HIPAA Collaborative of Wisconsin 2015 Spring Conference Oconomowoc, Wisconsin April 10, 2015 © 2015 CAQH. All rights reserved. • ACA Mandate Scope and Updates • Third Set of Draft CAQH CORE Operating Rules • Draft Phase IV Connectivity Rule Overview • Q&A © 2015 CAQH. All rights reserved. ACA Mandated and HHS Health Plan Certification Scope and Updates 1 About CAQH CORE Vision Mission 4 CAQH CORE is an industry-wide stakeholder collaboration committed to the development and adoption of national operating rules for administrative transactions. The more than 140 CORE Participants represent all key stakeholders including providers, health plans, vendors, clearinghouses, government agencies, Medicaid agencies, banks and standard development organizations. An industry-wide facilitator of a trusted, simple and sustainable healthcare data exchange that evolves and aligns with market needs. Drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers, and consumers. © 2015 CAQH. All rights reserved. CAQH CORE in Process of drafting rules HHS NPRM and deadline adjustment issued 12/31/13 Mandated Requirements available and should be in use in market Compliance in Effect as of January 1, 2013 5 • Eligibility for health plan • Claim status transactions HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules Compliance in Effect as of January 1, 2014 • Electronic funds transfer (EFT) • Health care payment and remittance advice (ERA) Proposes an adjusted Implementation: December 2015 Proposes health plans certify via either CORE certification or HIPAA Credential; applies to Eligibility/ Claim Status/EFT/ERA operating rules and underlying standards Implement by January 1, 2016 (Draft Rules available in Late 2014) HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules Applies only to health plans and includes potential penalties for incomplete certification; existing voluntary CORE Certification is for vendors/PMS/large providers, and health plans • • • • • Health claims or equivalent encounter information Enrollment/disenrollment in a health plan Health plan premium payments Referral, certification and authorization Health claims attachments (HHS Standard not yet mandated) © 2015 CAQH. All rights reserved. • ACA Section 1104 mandates that all HIPAA covered entities comply with healthcare operating rules; additional guidance on HIPAA covered entity designations may be found HERE • HIPAA Administrative Simplification standards, requirements and implementation specifications apply to2: – Healthcare Providers: Any person or organization who furnishes, bills, or is paid for healthcare in the normal course of business3 • • 1 Examples include but are not limited to: Doctors, Clinics, Psychologists, Dentists, Chiropractors, Nursing Homes, and Pharmacies Covered ONLY if they transmit any health information electronically (directly or through a business associate) in connection with a transaction for which HHS has adopted a standard2 – Health Plans (including Self-insured and Group Health Plans, Long-term Care, Medicare, Medicaid, etc.) – Healthcare Clearinghouses Covered Entity Charts Administrative Simplification: 45 CFR §§ 160.102, HIPAA Administrative Simplification: 45 CFR § 160.103 2 HIPAA 3 6 © 2015 CAQH. All rights reserved. 2 ACA § 1104 Requires HHS to adopt and update operating rules for HIPAA transactions HHS CAQH CORE Sept. 2012: HHS designates CAQH CORE as the operating rule authoring entity for remaining transactions: 2013-2015: CAQH CORE develops and submits the set of Phase IV CAQH CORE Operating Rules approved by the CORE Participants via the CORE Voting Process to HHS/NCVHS as appropriate 1. Health claims or equivalent encounter information 2. Health plan enrollment/disenrollment 3. Health plan premium payments 4. Referral certification and authorization 5. Health claims attachments* * NOTE: HHS has not adopted a standard for health claims attachments or indicated what standard(s) it might consider for the transaction, and an effective date for these operating rules is not included in the ACA. Thus, the immediate focus of CAQH CORE will not include attachments. 