 837P claim file

• Requires that:

- All claims for laboratory services subject to the CLIA include the CLIA

ID number for the servicing care provider and the servicing care

provider’s physical laboratory address if that address is different than

the billing care provider’s address listed on the claim

- The billing or servicing care provider address submitted on the claim

must match the address associated with the CLIA ID number.

• Affects:

- All lines of business

• Contains:

- Specific guidance around the claims submission process and CLIA-

specific resource links.

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Claims Submission Process

•

5

Claim

Format and

Elements

CLIA

Number

Location

Options

Ordering Provider

Name and

National Provider

Identifier (NPI)

Number Location

Options

Servicing Laboratory Physical

Location

CMS-1500

(formerly

HCFA 1500)

Must be

represented

in field 23

Submit the ordering

care provider name

and NPI number in

fields 17 and 17b.

Submit the servicing provider name, full

physical address and NPI number in

fields 32 and 32A. The servicing

provider address must match the

address associated with the CLIA ID

entered in field 23.

CMS-1500

(formerly

HCFA 1500)

– State of

Virginia

Requirement

Must be

represented

in field 19

Submit the ordering

care provider name

and NPI number in

fields 17 and 17b.

Submit the servicing provider name, full

physical address and NPI number in

fields 32 and 32A. The servicing

provider address must match the


entered in field 19.



Claims Submission Process – Cont’d

•

6

Claim

Format and

Elements

CLIA

Number

Location

Options

Ordering Provider

Name and NPI

Number Location

Options

Servicing Laboratory Physical

Location

HIPAA 5010

837

Professional

Must be

represented

in the 2300

loop, REF02

element

Submit the ordering

provider name and

NPI number in the

2310A loop, NM1

segment.

Physical address of servicing care

provider must be represented in the

2310C loop if it isn’t the same as the

billing address and must match the


submitted in the 2300 loop, REF02.

HIPAA 5010

837

Institutional

Not

applicable for

institutional

claims

Submit the ordering

provider name and

NPI number in 2310A

loop, NM1 segment.

Not applicable for institutional claims



Compliance

• We may reject or deny any claim as incomplete if it:

- Doesn’t contain the CLIA ID

- Is submitted with an invalid CLIA ID

- Is submitted without the complete servicing care providers demographic

information

• Claim line edits may also be applied if the provider’s CLIA certification type

doesn’t support the billed service code.

• Laboratory service providers who don’t meet the reporting requirements

and/or don’t have the appropriate type of CLIA certificate for the services

reported may not be reimbursed.

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Summary

Applies to all laboratory services that are subject to the CLIA and

submitted using:

• CMS 1500 claim form; or

• HIPAA 5010 837P claim file

Include the CLIA ID number for:

• The servicing care provider

• The servicing care provider’s physical laboratory address if it’s

different than the billing care provider’s address listed on the

claim

Check to make sure:

• The billing or servicing care provider’s address you submit on

the claim matches the address associated with the CLIA ID

number.

8



Reference and Contacts

Reference Materials

• UnitedHealthcare Commercial Policies: UHCprovider.com > Policies and

Protocols > Commercial Policies > Reimbursement Policies for

UnitedHealthcare Commercial Plans

• UnitedHealthcare Medicare Advantage Policies: UHCprovider.com >

Policies and Protocols > Medicare Advantage Policies > Reimbursement

Policies for Medicare Advantage Plans

• UnitedHealthcare Community Plan Policies: UHCprovider.com > Policies

and Protocols > Community Plan Policies > Reimbursement Policies for

Community Plans

Key Contacts

• Debra L. Locke, RN, MLT [ASCP], CPC, Process Consultant, UHC Payment

Integrity/ Laboratory SME

• Shelly Woelfel, CLIA Program Manager, UHC Payment Integrity

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https://www.uhcprovider.com/en/policies-protocols/commercial-policies/commercial-reimbursement-policies.html?rfid=UHCOContRD

https://www.uhcprovider.com/en/policies-protocols/medicare-advantage-policies/medicare-advantage-reimbursement-policies.html?rfid=UHCOContRD



Questions?

Thank you!

