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Operating Rules270/271 EligibilityThe technical checklist for assuring and maintaining compliance
Kevin DaySenior Solutions Consultant
Ruby RaleyAVP Product Marketing
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Agenda Today, we are going to meet a fictional team who has been
challenged to explain Operating Rule Eligibility compliance and what it
means for their organization.
To thank you for your time, we have built these handouts that you will
receive after the webinar as a thank you for attending.
Requirements for Eligibility including guidance for testing and monitoring
Solution Architecture diagram for continuing compliance
Lessons LearnedSuggested executive metrics for
eligibility compliance
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Introducing the Scenario
Kevin is the Senior Architect for the Clearly Better Health plan. He works directly with the business and IT teams to align business requirements and technology.
Ruby is the Compliance Officer looking after Healthcare mandates such as Operating Rules. She works across teams to ensure Clearly Better Health plan meets regulations.
The Exec team heard that there may be a final rule of Certification and/or HIPAA Attestation in Q1 of 2016. They want a detailed briefing of how Clearly Better Health plan complies with Operating Rules. They want to be sure that we are in good shape or quickly identify what resources are needed to get us compliant
Clearly Better Health Plan serves a tri-state area with over 200,000 members. They receive claims from a clearinghouse. They have several lines of business with different eligibility systems. Like many plans, they have a variety of legacy applications.
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The penalties apply by statute on 1/1/16.
Compliance to standards was mandatory 12/31/14.
The new rule concerns the process for certification.
The question is: Are we compliant? Most plans are saying that they are compliant but recent surveys show gaps in compliance across the board. About 200 plans, vendors and clearinghouses hold a CORE Seal. There are at least 2000 CHP (Controlling Health Plans) that will require certification.
The current NPRM for HPID and Certification will be replaced with a new NPRM in Q2 2016. This does not change the requirement in place to be compliant with Operating Rules 1, 2 and 3 as of 12/31/14.
Monetary fines still apply but they don’t increase to $1 pm/pd until the final rule is published- date TBD.
HHS is indicating that new enforcement efforts will be a priority agenda of the National Standards Group (OeHSS) and will step up now under existing rules
Audits can be triggered by unhappy providers and attorney generals with an ax to grind
Proof of ‘Good Faith’ efforts may buy 30-60 days to comply.
Chances are that without proactive continuous monitoring we will not know we are out of compliance until HHS comes knocking.
Here is the big picture The Exec Team: do we need to act to reduce our risk?
What is required now? What is changing? Why are we concerned?
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No rule for CORE Certification or HIPAA Attestation in effect in Q1 2016.
2nd NPRM expected in April. Earliest final rule H2 2016 (late Q3). NPRM + Time for Comments + Time
for Review + Time to publish Final Rule
CMS will look to publish the New Rule before the end of the year
COMPLIANCE TAKEAWAYS Operating Rules are written into the
law and are in effect now
CORE Seal is the only objective certification available and CAQH CORE wrote the rules for HHS
Lower penalties apply now
We need to be compliant and auditable now as enforcement efforts are expected to be stepped up
Unified Agenda for 2016 What insights can we gain?
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Implementation Approach
Gap Analysis/Health Check Implementation First Certification & Production Level Testing
Review rules Identify business process
level gaps/transaction support gaps
Identify transaction content and infrastructure gaps
Baseline current performance levels and identify gaps
Implement new transactions (as necessary)
Make system and hardware changes
Select First Certification method
Plan and allocate resources Test with trading partners
(HIPAA credential method) Set up data and iteratively
test on certification testing website till successful completion (CORE certification method)
Conduct production level testing
Attest compliance
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Operating Rule Eligibility Requirements Transaction Data Content
Patient financials in response. Patient Name normalization. 271 AAA
Transport Protocol Exchange protocols (HTTP/MIME & WS). Request/Response orchestration sequence of messages, re-tries, etc. SLAs, Security certs, authentication, etc.
Measurement and Reporting Real-time: 20 seconds and compliant 90% of time during month Batch: 9PM receipt with response by 7am and compliant 90% of time
during month Documentation & Availability
Master Template for Companion Guide - Payer specific edits 86% system availability per calendar week. Downtime and maintenance alerts and notices
Achieving Eligibility Compliance
Gap Analysis / Health Check
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Challenges with implementation of Operating Rules
Getting Started• Getting executive buy-in• Understanding rules and
compliance• Determining gaps to compliance
Configuration• Mapping benefits to service types• CARC/RARC and business
scenarios• CORE compliance involved a
great deal more detail than our current 271 gen was providing and some of the data doesn’t even exist based on LOB (e.g. Medicare members have no deductibles)
Infrastructure• Meeting real-time performance
needs• Testing upfront with production
like volume and trend • Initially thought our existing
Provider portal satisfied the communication protocol requirements.
Communication• Onboarding trading partners on
CORE channel• Initial set up with providers (user
id/password)
WatchRecorded webinar
Operating Rules
Questions? Contact us [email protected] USUpcoming Webinar
The 276 / 277 Claim Status TransactionsThursday, January 28 l 1 p.m. ET
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