7 © 2015 CAQH. All rights reserved. • Health claims or equivalent encounter information • Referral, certification, and authorization • *Enrollment and disenrollment in a health plan • *Health plan premium payments ================================= • Health claims attachments Goal: Have draft rules in early 2015 and begin formal CORE voting process • • Rules are infrastructure-focused (vs. content) and apply across transactions; built on existing rules. *These two transactions are being used in the Insurance Exchanges (HIXs) – • 8 CORE rules will apply to HIPAA covered entities only, yet use in HIX environment is informative. Research conducted on behalf of CAQH CORE by a Firm with Federal and State HIX experience summarized lessons learned in HIX market. Report was shared with the Benefit Enrollment & Maintenance/Premium Payment Subgroup, which verified findings regarding HIX and traditional HIPAA use of these transactions. Attachment standard(s) not adopted; CAQH CORE has developed potential vision – Held a series of CORE-only calls to review and verify CORE findings on current volumes, attachment formats, future plans and related ROI, knowledge levels, etc. – Research indicates industry neutral standards, e.g., PDF, may have significant benefit and that industry education will be key given current level of knowledge of key standards such as HL7 C-CDA – Pursuing pilot to inform rule writing, which will be started when standard(s) adopted by CMS © 2015 CAQH. All rights reserved. TBD – Rule Development for Attachments (Pilot being done separate from CORE) Q1 Q2 Q3 Q4 • CORE Technical and Rules Workgroups Meet • Draft Phase IV Rules Open for Full CORE Membership Vote Draft • Phase IV Rules Open for CORE Board Vote • CAQH CORE will create Tools and Resources to aid in the understanding and implementation of the Phase IV Operating Rules • Full set of FINAL Phase IV Operating Rules Released Rule development for Attachments TBD (pilot conducted separately from CORE) NOTE: CAQH CORE as authoring entity must update NCVHS on CORE rules; as advisor to HHS Secretary, NCHVS will make a recommendation to HHS regarding the CORE rules and actions they suggest CORE take. 11 © 2015 CAQH. All rights reserved. 3 Development of Phase IV CAQH CORE Operating Rules Estimated 2015 Timeline The CAQH CORE Board’s normal voting procedures would apply. If the Board does not approve any proposed Operating Rule, the Board will issue a memorandum setting forth the reasons it did not approve the proposed Operating Rule and will ask the CORE Subgroups and Work Groups to revisit the proposed Operating Rule Work Groups require a quorum of 60% of all participants that are voting members. Simple majority vote (greater than 50%) by this quorum is needed to approve a rule. Technical/Rules Work Group Review & Balloting Q1 2015 CORE Board Q2 2015 Q3 2015 Full CAQH CORE Voting Member Ballot Full CORE Voting Membership vote requires for a quorum that 60% of all Full CORE Voting Member organizations (i.e., CORE Participants that create, transmit, or use transactions) vote on the proposed rule at this stage. With a quorum, a 66.67% approval vote is needed to approve a rule. NOTE: CAQH CORE as authoring entity must update NCVHS on CORE rules; as advisor to HHS Secretary, NCHVS will make a recommendation to HHS regarding the CORE rules and actions they suggest CORE take. 10 © 2015 CAQH. All rights reserved. Draft Phase IV CAQH CORE Operating Rules are publically available for download from the CAQH CORE website by clicking HERE. Draft Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule v4.0.0 • Draft Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and Response (278) Infrastructure Rule v4.0.0 • Draft Phase IV CAQH CORE 454 Benefit Enrollment & Maintenance (834) Infrastructure Rule v4.0.0 * • Draft Phase IV CAQH CORE 456 Payroll Deducted and Other Group Premium Payment for Insurance Products (820) Infrastructure Rule v4.0.0 * • Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 • • • • XML Schema Specification (normative) Web Services Definition Language (WSDL) Specification (normative) Draft Phase IV CAQH CORE Required Processing Mode and Payload Type Tables v4.0.0 *Draft Rules will be posted to the CAQH CORE website once the draft rules are approved for Rules Work Group review. 