10

The Enterprise Medical Records

(EMR) Program and EMR

Interoperability

© 2018 United HealthCare Services Inc. Proprietary information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

PCA-1-010085-03162018

Agenda

❑ Opening and Purpose

❑ EMR Point of Care, Access and Connectivity

Solutions Overview

• Direct EMR Access

• Structured Clinical Data Exchange

• UHC EMR Point of Care Solutions

❑ Resources and Contacts

❑ Call to Action

❑ Q&A

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Why We Request Medical Records

13

UnitedHealthcare often needs clinical information to process claims correctly. We also

conduct a number of reviews for medical necessity, risk adjustment, fraud and payment

integrity, level of care, DRG, compliance regulations and other reasons. Many teams

request medical records, including:

• Clinical Services

• Complex Care

• Eligibility

• Medical Underwriting

• Payment Integrity

• Pharmacy

• Risk Adjustment

• And others


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The High Cost of Record Requests

14

Currently UnitedHealthcare and our vendors make 13 million

medical record requests a year – and that number is growing.

Our care providers often receive multiple requests for the

same information.

Requests from different teams and different lines of business can

be inconsistent, repetitive and confusing.

These requests drive up administrative costs for the care provider

and take time away from patient care.

Care providers are frustrated by delayed claims processing and

spend additional time filing appeals and reconsideration requests.

They frequently contact us about the volume and frequency of

these requests.

Now the UnitedHealthcare Enterprise Medical Record Program is making it easier for care providers to do business with us.

Our goal is to:

• Reduce care provider frustration

• Offer an easy and efficient provider experience

• Improve NPS scores


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Care Provider Benefits

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The UnitedHealthcare Enterprise Medical

Record Program improves the care

provider experience in multiple ways,

including:

• Lowered administrative costs

• More time to focus on patient care

• Reduction in medical record requests

• Elimination of duplicate requests

• Faster timeframe for accounts receivables

• Drop in the number of pended or denied claims

requiring clinical information

• Reduced filing of appeals and reconsiderations

• Increased revenue for HEDIS and Star Ratings


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EMR Point of Care, Access and Connectivity Solutions

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1. Direct EMR Access

Information delivery to the EMR by requesting and receiving medical records.

➢ Example:

▪ EMR All Access - Minimizes the need for medical record requests by allowing UHG staff to remotely

retrieve medical records directly from the care provider’s EMR – safely downloading clinical information

such as progress notes, operation reports, labs, radiology results and more.

2. Structured Clinical Data Exchange

Accessing specific sets of patient data from the EMR and receiving that data.

➢ Examples:

▪ Admit Discharge Transfer Documents (ADTs) - By automatically receiving these records, our staff can

address medication errors, Educate members on their prescriptions , and lower the risk for adverse

medication interactions – helping us potentially avoid unnecessary readmissions

▪ 278N for authorization - By automatically receiving these records, we reduce provider abrasion

eliminate inbound and outbound faxes for authorization thus providers see faster aster authorization

decisions with less administrative burden

▪ Health Information Exchanges (HIEs) - We are willing to explore using an HIE for the ADT records and

eligibility/authorization information if it feasible

3. UHC EMR Point of Care Solutions

Transaction-based solutions embedded in the physician work flow with the goal of delivering real-time accurate data to the provider at the point of care.

➢ Example:

▪ PreCheck MyScript (PCMS) - An innovative pharmacy solution providing real time accurate data at time

of prescribing

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Direct EMR Access


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EMR All Access

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EMR All Access takes the

hassle out of medical record

collection for care providers.

Unlike other technology that only allows

viewing medical records, EMR All Access

allows UHG staff to remotely retrieve

medical records directly from the care

provider’s EMR – safely downloading

clinical information such as progress

notes, operation reports, labs, radiology

results and more.

This direct access to care provider

records is already established in our

Provider Agreements.

https://hub.uhg.com/sites/hub/Resources/Brand/UnitedHealth-Group-Brand/ImagesClinical/FAN9003114.jpg


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EMR All Access Benefits

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EMR All Access is secure and compliant – meeting all HIPAA and

other compliance regulations.

Because the care provider is not disrupted, they can:

• Reduce their collection and submission costs

• Lighten their staff’s administrative burden

• Focus on providing care to their patients

• Speed up their accounts receivables

https://hub.uhg.com/sites/hub/Resources/Brand/UnitedHealth-Group-Brand/ImagesLifestyle/174854184.jpg


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EMR All Access Provider Benefits

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Since the EMR All Access pilot was launched, we’ve seen:

• Reduction (up to 55%) percent reduction in claim adjudication turnaround times

• Reduction (60% - 85%) in the number of requests for medical records

• Reduction (up to 82%) in the number of claims denials related to requests for

additional information

Our Community Transitions Program will use it to help with coordination of care post

discharge and medication reconciliation.

