Embed Size (px)
Citation preview
X12 Clearinghouse Caucus
June 6, 2017- 5:00 - 6:15pmHyatt Regency San Antonio
Rio Grande East / Center
Clearinghouse Caucus Sponsors
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
Our Members
Clearinghouse Caucus - ASC X12 Standing MeetingJune 6, 2017 - 5:00 - 6:15pm
Hyatt Regency San Antonio / Rio Grande East / Center
Welcome and Introduction Sherry Wilson, Board Chair, Cooperative Exchange and EVP/ CCO, JopariSolutions
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
ASC X12 UpdateStacy Barber, Chair, ASC X12N
Getting Started on Attachment Implementation for Claims and Prior Authorizations
Mary Lynn Bushman, AnthemDurwin Day, HCSC Bruce Bellefeuille, Aetna
Moderator: Debbi Meisner, Board of Directors, Cooperative Exchange and Vice President Regulatory Compliance, Change Healthcare
Cooperative ExchangeNational Clearinghouse Association
Attachment Survey – February 16, 2016Over 49 Million Electronic Attachments Processed Annually
Electronic Attachments by Healthcare Line of Business55% Property and Casualty15% Dental15% Commercial15% Government
Electronic Attachment Utilization –Business Process83% Claims Adjudication i.e., high% unsolicited)11% Post Adjudication (i.e., appeal/audit)3% Referral/Notification3% Prior Authorization
Electronic Attachment Format Type95% Unstructured (e.g., TIF, PDF, etc.)5% Structured (C-CDA)
Variety of Attachment Transport Methodology53% Web Portal Upload (Single or Batch)27% EDI using ASCX12 27514% EDI (e.g., SFTP with PGP Encrypted)3% Secure Fax1% Secure Email1% IHE Profile (XDS, XDR)
*Cooperative Exchange NCVHS Feb 2016 Attachment Testimony: http://www.cooperativeexchange.org/
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
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)
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 006020 at the NCVHS hearings in February 2016.
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 .
Activities Requiring Attachments
Claims
Claim Submission Professional
Institutional
Dental
Post Payment Audits
Prior Authorizations
Request for Authorization
Referrals Notifications
Structured vs. Unstructured
Codified Content C-CDA
1. Care Plan2. Consultation Note3. Continuity of Care Document 4. Diagnostic Imaging Report 5. Discharge Summary6. History and Physical7. Operative Note8. Procedure Note9. Progress Note10. Referral Note11. Transfer Summary
Non-codified
MSWORD PDF Plain Text RTF Text HTML Text GIF Image TIF Image JPEG Image PNG Image
Solicited vs. Unsolicited
Requested
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.
PreDefined
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).
Solicited vs. Unsolicited
Payer
The entity creating (payer) the request for additional informationwould assign an Attachment Control Number used to re-associate the Attachment response to the original Attachment request. This Attachment Control Number must be returned with the Attachment response.
Provider
The provider would assign an Attachment Control Number. This identifier must be provided with the Attachment to be re-associated with the healthcare administrative activity.
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).
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.
http://loinc.org/attachments
LOINC Mapping Assistant
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
Attachment Control Number in X12
Transactions Location Industry NameVersion 5010 (Required under HIPAA)X222 Professional Claim (837)X223 Institutional Claim (837)X224 Dental Claim (837)
Loop 2300 & 2400PWK05
Code AC Attachment Control Number
Loop 2300 & 2400 PWK06
Attachment Control Number
X217 Services Review (278) Loop 2000E & 2000FPWK05
Code AC Attachment Control Number
Loop 2000E & 2000FPWK06
Attachment Control Number
Version 6020 (Recommended for adoption under HIPAA)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 & 2000FPWK05
Code AC Attachment Control Number
X316 Additional Information to Support Health Services Review (275)
2000A TRN02 Attachment Control Trace Number
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
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 Number23
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
Example of Conformance for Unstructured DocumentsAIGEX-UD1: All unstructured documents SHALL conform to the HL7 Unstructured Document, templateId 2.16.840.1.113883.10.20.22.1.10 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 the @code 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 one @mediaType (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 4648 .
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
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.
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.
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.
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.
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.
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.
PWK Use in the X12 278 5010 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’ – E-mail as a workaround along with adding the actual URL versus the e-mail 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.
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
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
EDI Readiness – Present & Future
Moderator: Debra Strickland, Education Chair, Cooperative Exchange and Project Manager, Conduent
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
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
Open Floor
Clearinghouse Caucus Sponsors
Thank You
Cooperative Exchange Contact Information
Lisa Beard, Executive Director, Cooperative [email protected]://www.cooperativeexchange.org/
Sherry Wilson, Board Chair Cooperative ExchangeEVP and Chief Compliance Officer Jopari [email protected]