21 © 2015 CAQH. All rights reserved. Infrastructure Requirement Prior Authorization1 Claims1 Enrollment2 Premium Payment2 Batch OR Real Time Required Batch Required; Real Time Optional Batch Required; Real Time Optional Batch Required; Real Time Optional Batch Processing Mode Response Time If Batch Offered X X X Batch Acknowledgements If Batch Offered X X X Real Time Processing Mode Response Time If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered Real Time Acknowledgements Processing Mode If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered Safe Harbor Connectivity and Security3 X X X X System Availability X X X X Companion Guide Template X X X X N/A Include guidance for COB in companion guide Timeframe requirements to process data after successful receipt and verification of transaction Timeframe requirements to process data after successful receipt and verification of transaction Other X = Required 1. Draft Rules approved by Claims/Prior Authorization Subgroup under Rules Work Group review. 2: Draft Rules being straw polled by Benefit Enrollment & Maintenance/Premium Payment Subgroup. 3: Draft Connectivity Rule approved by Connectivity & Security Subgroup under Technical Work Group review. 12 © 2015 CAQH. All rights reserved. 4 Batch Processing Mode Response Time requirements specify the overall length of elapsed time from when a transaction is sent to a health plan and when the acknowledgement(s) or response to the transaction is available for pick up (retrieval) by the provider/health plan purchaser (sender). 1 Sent by 9 pm ET on a business day Health Plan Sender 2 Available by 7 am ET within second or third business day depending on transaction Applicability of Requirements 13 Infrastructure X12N v5010 X12N v5010 X12N v5010 X12N v5010 Requirement 837 278 834 820 Batch Processing Mode Response Time X X X X © 2015 CAQH. All rights reserved. 837/278/834/820 Sender Health Plan 999/277CA • Requirements for 837 - • W hen any Functional Group of an ASC X12N v5010 837 Claim Transaction Set is accepted, accepted with errors, or rejected, an entity must return a ASC X12C v5010 999. A health plan must acknowledge each claim received in any institutional, professional, or dental ASC X12N v5010 837 Transaction Set using the ASC X12N v5010 277CA unless previous processing resulted in a rejection of the Interchange or a Transaction Set in a Functional Group. Requirements for 278, 834 & 820 - W hen any Functional Group of these transaction is accepted, accepted with errors, or rejected, an entity must return an ASC X12C v5010 999. Applicability of Requirements Infrastructure Requirement Batch Acknowledgement 14 X12N v5010 837 X12N v5010 278 X X12N v5010 834 X X12N v5010 820 X X © 2015 CAQH. All rights reserved. Real Time Processing Mode Response Time requirements specify the overall length of elapsed time from when a provider/health plan purchaser (sender) sends a transaction to a health plan and the related response transaction is received by the sender. 20 Seconds Round Trip Max Response Time Sender Health Plan Applicability of Requirements Infrastructure Requirement Real Time Processing Mode Response Time X12N v5010 X12N v5010 X12N v5010 X12N v5010 837 278 834 820 If Real Time Used If Real Time Used If Real Time Used If Real Time Used 15 5 837/278/834/820 Sender Health Plan 999/277CA • Requirements for 837 (NOTE: RTA is not in scope for this draft Phase IV rule) - W hen any Functional Group of an ASC X12N v5010 837 Claim Transaction Set is accepted, accepted with errors, or rejected, an entity must return a ASC X12C v5010 999. A health plan must acknowledge each claim received in any institutional, professional, or dental ASC X12N v5010 837 Transaction Set using the ASC X12N v5010 277CA unless previous processing resulted in a rejection of the Interchange or a Transaction Set in a Functional Group. • Requirements for 278 • Requirements for 834 & 820 - - A receiver must return one response to an ASC X12N v5010 278 request: either an ASC X12C v5010 999 rejection or an ASC X12N v5010 278 response. A health plan must return an ASC X12C v5010 999 for any Functional Group of any ASC X12N v5010 transaction to indicate if the Functional Group is accepted, accepted with errors, or rejected. Applicability of Requirements Infrastructure X12N v5010 Requirement 837 278 834 820 Real Time Acknowledgement If Real Time Used X12N v5010 If Real Time Used X12N v5010 If Real Time Used X12N v5010 If Real Time Used 16 The System Availability requirements establish the amount of time a system must be available to process the specified transactions: Minimum of 86 percent system availability (per calendar week) Publish regularly scheduled downtime Provide one week advance notice on nonroutine downtime Provide information within one hour of emergency downtime Applicability of Requirements 20 Infrastructure X12N X12N X12N X12N Requirement