“Since the ERM All Access go live, where we have shifted theadministrative burden of clinical data collection toUnitedHealthcare, claims are paying faster and earlier in theirlifecycle and, as an example, the UnitedHealthcare ManagedMedicare product has seen an improvement of 7% in our 60+days-in-accounts receivable category and 7% in our 90+ days-in-accounts receivable category.” Centura Health, Colorado

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Structured Clinical Data

Exchange


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Admit/Discharge Notification and Discharge Summary Data Exchange Program

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Our new automated data exchange process lets care providers send

over Admit, Discharge, Transfers (ADTs), Discharge Summaries and

prescribed medication lists.

By automatically receiving these records, our staff can:

• Address medication errors

• Educate members on their prescriptions

• Lower the risk for adverse medication interactions – helping us potentially avoid

unnecessary readmissions

Making the Switch

We support multiple industry standard exchange options for setting up an automated

process for sending ADT, Discharge Summaries with Medication list, including

• Standard HL7 format for ADT

• Master Document Management (MDM) process for Discharge Summary

• Medication List sent using Continuity of Care Document (CCD)


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Other Clinical Structured Data Exchanges

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Health Information Exchanges (HIEs)

Benefit: Provider can, with a single access, provide information to multiple

providers.

Can we get the right data via the Health Information Exchange?

HL7 for Prior Authorization/ 278 NBy automatically receiving these records, we reduce provider abrasion,

eliminate inbound and outbound faxes for authorization.

Benefit: Faster authorization decisions with less administrative burden

Continuity of Care Documents (CCDs)

?

For Internal Use Only


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UHG Current State

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Talking Points

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PreCheck MyScript (PCMS) Facts

• PreCheck MyScript dashboard version is now available through the Link Marketplace.

• PreCheck MyScript Point of Care version is available through the following

EMR partners:

− DrFirst and partner EMRs – Current

− AthenaHealth and NewCrop – May 2018

− RxRevu (Cerner/Epic) and Center X (Epic) July 2018

− Allscripts September 2018


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Talking Points

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• The functionality of PCMS can be embedded in EMR.

We are looking to use the influence of the provider group with their EMR to request it be

implemented. The following EMRs have or will have the functionality

− DrFirst and their partners – currently has functionality embedded

− Allscripts – currently working to add the functionality

− AthenaHealth – currently working to add the functionality

− NewCrop – currently working to add the functionality

• No cost for providers or staff using the solution

• No “all payer” real-time pharmacy benefits solution exists in the marketplace

• Functionality for UHG patients will only be available via PreCheck MyScript

connectivity

• Available to all providers seeing UHC M&R, C&S and E&I members

Collateral - External

29

Externally approved provider materials are available at: https://www.uhcprovider.com/en/resource-library/uhc-enterprise-medical-records.html

https://www.uhcprovider.com/en/resource-library/uhc-enterprise-medical-records.html

Payment Integrity Iowa Administrative Advisory Committee

November 15, 2017

Payment Integrity (PI)

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Payment Integrity delivers solutions that improve healthcare affordability. Our mission is to ensure UnitedHealth Group pays what it owes and to comply with Centers for Medicare and Medicaid Services (CMS) and state program integrity guidelines.

By the responsible party for eligible members

According to terms of the contract

Free of fraudulent and abusive practices

Not in error, waste or duplicate

Payment Integrity ensures the medical claim is paid:

