HIPAA Collaborative of Wisconsin 2015 Spring Conference Oconomowoc, Wisconsin April 10, 2015 © 2015 CAQH. All rights reserved. CAQH CORE Operating Rules – Key Requirements • Phase I and II* • Phase III* • Phase IV – currently in draft Implementation Framework, Challenges & Issues • Audience Open Discussion *ACA Mandated © 2015 CAQH. All rights reserved. 2 ACA Mandated and HHS Health Plan Certification Scope and Updates © 2015 CAQH. All rights reserved. 1 Scope: ACA-Mandated CAQH CORE Operating Rules and Certification Compliance Dates HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules • 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 CAQH CORE in Process of drafting rules 4 • Eligibility for health plan • Claim status transactions Compliance in Effect as of January 1, 2014 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 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. CAQH CORE Eligibility & Claim Status Operating Rules were initially developed in two phases; for ease of use the rules are presented here by transaction addressed and rule type rather than by phase • Rules Addressing the ASC X12N v5010 270/271 Eligibility & Benefits Transactions – Data Content Related Rules • • • – • CAQH CORE 154 & 260: Eligibility & Benefits Data Content Rules CAQH CORE 258: Normalizing Patient Last Name Rule for Eligibility CAQH CORE 259: AAA Error Code Rule for Eligibility Infrastructure Related Rules • • • CAQH CORE 150: Batch Acknowledgements Rule for Eligibility (999)* CAQH CORE 151: Real Time Acknowledgements Rule for Eligibility (999)* CAQH CORE 152: Companion Guide Rule • • • • CAQH CORE 155: Batch Response Time Rule for Eligibility CAQH CORE 156: Real Time Response Rule for Eligibility CAQH CORE 157: System Availability Rule CAQH CORE 153 & CAQH CORE 270: Connectivity Rules Rules Addressing the ASC X12N v5010 276/277 Claim Status Transactions • CAQH CORE 250: 276/277 Claim Status Infrastructure Rule* *NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.” 5 © 2015 CAQH. All rights reserved. ACA-Mandated CAQH CORE Eligibility and Claim Status Operating Rules: Requirements Scope Current healthcare operating rules build upon a range of standards – healthcare specific (e.g., ASC X12) and industry neutral (e.g., OASIS, W3C, ACH CCD+) Rules Infrastructure Data Content Eligibility & Benefits Eligibility, Benefits & Claims Status High-Level CAQH CORE Key Requirements Respond to generic and explicit inquiries for a defined set of 50+ high volume services with: • Health plan name and coverage dates • Static financials (co-pay, co-insurance, base deductibles) • Benefit-specific and base deductible for individual and family • In/Out of network variances • Remaining deductible amounts • Enhanced Patient Identification and Error Reporting requirements • Companion Guide – common flow/format • System Availability service levels – minimum 86% availability per calendar week • Real-time and batch turnaround times (e.g., 20 seconds or less for real time and next day for batch) • Connectivity via Internet and aligned with NHIN direction, e.g., supports plug and play method (SOAP and digital certificates and clinical/administrative alignment) • Acknowledgements (transactional)* *NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH C ORE rules we are adopting herein.” A PowerPoint overview of the Phase I & II CAQH CORE Rules is available HERE; the complete rule sets are available HERE. 6 © 2015 CAQH. All rights reserved. 2 ACA-Mandated CAQH CORE Eligibility & Claim Status Operating Rules: Phase I & II Rules in Action Pre- or At-time of Service Post-Claim Submission Eligibility Inquiry (270) Claim Status Request (276) Health Plan Provider Provider Eligibility Response (271) Content Enhanced Patient Identification Health Plan Claim Status Response (277) Content Uniform Error Reporting Content Robust Eligibility Data, e.g., Patient Financials (YTD deductibles, Co-pay, Indicates where a CAQH CORE Phase I or II Rule comes into play Co-insurance, in/out network variances) E.G., SOAP+ WSDL Infrastructure Rules Standard Companion Guides 10 Real-time and Batch Response Times Internet Connectivity and Security Increased System Availability © 2015 CAQH. All rights reserved. ACA-Mandated CAQH CORE EFT & ERA Operating Rules: Requirements Scope Infrastructure Data Content Rule High-Level Requirements • Identifies a minimum set of four CAQH CORE-defined Business Scenarios with a maximum set of CAQH CORE-required code combinations that can be applied to convey details of the claim denial or payment to the provider EFT Enrollment Data Rule • • • Identifies a maximum set of standard data elements for EFT enrollment Outlines a flow and format for paper and electronic collection of the data elements Requires health plan to offer electronic EFT enrollment ERA Enrollment Data Rule • Similar to EFT Enrollment Data Rule EFT & ERA Reassociation (CCD+/835) Rule • Addresses provider receipt of the CAQH CORE-required Minimum ACH CCD+ Data Elements required for re-association Addresses elapsed time between the sending of the v5010 835 and the CCD+ transactions Requirements for resolving late/missing EFT and ERA transactions Recognition of the role of NACHA Operating Rules for financial institutions Uniform Use of CARCs and