ACA Mandated and HHS Health Plan Certification Scope and Updates

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Stanley Cummings
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1 HIPAA Collaborative of Wisconsin 2015 Spring Conference Oconomowoc, Wisconsin April 10, 2015 ACA Mandate Scope and Updates Third Set of Draft CAQH CORE Operating Rules Draft Phase IV Connectivity Rule Overview Q&A ACA Mandated and HHS Health Plan Certification Scope and Updates 1

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 About CAQH CORE CAQH CORE is an industry-wide

The more than 140 CORE Participants represent all key stakeholders including providers, health plans, vendors, clearinghouses, government agencies, Medicaid agencies, banks and standard development

2 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 About CAQH CORE 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. Vision An industry-wide facilitator of a trusted, simple and sustainable healthcare data exchange that evolves and aligns with market needs. Mission 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. 4 Compliance in Effect as of January 1, 2013 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) HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules 5 Proposes an adjusted Implementation: December 2015 Implement by January 1, 2016 (Draft Rules available in Late 2014) Proposes health plans certify via either CORE certification or HIPAA Credential; applies to Eligibility/ Claim Status/EFT/ERA operating rules and underlying standards 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) 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 to 2 : Healthcare Providers: Any person or organization who furnishes, bills, or is paid for healthcare in the normal course of business 3 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 standard 2 Health Plans (including Self-insured and Group Health Plans, Long-term Care, Medicare, Medicaid, etc.) Healthcare Clearinghouses 1 Covered Entity Charts 2 HIPAA Administrative Simplification: 45 CFR , 3 HIPAA Administrative Simplification: 45 CFR

3 ACA 1104 Requires HHS to adopt and update operating rules for HIPAA transactions HHS Sept. 2012: HHS designates CAQH CORE as the operating rule authoring entity for remaining transactions: 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* CAQH CORE : 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 * 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 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) 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 8 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 3

4 Development of Phase IV CAQH CORE Operating Rules Estimated 2015 Timeline 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. 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 Technical/Rules Work Group Review & Balloting Full CAQH CORE Voting Member Ballot CORE Board Q Q Q 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 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 Infrastructure Requirement Processing Mode Batch Processing Mode Response Time Batch Acknowledgements Real Time Processing Mode Response Time Prior Premium Authorization 1 Claims1 Enrollment2 Payment 2 Batch OR Real Time Required Batch Required; Real Time Optional Batch Required; Real Time Optional Batch Required; Real Time Optional If Batch Offered X X X If Batch Offered X X X If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered Real Time Acknowledgements If Real Time Offered If Real Time Offered If Real Time Offered If Real Time Offered Safe Harbor Connectivity and Security 3 X X X X System Availability X X X X Companion Guide Template X X X X Other 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 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 4

5 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 Sender Health Plan 2 Available by 7 am ET within second or third business day depending on transaction Applicability of Requirements Infrastructure X12N v5010 X12N v5010 X12N v5010 X12N v5010 Requirement Batch Processing Mode X X X X Response Time 13 Sender 837/278/834/ /277CA Health Plan Requirements for W hen any Functional Group of an ASC X12N v Claim Transaction Set is accepted, accepted with errors, or rejected, an entity must return a ASC X12C v A health plan must acknowledge each claim received in any institutional, professional, or dental ASC X12N v Transaction Set using the ASC X12N v CA unless previous processing resulted in a rejection of the Interchange or a Transaction Set in a Functional Group. Requirements for 278, 834 & W hen any Functional Group of these transaction is accepted, accepted with errors, or rejected, an entity must return an ASC X12C v Applicability of Requirements X12N v5010 X12N v5010 Infrastructure X12N v5010 X12N v5010 Requirement Batch Acknowledgement X X X X 14 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. Sender 20 Seconds Round Trip Max Response Time Health Plan Applicability of Requirements Infrastructure X12N v5010 X12N v5010 X12N v5010 X12N v5010 Requirement Real Time If Real Time If Real Time If Real Time If Real Time Processing Mode Used Used Used Used Response Time 15 5