v5010 837 v5010 278 v5010 834 v5010 820 System Availability X X X X © 2015 CAQH. All rights reserved. When an entity publishes a Companion Guide the CAQH CORE Companion Guide requirements establish the format and flow of Companion Guides. CORE v5010 Master Companion Guide Template Companion Guides Format & Flow Specified in Template • • • • • Introduction Getting Started Testing with the Payer Connectivity with Payer/Communications Contact Information • • • • • Control Segment/Envelopes Payer Specific Business Rules and Limitations Acknowledgements and/or Reports Trading Partner Agreements Transaction Specific Information For Companion Guides addressing the X12N v5010 837 Claim, entities are also required to include their requirements for coordination of benefits in specified Sections. Applicability of Requirements 18 Infrastructure Requirement X12N v5010 837 X12N v5010 278 X12N v5010 834 X12N v5010 820 Companion Guide X X X X © 2015 CAQH. All rights reserved. 6 It is anticipated that the regulatory process for adoption of the ACA-mandated Phase IV Operating Rules will be similar to the process for EFT & ERA and include opportunities for public comment. That process includes the following key steps: =Public Comment Opportunity Step Five: Step One: Once comments have been reviewed, HHS will publish a Final Rule that may or may not include adjustments based on the public comments CAQH CORE will update NCVHS on the status of the draft Phase IV Operating Rules at its next 2015 meeting 19 Step Two: Step Three: As appropriate, NCVHS will make an adoption recommendation to the HHS Secretary or ask for CORE to return to NCVHS later in 2015 before NCVHS makes its recommendation HHS will publish a regulation in the Federal Register once it receives a final set of rules from CORE and determines what is appropriate for Federal mandate © 2015 CAQH. All rights reserved. Step Four: A public comment period (60 days or more) will follow publication of the regulation whereby entities can submit comments on the regulation to CMS/HHS NOTE: In February 2015, CAQH will release the 2014 Index report. This report provides an aggregated analysis of the adoption and cost of eight claims transactions based on blinded claims data from nearly half of the country’s commercially insured.. CAQH CORE will help organizations understand and implement the Phase IV Operating Rules by developing a suite of tools and resources similar to those available for Phases I, II and III, such as: Analysis and Planning Guide Informational Webinars with downloadable recording and presentations 20 Dedicated Phase IV Webpage If you have any suggestions for Tools and/or Resources that will help you better understand or more easily implement the rules, please let us know at [email protected] FAQs Staff Experts are always available to answer your questions © 2015 CAQH. All rights reserved. Non-CORE Participants should continue to follow the Phase IV CAQH CORE Rule Development Process by: ◦ Checking the Phase IV CAQH CORE Operating Rule Website for updates and links to the Draft Phase IV CAQH CORE Operating Rules ◦ Attending upcoming CAQH CORE Education Sessions on the Phase IV Rules ◦ Following the regulatory process via HHS including the upcoming NCVHS HIPAA covered entities, e.g. health plans, providers, and clearing houses along with their business associates should also begin to familiarize themselves with the draft rule requirements and schedule preliminary, internal discussions to begin implementation planning © 2015 CAQH. All rights reserved. 7 • CAQH CORE Work Groups and Subgroups – Open to all individuals from CORE Participating entities – Each Subgroup/Work Group is chaired by two or more experts representing different stakeholders from CORE Participating entities who facilitate meetings – CAQH CORE staff support CORE activities, Work Groups, and Subgroups • • • CAQH CORE retains consultants to provide technical and other expertise CAQH CORE meeting frequency (during rule-writing or if key maintenance needed) – Rule-development Subgroup meetings are held via conference call weekly or bi-weekly; calls are typically 1.5 hours – Work Group conference calls are held bi-weekly or monthly – Call schedule is developed and communicated by CAQH CORE and Co-Chairs Meeting materials – Are available on the CAQH CORE Member Calendar – CAQH CORE staff/consultants assist Co-chairs with drafting meeting materials and ensure they are made