PI FOCUS THROUGHOUT THE CLAIM LIFECYCLE

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AUTOMATION

HIGH DOLLAR

CONTRACT AUDIT

PAYMENT POLICYCOORDINATION OF

BENEFITSFRAUD, WASTE, ABUSE

& ERROR

INJURY COVERAGE COORDINATION

FRAUD, WASTE, ABUSE & ERROR

COORDINATION OF BENEFITS

SUBROGATION

DATA MINING

CREDIT BALANCE RESOLUTION

RECOVERY

PREMIUM AUDIT SERVICES

PI FOCUS

PISERVICES

CLAIMCYCLE

ADVANCED ANALYTICS DRIVES PRECISION

CLAIMSEDITING

ELIGIBILITY VERIFICATION

CLAIM VALIDATION

CLAIM PROCESSING RECOVERY

PROSPECTIVE RETROSPECTIVE

POST-SUBMISSION;PRE-ADJUDICATION

POST-PAYADJUDICATION

POST-ADJUDICATIONPRE-PAY

Why Payment Integrity Requests Medical Records

33

By the responsible party for eligible members

According to contractual terms

Free of fraudulent and abusive practices

Not in error, waste or duplicate

Data on the claim form alone is insufficient to validate billing

accuracyCauses of Erroneous Billing

Services Not Performed

Unbundling

Upcoding

Incorrect Coding

Modifier Not Supported

Fraud

Sanctions / Exclusions

• UnitedHealth Group has a fiduciary responsibility to protect our clients and members from the impact of erroneous billing.

• Medical records validate that the services provided are the services reflected on the claim and are properly billed.

• Medicare rules indicate that if it is not documented it is as if the service was not rendered.

Experts estimate 1/3rd of the $3.2 trillion spent on U.S. healthcare in 2015 was either fraudulent, waste and error, or abusive

– Institute of Medicine of the National Academies

Keying Errors

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Medical Record Request Process Overview

Review Approach:1. Pre Payment – Identify and stop high risk claims prior to payment2. Post Payment – Identify and stop high risk claims after payment.

Detect

• Provider- and claim-centric approaches

• Various analytic techniques employed

• Pattern recognition

• Outlier/peer comparison

• Risk scoring

• Predictive modeling

Evaluate

• Determine whether claim properly billed

• Majority of claims stopped require review of documentation (medical records)

Take Action

• Pay or deny claim based on results of documentation review

• Arrange for provider education if warranted

• Recover overpayment if claim already paid

Fraud, Abuse, Waste and Errors

Identify claims and claim patterns that indicate potential for fraud, waste, abuse or errors using sophisticated algorithms and predictive models.

Intentionally misrepresenting or concealing facts to obtain something of valueFraud

Unintentional practices that result in unnecessary costs; providing information on a health care claim in way that improperly uses resources for personal gain or benefit

Abuse

WasteInaccurate payments for services such as unintentional duplicate payments; may include inappropriate utilization and/or inefficient use of resources.

There are times when something that looks like potential fraud, waste, or abuse is really an error made by providers, members, vendors, employees, or contractors.

Error

Medical Record Request Volumes and Perspective

• Payment Integrity has thousands of analytics and algorithms working to detect

Fraud, Waste, Abuse, and Errors.

• From the medical record reviews that result in a denial:

o 94% are attributed to errors that may be subsequently paid as a result of the provider furnishing additional information or submitting a corrected claim.

o 6% are attributed to potential waste or abuse and are not resubmitted for payment.

• Less than 1% of all the claims submitted result in a request for medical records.

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Who is Requesting Medical Records to perform

Payment Integrity Reviews?

• Optum (A UnitedHealth Group company) performs the majority of our prepayment medical record reviews as well as some post

payment reviews.

• UnitedHealthcare also uses several vendors to perform post payment reviews for Hospitals.

• Each letter requesting a medical record and the Determination letter should provide the name of the entity performing the review and

their telephone numbers. The Determination or Findings letter will also have the contact information for any dispute requests.

• Reviews are conducted by Certified Coders

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Vendors

Product Phone Number

Employer & Individual/Commercial

(866) 230-5783

Medicare & Retirement (844) 464-8227

Community & State/Medicaid (800) 864-9084

Oxford (866) 230-8320

Texas ERS, Empire, NY Exchange, UHG Employees

(866) 235-5271

Optum

Vendor Name Phone Number Website

Omniclaim (781) 932-4600 Omniclaim.com

ChangeHealthcare/EquiClaim (630) 282-9300 Changehealthcare.com

Cotiviti/Connolly (800) 530-1013 Cotiviti.com

HMS/HDI (888) 700-3282 Hms.com

CERiS/Corvel (844) 868-0058 Ceris.com/provider-relations/customer-service

MedReview (212) 897-6006 Medreview.us

SCIO Home Health (866) 709-60533DME (866) 628-3488 ext.7411

Sciohealthanalytics.com

Medical Record Requests – Improvements Underway

• Reducing duplicative medical record requests across UnitedHealth Group

• Improving the precision of our medical record requests

• Improving education and collaboration with our providers to identify and

correct trended coding errors.

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LINK and UHC On-Air

• Updates

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Questions and Answers