6 Sender 837/278/834/ /277CA Health Plan Requirements for 837 (NOTE: RTA is not in scope for this draft Phase IV rule) - W hen any Functional Group of an ASC X12N v Claim Transaction Set is accepted, accepted with errors, or rejected, an entity must return a ASC X12C v A health plan must acknowledge each claim received in any institutional, professional, or dental ASC X12N v Transaction Set using the ASC X12N v CA unless previous processing resulted in a rejection of the Interchange or a Transaction Set in a Functional Group. Requirements for A receiver must return one response to an ASC X12N v request: either an ASC X12C v rejection or an ASC X12N v response. Requirements for 834 & A health plan must return an ASC X12C v 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 X12N v5010 X12N v5010 X12N v5010 Requirement Real Time If Real Time If Real Time If Real Time If Real Time Acknowledgement Used Used Used 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) Provide one week advance notice on nonroutine downtime Publish regularly scheduled downtime Provide information within one hour of emergency downtime Applicability of Requirements X12N X12N X12N Infrastructure X12N Requirement v v v v System X X X X Availability 20 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 Control Segment/Envelopes Getting Started Payer Specific Business Rules and Limitations Testing with the Payer Acknowledgements and/or Reports Connectivity with Payer/Communications Trading Partner Agreements Contact Information Transaction Specific Information For Companion Guides addressing the X12N v Claim, entities are also required to include their requirements for coordination of benefits in specified Sections. Infrastructure Requirement Companion Guide Applicability of Requirements X12N X12N X12N X12N v v v v X X X X 18 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.

Five: Once comments have been reviewed, HHS will publish a Final Rule that may or may not include adjustments based on the public comments 19 Step Two: As appropriate, NCVHS will make an adoption

in the Federal Register once (60 days or more) will follow it receives a final set of rules publication of the regulation from CORE and determines whereby entities can submit what is appropriate for

7 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 One: CAQH CORE will update NCVHS on the status of the draft Phase IV Operating Rules at its next 2015 meeting Step Five: Once comments have been reviewed, HHS will publish a Final Rule that may or may not include adjustments based on the public comments 19 Step Two: 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 Step Three: Step Four: HHS will publish a regulation A public comment period in the Federal Register once (60 days or more) will follow it receives a final set of rules publication of the regulation from CORE and determines whereby entities can submit what is appropriate for comments on the regulation Federal mandate 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 Dedicated Phase IV Webpage FAQs Informational Webinars with downloadable recording and presentations 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 CORE@caqh.org Staff Experts are always available to answer your questions 20 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 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

8 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 Draft Phase IV CAQH CORE 470 Connectivity Rule Version Rule Scope, Requirements & Relationship to Prior Connectivity Rules 23 1 Conduct Environmental Scan (Market and Business Analysis) 2 Agree on Phase IV Business and Technical Evaluation Criteria 3 Identify Phase IV Rule Opportunities using Market and Business Analysis 4 Evaluate Candidate Rule Opportunities using Business and Technical Evaluation Criteria 5 Prioritize Rule Opportunities using Criteria, and Identify Set of Phase IV High Priority Rule Opportunities 6 Agree to Rule Option(s) to Address High Priority Rule Opportunities 7 Agree to Technical Rule Requirements for Selected Rule Option(s) 8

9 Legislative and National Initiatives Movement towards increased adoption of Standards Legislative Movement HIPAA covered entities are implementing CAQH CORE Connectivity for ACA Section 1104 compliance Meaningful Use Stage 2 has transport requirements for Providers/EHR systems such as use of ONC DIRECT HITECH Act added security breach reporting requirements and increased penalties for security violations. Market Movement towards increased Connectivity, new Business Needs Market Movement Market movement from paper based to Internet based electronic transactions. Efficiencies of scale gained as more trading partners support electronic transactions Improved efficiency as more electronic transactions become standards based Interoperability Initiatives CAQH CORE ehealth Exchange (formerly NwHIN) ONC S&I esmd has adopted CAQH CORE Connectivity Trust policy frameworks developed by DirectTrust, white papers by ONC S&I esmd Author of Record Technical Impact of Direct Connectivity Need to support standards in new areas such as attachments Need for reliability and security in support of the new business transactions Government PKI Infrastructures Federal Bridge is built and operational supporting cross-certification of trusted PKIs 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 HealtheWay - ehealth Exchange (formerly NwHIN Exchange) (included in Meaningful Use-2) ONC S&I Electronic Submission of Medical Documents (esmd) and Electronic Determination of Coverage (edoc) NCPDP Connectivity Guide (Retail Pharmacy based on CORE Connectivity) Health Level 7 (HL7) Industry Initiatives (See Appendix Slide 19 for Details on Initiatives) ONC DIRECT (included in DirectTrust Meaningful Use-2) 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 Better Interoperability (Single Message Envelope Standard) Improved Security (Authentication, Transport) Processing Mode Definitions for 3 rd Set of ACA Mandated Transactions Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 Key Features Improved Support for Business Workflows (Push / Pull) Easier Maintenance using Companion Payload and Processing Mode Document Improved Rule Language Clarity based on Implementer Feedback 9

Key Decisions Made By Phase IV CAQH CORE Connectivity & Security Subgroup 27 Background: The Phase II CAQH CORE 270 Connectivity Rule v2.2.0 has two message envelope standards (SOAP+WSDL and HTTP+MIME).