available on the calendar 24 hours prior to the call – Meeting summaries are created after each call/meeting and approved by the Work Group/Subgroup 22 © 2015 CAQH. All rights reserved. Draft Phase IV CAQH CORE 470 Connectivity Rule Version 4.0.0 Rule Scope, Requirements & Relationship to Prior Connectivity Rules 23 © 2015 CAQH. All rights reserved. Conduct Environmental Scan (Market and Business Analysis) 1 Agree on Phase IV Business and Technical Evaluation Criteria 2 Identify Phase IV Rule Opportunities using Market and Business Analysis 3 Evaluate Candidate Rule Opportunities using Business and Technical Evaluation Criteria 4 Prioritize Rule Opportunities using Criteria, and Identify Set of Phase IV High Priority Rule Opportunities 5 Agree to Rule Option(s) to Address High Priority Rule Opportunities 6 7 Agree to Technical Rule Requirements for Selected Rule Option(s) © 2015 CAQH. All rights reserved. 8 Legislative and National Initiatives Movement towards increased adoption of Standards Market Movement towards increased Connectivity, new Business Needs Legislative Movement Market Movement HIPAA covered entities are implementing Market movement from paper based to Internet based electronic transactions. CAQH CORE Connectivity for ACA Section 1104 compliance Efficiencies of scale gained as more Meaningful Use Stage 2 has transport trading partners support electronic transactions requirements for Providers/EHR systems such as use of ONC DIRECT Improved efficiency as more HITECH Act added security breach electronic transactions become standards based reporting requirements and increased penalties for security violations. Interoperability Initiatives Technical Impact of Direct Connectivity CAQH CORE eHealth Exchange (formerly NwHIN) ONC S&I esMD has adopted CAQH CORE Need to support standards in new areas such as attachments Need for reliability and security in support of the new business transactions Connectivity Trust policy frameworks developed by DirectTrust, white papers by ONC S&I esMD Author of Record Government PKI Infrastructures Federal Bridge is built and operational supporting cross-certification of trusted PKIs © 2015 CAQH. All rights reserved. Many prominent public and private industry initiatives in healthcare connectivity and security were reviewed to identify industry trends and opportunities for CORE Connectivity Rule Improvement ONC S&I Electronic Submission of Medical Documents (esMD) and Electronic Determination of Coverage (eDoc) HealtheWay eHealth Exchange (formerly NwHIN Exchange) (included in Meaningful Use-2) Industry Initiatives ONC DIRECT (included in Meaningful Use-2) NCPDP Connectivity Guide (Retail Pharmacy based on CORE Connectivity) Health Level 7 (HL7) DirectTrust (See Appendix Slide 19 for Details on Initiatives) PHASE IV Connectivity Subgroup Review Processes Key Industry Trends (See Appendix Slide 26 for a full list of Trends) Use of SOAP Envelope Standard for Healthcare Data Exchange Use of X.509 Digital Certificates Increased Emphasis on Security Use of SSLv3 with movement to TLS 1.1 and Higher © 2015 CAQH. All rights reserved. Improved Security (Authentication, Transport) Better Interoperability (Single Message Envelope Standard) Processing Mode Definitions for 3rd Set of ACA Mandated Transactions Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 Easier Maintenance using Companion Payload and Processing Mode Document Key Features Improved Support for Business Workflows (Push / Pull) Improved Rule Language Clarity based on Implementer Feedback © 2015 CAQH. All rights reserved. 9 Key Decisions Made By Phase IV CAQH CORE Connectivity & Security Subgroup © 2015 CAQH. All rights reserved. 27 Background: The Phase II CAQH CORE 270 Connectivity Rule v2.2.0 has two message envelope standards (SOAP+WSDL and HTTP+MIME). This rule identified convergence to single envelope standard as a vision for future phases of connectivity based on greater industry experience with implementing the two message envelope standards specified in the rule. Subgroup Decision and Rationale: After extensive analysis CAQH CORE determined that converging on the use of SOAP+WSDL as the single message envelope standard in this Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 includes these benefits • relatively simple rule change • simplicity of rule requirements • reduction of implementation cost and complexity by having fewer options • XML based and therefore