Implementing HIPAACenters for Medicare & Medicaid Services

Fourth National HIPAA SummitApril 25, 2002

Jared A. Adair

Director

Office of Operations Management

CMS’s Commitment to Implementing HIPAA

• Office of Operations Management– New– Focal Point for the Agency for Administrative

Simplification– Work continues throughout the Agency

• HIPAA Steering Committee

• HIPAA Roundtable Discussions

CMS’s Dual Roles

• Responsible for regulations that adopt HIPAA standards…

• …and modifications to those standards

• Operate health plans that must be compliant– Medicare (fee-for-service and managed care)– Medicaid and SCHIP

Medicare Fee-for-Service

• CMS directly responsible for readiness

• Business partners– Medicare carriers and fiscal intermediaries– Claims processing systems maintainers

• Environment: Quarterly systems releases

Medicare FFS - Basic Concepts

• Can’t do it all at once– Risk – Resources

• Used WEDI sequencing white paper as guidance

• Minimize changes to ‘core system’ processes

Medicare FFS - Implementation Instructions

• Effort began almost two years ago

• JAD technique, involving our partners extensively

• Instructions contain:– Requirements– Flat file formats/crosswalks– Edit documents and other guidance

Medicare FFS - Instructions Progress

• Published:– Inbound claim and outbound COB (837)– Remittance Advice (835)– Claims status query/response (276/277)– Testing

• In Progress:– Eligibility query/response (270/271)– Referral/authorization (278)– Retail Pharmacy (NCPDP)

Medicare FFS - Status

• Medicare contractors using Claredi for testing and certification

• Testing with partners is sequenced by transaction:– Claim - began mid-April– Remittance Advice - mid-May– COB - mid-June– Claims Status - mid-July

Medicare Managed Care

• Providing technical assistance and oversight• Sponsoring conferences and training• Transactions:

– Will use 820 for premium payments– Plans will have the option of batch 270/271 or DDE

for eligibility inquiries– Plans will have the option to use 837 to report risk

adjustment data to CMS (this transaction does not require a HIPAA standard)

State Medicaid Programs

• Providing technical assistance and oversight

• Developed a HIPAA compliance “road map” for States– CD-based tool– Provides gap analysis, resources

• Facilitating cooperative working relationships among States to identify issues

CMS Outreach

• Tremendous effort to reach entire health care industry - not just Medicare and Medicaid Providers

• Website• Periodic satellite broadcasts and video tapes• Industry roundtable conference calls• Participation in major industry conferences• We are challenged to reach everyone...