RARCs (835) Rule Claim Adjustment Reason Code (CARC) Remittance Advice Remark Code (RARC) • • • • Health Care Claim Payment/Advice (835) Infrastructure Rule • • • Specifies use of the CAQH CORE Master Companion Guide Template for the flow and format of such guides Requires entities to support the Phase II CAQH CORE Connectivity Rule. Includes batch Acknowledgement requirements* Defines a dual-delivery (paper/electronic) to facilitate provider transition to electronic remits * CMS-0028-IFC excludes requirements pertaining to acknowledgements. The complete Rule Set is available HERE. 8 © 2015 CAQH. All rights reserved. Connectivity Dual Delivery Batch Acknowledgements1 • Entities must be able to support the CAQH CORE Connectivity Rule Version 2.2.0 for transmission of the v5010 835 • A health plan that currently issues proprietary paper claim remittance advices is required to continue to offer such paper remittance advices to each provider during that provider’s initial implementation testing of the v5010 X12 835 for a minimum of 31 calendar days from the initiation of implementation • Upon mutual agreement between the provider and the health plan, the timeframe for delivery of the proprietary paper claim remittance advices may be extended • See §4.3 for more detail • A receiver of a v5010 X12 835 transaction must return: - A v5010 X12 999 Implementation Acknowledgement for each Functional Group of v5010 X12 835 transactions to indicate that the Functional Group was either accepted, accepted with errors or rejected, and - To specify for each included v5010 X12 835 transaction set that the transaction set was either accepted, accepted with errors or rejected • A health plan must be able to accept and process a v5010 X12 999 for a Functional Group of v5010 X12 835 transactions • When a Functional Group of v5010 X12 835 transactions is either accepted with errors or rejected, the v5010 X12 999 Implementation Acknowledgement must report each error detected to the most specific level of detail supported by the v5010 X12 999 Implementation Acknowledgement Companion Guide • Specifies use of the CAQH CORE Master Companion Guide Template for the flow and format of such guides for the v5010 835 1 NOTE: CMS-0028-IFC does not adopt the Batch Acknowledgement Requirements in Section 4.2 of CAQH CORE Rule 350, as the Secretary has not yet adopted HIPAA standards for acknowledgements. © 2015 CAQH. All rights reserved. 3 Indicates where a CAQH CORE EFT/ERA Rule comes into play Pre- Payment: Provider Enrollment Claims Payment Process Content: Uniform Use of CARCs & RARCs Rule Infrastructure Rules Health Plan EFT Enrollment Data Rule Claims Processing ERA Enrollment Data Rule Provider Billing & Collections Payment/Advice (835) Content: EFT & ERA Reassociation (CCD+/835) Rule Content: Provider first enrolls in EFT and ERA with Health Plan(s) and works with bank to ensure receipt of the CORErequired Minimum ACH CCD+ Data Elements for reassociation Bank Treasury Bank Treasury Electronic Funds Transfer (CCD+/TRN) Stage 1: Initiate EFT Infrastructure Rules Real-time and Batch Response Times Standard Companion Guides Increased System Availability Internet Connectivity and Security 10 © 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 ballot. 2: Draft Rules approved by Benefit Enrollment & Maintenance/Premium Payment Subgroup under Rules Work Group review. 3: Draft Connectivity Rule approved by Connectivity & Security Subgroup under Technical Work Group ballot. 11 © 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. 4 CAQH CORE Connectivity Rule Versions Graphical View and Comparison Phase II CORE Connectivity Rule 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 MIME Multipart SOAP+WSDL (MTOM for Batch only) Message Envelope(s) 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 Implementation Framework & Steps A Real World Approach by a State Medicaid © 2015 CAQH. All rights reserved. 14 Planning • Phase I and II planning kicked off September 24, 2012 • Phase III planning kicked off May 7, 2013 • Identified and engaged appropriate resources across teams – EDI, Eligibility, Claims, Financial, Banking, Reference, Enrollment • Coordinated with other priority projects © 2015 CAQH. All rights reserved. 5 Planning Gap Analysis • Subject matter experts completed gap analysis worksheets from CAQH Analysis & Planning Guide • Attended CAQH education events and submitted questions • Reviewed FAQs on CAQH website • Emailed CAQH our questions • Attended workgroup sessions and discussed with other states 16 © 2015 CAQH. All rights reserved. Planning Gap Analysis Design • Developed solution based on gap analysis and rule requirements • Chose to implement generic response option for Safe Harbor connection (Rule 270 § 4.3.1.3 Batch Response Pickup) – Allows trading partners to view a list of available files for retrieval 17 © 2015 CAQH. All rights reserved. Planning Gap Analysis Design Implementation • Project schedule was developed – Phases I and II were implemented on August 22, 2013 (11 months) – Phase III was implemented on December 27, 2013 (8 months) • Provider outreach activities began two months ahead of golive date, whenever possible © 2015 CAQH. All rights reserved. 