extensible • good tooling support for SOAP in most platforms • alignment with clinical initiatives and industry trends • significant ROI through improvements in interoperability • limits variations in use of SOAP for real time and batch processing modes by requiring the use of MTOM for both processing modes © 2015 CAQH. All rights reserved. Background: The Phase II CAQH CORE 270 Connectivity Rule defined message interactions for conducting Real Time and Batch interactions. Phase IV preserves the Real Time and Batch interactions while adding some message interactions that could be used as generic building blocks for supporting current or future transactions. The following interactions were added or fully specified in this phase: Generic Push Client Batch Payload -Transactions Client submits or “pushes” a Batch Payload to a Server, then Retrieves The associated acknowledgment or error Generic Pull Client Subgroup Decision and Rationale: • • Server Batch Payload – Transactions Client retrieves or “pulls” a Batch Payload from a Server, then submits The associated acknowledgment or error Server ASC X12N 820 and ASC X12 834 transactions need both Generic Push and Generic Pull Batch Interactions to be supported by the rule. Provides flexibility to support common industry message interaction patterns for ASC X12N 820 and ASC X12 834, where: • Health Plan Sponsor (Client), can “Push” a Batch to a Health Plan (Server) • Health Plan (Client) can “Pull” a Batch from Health Plan Sponsor (Server) © 2015 CAQH. All rights reserved. 10 Technical Requirements of Draft Phase IV CAQH CORE 470 Connectivity Rule Version 4.0.0 and the Relationship to Requirements of Previous Phases Connectivity Rule Area CORE Phase I Connectivity Rule Requirements CORE Phase II & III Connectivity Rule Requirements CORE Phase IV Connectivity Rule Requirements Network Internet Internet Internet Transport HTTP HTTP HTTP Transport Security SSL SSL 3.0 with optional use of TLS 1.x SSL 3.0, and optionally TLS 1.1 or higher. TLS 1.1 or higher can be used in lieu of SSL 3.0. Submitter (Originating System or Client) Authentication Name/Password Name/Password or X.509 Certificate (subject to conformance requirements) X.509 Certificate based authentication over SSL/TLS Envelope and Attachment Standards Unspecified SOAP 1.2 + W SDL and MTOM (for Batch) or HTTP+MIME (subject to conformance requirements) SOAP 1.2 + WSDL and MTOM (for both Real Time and Batch) Envelope Metadata Unspecified Metadata defined (Field names, values) (e.g., PayloadType, Processing Mode, Sender ID, Receiver ID) • Metadata defined (Field names, values) (e.g., PayloadType, Processing Mode, Sender ID, Receiver ID) • FIPS 140-2 compliant implementations can use SHA-2 for checksum. Message Interactions/ Routing Real-time Batch (Optional if used) Real-time Batch (Optional if used) • Batch and Real-Time processing requirements defined for each transaction • Push and Pull messaging support for 820/834 Payload level Security Unspecified Considered and deferred Considered and deferred Acknowledgements, Errors Specified Enhanced Phase I, with additional specificity on error codes Errors updated based on Implementer feedback Basic Conformance Requirements for Client and Server Roles Minimally specified Well specified Considered and deferred to Infrastructure Rules Response Time Specified Maintained Phase I requirements Companion Implementation Specified Enhanced Phase I, with additional specificity 3G4uidCeORE Technical Workgroup Call CAQH CORE Connectivity Rule Versions Graphical View and Comparison Phase II CORE Connectivity Rule Maintained Phase I requirements d.Enhanced Phase I, with additional specificity Draft Phase IV CORE Connectivity Rule to be adopted under the ACA Mandated under the ACA Payload(s) X12 Administrative Transactions NCPDP, HL7 V2.x or V3 Messages Other X12 Administrative Transactions NCPDP, HL7 V2.x or V3 Messages Other Submitter (Client) Authentication Username/Password (WS-Security Token) X.509 Digital Certificate X.509 Digital Certificate over SSL/TLS Processing Mode/Message Interactions Required: Real Time Optional: Batch Required: Batch, Generic Push and Pull Optional: Real Time Message Envelope Metadata CORE Specified Message Envelope Metadata CORE Specified Message Envelope Metadata Message Envelope(s) MIME Multipart SOAP+WSDL (MTOM for Batch only) Communications Channel Security Secure Sockets Layer - (SSLv3 required with optional use