10 Key Decisions Made By Phase IV CAQH CORE Connectivity & Security Subgroup 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 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 Server Generic Pull Batch Payload Transactions Client Client retrieves or pulls a Batch Payload from a Server, then submits Subgroup Decision and Rationale: The associated acknowledgment or error ASC X12N 820 and ASC X 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) Server 10

11 Technical Requirements of Draft Phase IV CAQH CORE 470 Connectivity Rule Version and the Relationship to Requirements of Previous Phases Connectivity Rule Area CORE Phase I Connectivity Rule Requirements CORE Phase II & III Connectivity Rule Requirements Network Internet Internet Internet Transport HTTP HTTP HTTP CORE Phase IV Connectivity Rule Requirements 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 WSDL and MTOM (for Batch) or HTTP+MIME (subject to conformance requirements) SOAP 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 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 Maintained Phase I requirements Companion Implementation 3G4uidCeORE Technical Workgroup Call Specified Enhanced Phase I, with additional specificity d. Enhanced Phase I, with additional specificity CAQH CORE Connectivity Rule Versions Graphical View and Comparison Phase II CORE Connectivity Rule Mandated under the ACA Draft Phase IV CORE Connectivity Rule to be adopted 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) SOAP+WSDL (MTOM for both Real Time and Batch) Communications Channel Security Secure Sockets Layer - (SSLv3 required with optional use of TLS1.0 or higher) 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) Transport HTTP over TCP HTTP over TCP Network Public Internet 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. 11

12 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 ASC X12N v I ASC X12N v P ASC X12N v D ASC X12N v Request and Response ASC X12N v ASC X12N v Processing Modes Batch Mode Required, Real Time Optional Batch Mode Required, Real Time Optional Batch Mode Required, Real Time Optional Either Real Time or Batch Mode; both modes may be implemented, at least one mode must be implemented Batch Mode Required, Real Time Optional Batch Mode Required, Real Time Optional 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 (Transport) Protocol Network Message Envelope + Message Metadata Message Payload (Content) = Public Internet (TCP/IP) - established in CAQH CORE Phase I Connectivity = HTTP over SSL 3.0, or optionally TLS 1.1 or higher. (HIPAA covered entities that wish to use stronger security or must also be FIPS compliant may implement TLS 1.1 or higher in lieu of SSL 3.0) = Message Envelope & Message Metadata (SOAP + MTOM) CAQH CORE Phase IV Connectivity = HIPAA Administrative Transactions (X12) HL7 Clinical Messages Zipped Files Personal Health Record Other Content 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 12

13 Connectivity Safe Harbor HTTP 1.1 Other key rule requirements: Health Plan Provider Rule applicable to HIPAA mandated ASC X12N v , 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 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 37 Appendix CAQH CORE Operating Rules Industry Adoption Update 13

14 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 Voluntary CORE Certification Phase I and II Eligibility and Claims Status CORE Certifications Recent certifications include Meditech, Florida Medicaid, MaineCare, Oklahoma Office of Management and Enterprise Services, etc. Phase III EFT & ERA CORE Certifications 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 Polling data from Q1, Q2 and Q 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 Unlike for other HIPAA transactions, use of the ACH network for CCD+ enables tracking of this transaction (if entities use trace number) 41 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 Q to the beginning of Q Source: NACHA *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

15 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 Planning & Analysis Well Underway Nearing Completion Complete N=925 N=607 N=326 N=201 N=122 N=165 29% 36% +9 38% 48% 53% % 51% % % % +1 18% % 16% -6% 18% 12% +5 12% 17% 19% +13 % % 31% +2 25% 21% - 21% % 34% 4% 26% 3% - 13% 13% 15% - 21% 8% 12% Q Q Q Q Q Q Health Plan/TPA/Payer PMS/Vendor Clearinghouse 11 15

Analysis & Planning Guide for Implementing the Phase IV CAQH CORE Operating Rules

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