18 6 All Phase III Operating Rules Challenge: Difficulty understanding specific rule requirements, or determining if a requirement was applicable to our business Solution: • Attended CAQH education events and submitted questions • Reviewed FAQs on CAQH website • Emailed CAQH our questions • Attended workgroup sessions and discussed with other states © 2015 CAQH. All rights reserved. 19 All Phase III Operating Rules Challenge: Difficulty understanding specific rule requirements, or determining if a requirement was applicable to our business Solution: • Attended CAQH education events and submitted questions • Reviewed FAQs on CAQH website • Emailed CAQH our questions • Attended workgroup sessions and discussed with other states © 2015 CAQH. All rights reserved. 20 Rule 360: Uniform Use of CARCs and RARCs Challenge: Difficulty determining if an existing code combination was in one of the CORE-defined Business Scenarios Solution: • Generated listing of current and proposed code mapping • Mapping changes were reviewed and approved by subject matter experts across various teams © 2015 CAQH. All rights reserved. 21 7 Rule 360: Uniform Use of CARCs and RARCs Challenge: Difficulty determining if an existing code combination was in one of the CORE-defined Business Scenarios Solution: • Generated listing of current and proposed code mapping • Mapping changes were reviewed and approved by subject matter experts across various teams © 2015 CAQH. All rights reserved. 22 Rule 370: EFT & ERA Reassociation Challenge: Coordination with our financial institution during testing and implementation Solution: • Engaged banking operations to act as a liaison between development team and financial institution • Completed end-to-end testing prior to implementation © 2015 CAQH. All rights reserved. 23 Rule 370: EFT & ERA Reassociation Challenge: Coordination with our financial institution during testing and implementation Solution: • Engaged banking operations to act as a liaison between development team and financial institution • Completed end-to-end testing prior to implementation © 2015 CAQH. All rights reserved. 24 8 Rule 380/382: EFT & ERA Enrollment Data Challenge: “Account Number Linkage to Provider Identifier” • Provider preference for grouping claim payments on an EFT or ERA; however, we do not use either option (NPI or Tax ID) Solution: • Provided both options during enrollment and store information • Did not change how claim payments are grouped on EFT and ERA transactions 25 © 2015 CAQH. All rights reserved. Rule 380/382: EFT & ERA Enrollment Data Challenge: “Account Number Linkage to Provider Identifier” • Provider preference for grouping claim payments on an EFT or ERA; however, we do not use either option (NPI or Tax ID) Solution: • Provided both options during enrollment and store information • Did not change how claim payments are grouped on EFT and ERA transactions 26 © 2015 CAQH. All rights reserved. Communication is Critical! Education is key – Get executive buy-in early – Just Getting Started Fully understand your business processes and the mandates Among payers and their trading partners, penalties for noncompliance help make this a priority Engage Trading Partners Early and Often – It’s important to contact your trading partners early in the implementation process, clarify roles and responsibilities, and coordinate a timeline for completion Analysis and Planning Systems Design Determine Scope of Project – Identify the affected departments, processes, systems and trading partners Treat like any major business project – – Identify staff resources, e.g. Realistic timelines, e.g. don’t underestimate the complexity of the systems and adjustments involved Systems Implementation TEST, TEST, TEST! – Test your compliance with your trading partners and with your clients Integration & Testing Get Involved with CAQH CORE Deployment/ Maintenance – Give input on rule maintenance, and stay up-to-date on implementation developments © 2015 CAQH. All rights reserved. 9 Appendix Additional Resources 28 © 2015 CAQH. All rights reserved. CAQH CORE Free Resources Master the CAQH CORE Operating Rules If your implementation efforts/your vendor(s) are just getting started access CAQH CORE Analysis & Planning Guides for Eligibility & Claim Status Operating Rules and EFT & ERA Operating Rules If your implementation/your vendor(s) is fully underway or nearing completion: Education Sessions: CAQH CORE holds frequent sessions with partners such as ASC X12, NACHA, Medicaid workgroups, etc. FAQs: CAQH CORE has a list of FAQs to address typical questions regarding the operating rules; updated FAQs being loaded to website on a regular basis Request Process: Contact technical experts as needed at [email protected] If your implementation/your vendor(s) is complete or nearly complete, and/or you are testing readiness with trading partners: Consider Voluntary CORE Certification: Phase I & Phase II – If testing your implementation of operating rules with trading partners, then, take 5 minutes and tell others about your readiness at CORE Operating Rule Readiness: • Voluntary CORE Certification provides verification that your IT systems or product operates in accordance with the federally mandated operating rules © 2015 CAQH. All rights reserved. • To benefit from new EFT and ERA