of TLS1.0 or higher) Transport HTTP over TCP Network Public Internet SOAP+WSDL (MTOM for both Real Time and Batch) Secure Sockets Layer (SSLv3.0 with optional use of TLS1.1 or higher. Entities needing higher security can use TLS1.1 in lieu of SSLv3.0) HTTP over TCP Public Internet =Revised from the previous phase Background: • Phase II CAQH CORE 270 Connectivity Rule v2.2.0 had the Payload Type Table and Processing Modes defined as part of the rule document. • Addressing set of ACA-mandated transactions identified for third set of operating rule development could benefit from expanding the Payload Type enumeration. • Change management of the Payload Types Table and Processing Modes would benefit from de-coupling these from the rule version. Subgroup Decision and Rationale: • Use a companion document for the PayloadType table and Processing Modes and update for the new ACA mandated transactions or other content/transactions. • The PayloadType table can be updated without updating the entire CORE Connectivity Rule, making it easier to maintain the rule to address future business needs. This option increases flexibility by making it easier to add more PayloadType values. • Attachment standard(s) has/have not been selected for Federal mandate at this point; preliminary work in this area may need to be revisited after attachment standards are selected. © 2015 CAQH. All rights reserved. 11 Background: Addressing set of ACA-mandated transactions identified for third set of operating rule development requires defining the processing mode requirements for each transaction Subgroup Decision and Rationale: Subgroup considered several processing mode requirements, and after extensive discussion and straw polling, subgroup decided on the Processing Mode requirements listed below: Transaction Processing Modes ASC X12N v5010 837I Batch Mode Required, Real Time Optional ASC X12N v5010 837P Batch Mode Required, Real Time Optional ASC X12N v5010 837D Batch Mode Required, Real Time Optional ASC X12N v5010 278 Request and Response Either Real Time or Batch Mode; both modes may be implemented, at least one mode must be implemented ASC X12N v5010 820 Batch Mode Required, Real Time Optional ASC X12N v5010 834 Batch Mode Required, Real Time Optional © 2015 CAQH. All rights reserved. Scope: Draft Phase IV CAQH CORE 470 Connectivity Rule What the Rule Applies To – • • • • Layered View Message Envelope is outside the Message Payload (content), and inside the Transport Protocol envelope Transport Protocol Envelope corresponds to OSI Model Layer 3 and 4 Message Envelope corresponds to OSI Model Layers 5 and 6 Message Payload (content) corresponds to OSI Model Layer 7 Communications (T ransport) Protocol Netw ork Message E nvelope + Message Metadata = Public Internet (TCP /IP) - established in CAQ H CORE Phase I Connectivity Message Payload (Content) = HTTP over SSL 3.0, or optionally TLS 1.1 or higher. (HIPAA covered entities that wish to use stronger security or m ust also be FIPS 140-2 com pliant m ay im plem ent TLS 1.1 or higher in lieu of SSL 3.0) = Message Envelope & Message Metadata (SOAP + MTOM) – CA QH CORE Phase IV Connectivity = HIPAA Adm inistrative Transactions (X12) HL7 Clinical Messages Zipped Files Personal Health Record Other Content © 2015 CAQH. All rights reserved. Rule Applicability to Transactions Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 Claims Prior Authorizations Benefit Enrollments Premium Payments HIPAA Covered Entity HIPAA Covered Entity Phase II CAQH CORE 270 Connectivity Rule v2.2.0 Eligibility Inquiry Claim Status Inquiry Electronic Remittance Advice Phase I/II/III Rules Mandated under ACA © 2015 CAQH. All rights reserved. 12 Connectivity Safe Harbor HTTP 1.1 Health Plan Other key rule requirements: • • • • • • • • • • 37 Rule applicable to HIPAA mandated ASC X12N v5010 837, 278, 834, 820 transactions Transport Layer Security (SSL minimum/TLS instead of SSL when required by HIPAA covered entity’s security policy) Single Message Envelope Standard (SOAP v1.2) Single Submitter Authentication Method (X.509) Normative Message Envelope Metadata Standard CORE-specified Schema (.xsd) Standard CORE-specified Web Services Description Language (.wsdl) Transaction Specific Required/Optional Processing Modes Standard Payload Type Identifiers for each transaction for each processing mode Process for maintaining Processing Mode and Payload Type Identifiers Provider Enables trading partners to use different communications and security methods than what is specified in rule: • HIPAA covered entities must support CORE rule requirements for real time and batch processing modes (if that mode is required by the CORE rules) • Can offer other communications and security methods • Does not require trading partners to deimplement any existing connectivity methods not compliant with CORE rule © 2015 CAQH. All rights reserved. © 2015 CAQH. All rights reserved. Appendix CAQH CORE Operating Rules Industry Adoption Update © 2015 CAQH. All rights reserved. 