mandates, ensure your provider organization has requested the transactions from its health plans and EFT & ERA Operating Rule implementation status • To maximize the benefits available through the CAQH CORE Reassociation Rule, providers must request delivery of the necessary data for EFT and ERA reassociation • To help facilitate this request, CAQH CORE developed the Sample Provider EFT Request Letter • To help facilitate this request, CAQH CORE developed the Sample Provider EFT Reassociation Data Request Letter • Providers can use this sample letter as template email or talking points with health plan contacts to request enrollment in EFT/ERA and benefits of operating rules • Providers can use this sample letter as template email or talking points with bank contacts to request delivery of the reassociation data • The tool includes background on the benefits EFT, key steps for providers, an actual letter template, and glossary of key terms • The tool includes background on the benefits of the letter, key steps for providers, an actual letter template, and glossary of key terms © 2015 CAQH. All rights reserved. 30 10 • HIPAA Covered Entity Charts – Use the HIPAA Covered Entity Charts to determine whether your organization is a HIPAA covered entity • CMS FAQs – Frequently asked questions about the ACA, operating rules, and other topics • Affordable Care Act Updates – Updates on operating rules; compliance, certification, and penalties; and engagement with standards and operating rules – CMS eHealth University – What Administrative Simplification Does For You – This fact sheet explains the basics behind how Administrative Simplification will help improve health care efficiency and lower costs – Introduction to Administrative Simplification – This guide gives an overview of Administrative Simplification initiatives and their purposes – Introduction to Administrative Simplification: Operating Rules – A short video with information on Administrative Simplification operating rules • Additional Questions – Questions regarding HIPAA and ACA compliance can be addressed to: • Geanelle Herring, Health Insurance Specialist, [email protected] 44 © 2015 CAQH. All rights reserved. • ACH CCD+: The CCD+ format is a NACHA ACH corporate payment format used in Electronic Funds Transfers (EFT) with a single 80 character addendum record capability. The addendum record is used by the originator to provide additional information to the payment recipient about to the payment. • ACH Network: A batch processing, store-and-forward system, governed by The NACHA Operating Rules, which provide for the interbank clearing of electronic payments for participating depository financial institutions. • Accredited Standards Committee (ASC) X12: Develops and maintains the X12 electronic data interchange (EDI) standards along with XML schemas which drive business processes globally. The membership of ASC X12 includes technologists and business process experts, encompassing health care, insurance, transportation, finance, government, supply chain and other industries. • Business Associate: A person or organization that performs a function or activity on behalf of, or provides services to, a Covered Entity that involves Individually Identifiable Health Information • CMS Office of E-Health Standards and Services (OESS): The U.S. Department of Health and Human Services’ (HHS) component that enforces compliance with HIPAA transaction and code set standards, including operating rules, identifiers and other standards required under HIPAA by the Affordable Care Act. • Electronic Data Interchange (EDI): The computer-to-computer exchange of business data in standard formats. In EDI, information is organized according to a specified format set by both parties, allowing a "hands-off" computer transaction that requires no human intervention or rekeying on either end. All information contained in an EDI transaction set is, for the most part, the same as on a conventionally printed document. © 2015 CAQH. All rights reserved. • Healthcare Provider: Any person or Organization who furnishes, bills, or is paid for healthcare in the normal course of business. • Healthcare Transaction: The transmission of information between two parties to carry out financial or administrative activities related to health care • HIPAA-Covered Entities: Health Plans, Healthcare Clearinghouses, and Healthcare Providers who transmit any health information in electronic form in connection with certain transactions • NACHA (The Electronic Payments Association): A non-profit rule-making entity that manages the development, administration, and governance of the ACH Network, the backbone for the electronic movement of money and data. • Operating Rules: the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications • Transmission Media: Electronic form of transmitting information including, for example, the internet (wide-open), extranet (using internet technology to link a business with information accessible only to collaborating parties), leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media, because the information being exchanged did not exist in electronic form before the transmission. © 2015 CAQH. All rights reserved. 11
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