13 At present, the industry overall is facing several challenges that are critical to consider: Health Plan Certification HIPAA-covered health plans must be in compliance with HIPAA-mandated transaction standards and operating rules by December 31, 2015 ICD-10 Delay ICD-10 has been delayed to October 1, 2015, which may pose a challenge to entities working to meet the previous deadline Lagging Implementation CAQH CORE polling data indicates that a minority of entities are still in the process of implementing the CAQH CORE EFT & ERA Operating Rules The current burden on the industry demonstrates the limited bandwidth entities have to develop and implement operating rules for remaining transactions. This emphasizes the feasibility of implementing infrastructure rules. 40 © 2015 CAQH. All rights reserved. • Voluntary CORE Certification – Phase I and II Eligibility and Claims Status CORE Certifications – Phase III EFT & ERA CORE Certifications • • • Polling data from Q1, Q2 and Q3 2014 education sessions shows steady EFT & ERA Operating Rule implementation progress across all stakeholder group • Polling and registration information is always BLINDED and is taken in aggregate to protect personal information of registrants/attendees NACHA EFT transaction volume – 41 A number of entities have completed Phase III CORE certifications with many more in the pipeline. Recent examples include Centene Corp, Excellus Blue Cross Blue Shield, Horizon Blue Cross Blue Shield of New Jersey, AultCare, Ventanex, etc. CORE education session polling on industry status – • Recent certifications include Meditech, Florida Medicaid, MaineCare, Oklahoma Office of Management and Enterprise Services, etc. Unlike for other HIPAA transactions, use of the ACH network for CCD+ enables tracking of this transaction (if entities use trace number) © 2015 CAQH. All rights reserved. • These numbers reflect EFT payments that are clearly identified as healthcare payments by the use of the specific identifier “HCCLAIMPMT”* in the CCD+ transaction • There has been steady growth in the use of CCD+ for healthcare EFT payments with roughly a 200% net increase in CCD+ volume from the beginning of Q4 2013 to the beginning of Q4 2014 Source: NACHA 2 *NOTE: Some providers are receiving EFT payments without the HCCLAIMPMT identifiers in the CCD+. To identify an EFT payment as a healthcare EFT, originators of the transaction (i.e. Health Plans/Payers) need to include the HCCLAIMPMT identifier in the CCD+Addendum **November saw a drop in the total healthcare EFT volumes due to a limited number of processing days (18). The average number of credit transactions per day, however, was actually higher than October. 10 © 2015 CAQH. All rights reserved. 14 Pre-registration questions were used to identify implementation status and challenges • All stakeholder types have made great strides in their implementation with more than 50% of all stakeholder types having either completed implementation or are well on their way towards completion o Health Plans have had the biggest increase in completed implementations between Q1 and Q3 (+17%). o PMS/Vendors have increased in all categories from W ell Underway through Completion between Q1 and Q3 (+23% total). o Clearinghouses still are highest in the key categories of W ell Underway, Nearing Completion or Complete (89% for Q3) • Resource constraint remains the main challenge to implementation Not Started N=925 Planning & Analysis N=607 Well Underway N=326 29% 36% +17 % 15% -6% 12% 19% +2 % 21% 26% Q3 2014 Health Plan/TPA/Payer Nearing Completion N=165 48% 51% +2 % 16% +13 % 31% 25% 13% 15% 12% 34% 21% Q1 2014 Complete N=122 +1 % 18% 13% Q1 2014 38% +9 % 53% 18% N=201 Q3 2014 PMS/Vendor Q1 2014 +5 % 17% 4% 21% 3% 12% 8% Q3 2014 Clearinghouse 11 © 2015 CAQH. All rights reserved. 15
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