February HIPAA 5010 Systems Impacts

Transcription

1 February 2010 HIPAA 5010 Systems Impacts

2 Current Scenario The Center for Medicaid and Medicare Services (CMS) requires the health plans to adopt modifications to the HIPAA electronic transaction standards published on Jan 16, 2009, for exchanging healthcare specific administrative and financial transactions. The current version adopted by the industry is ASC X12 Version 4010A1 for healthcare transactions and NCPDP Version 5.1 for pharmacy transactions. Health plans are now required to implement recently published HIPAA version 5010 and NCPDP D.0 standards by Jan 1, These new versions address a variety of unmet business needs and concerns that were not thoroughly analyzed during earlier versions. The implementation of HIPAA 5010/ D.0 would require health plans to bring substantial changes to its business policies, processes and systems that submit claims, receive remittances, exchange claim status, maintain membership, pricing details etc. HCL with its wide IT service portfolio uses edittm 5.1 solution to help the health plans transition to HIPAA 5010 standards. HIPAA 5010 Changes Summary There are more than 3500 individual changes that have to be implemented across the enterprise. These changes are complex and require health plans to upgrade their systems, processes, databases etc. Figure 1.1 demonstrates the volume of changes in HIPAA version 5010 transactions. Changes in version 5010 can be categorized into four categories: Front matter, Technical improvements, Structural and Data content changes. HCL has studied the 5010 implementation guides in detail and evaluated the changes across different transactions. Based upon the complexity associated with each change, HCL has analyzed its impact on different processes and applications across health plan. Table below describes the summary of changes between HIPAA 4010A1 and 5010 for each transaction type. Figure 1.1 Figure 1.2

3 There are many modifications to the physical components of the transaction which would lead to system enhancements, database changes and report changes. Impact Changes System Impact Application changes Field length expansion Data Impact Other Impact Database changes Interfaces Report changes Data conversion Business logic change Change in screen inputs New elements Business policies and processes Addition/deletion of elements value changes Field length expansion User interface changes Modification to EDI interfaces External applications interfaces New fields Report layout Dual standard support during transition HIPAA 5010 Systems Impact 5010 changes have impact on policies, processes and applications across a health plan. HCL s understanding of the health plan s IT landscape facilitates the identification of impact of 5010/ D.0. Impact analysis output details out the modifications required for seamless implementation of changes in systems, processes and applications. This ensures a smooth transition to HIPAA 5010/D.0 with minimal disruption. Business Functions & Entities HCL has done the initial assessment for each HIPAA transaction type for identifying the impacted business areas and entities across health plans. In the table below, represents the impacted business areas and entities across all transaction types and represents the non impacted areas and entities. Business Areas X12 Transactions Electronic data interchange Electronic Medical Records Authorization Management Electronic Commerce Federal Regulations Management Data Analytics Member Benefits NCQA Accrediation Claims adjudication Claims payable Providers network Management Provider Reimbursement Recovery and settlement Fee Schedule Utilization Management Case Management

4 Impacted Entities Case Management X12 Transactions Accounting Member Services Accounts receivable Member Billing Affiliation Provider Payer Admission Employer Member Address Group Practice Service Claim Information Contract Authorization Receipt Information Invoice Info Claim Check Procedure Drug Detail Application components Table below describes the impact of HIPAA 5010 changes on health plans application components. This is described using 270 transaction as an example, this is sent from providers to health plans to enquire about the health care benefits and eligibility associated with a subscriber or dependent. HCL has similar analysis done for all the other HIPAA 5010 mandated transactions. HIPAA 5010 Changes Segment added Segment deleted Change in Field Length Identifier Description Segment Description HI Subscriber Healthcare Diagnosis AMT Subscriber Spend Down Total Billed Amount HI Dependent Healthcare Diagnosis PER Info receiver contact info BHT03 NM103 Last or Beginning of hierarchical transaction Information Source NM104 First Information Source Database Changes Business Logic External Interface UI Reports Data Migration / Update

5 HIPAA 5010 Changes Identifier Description Segment Description Database Changes Business Logic External Interface UI Reports Data Migration / Update Change in Field Length Value Added/ Deleted NM103 Last or Info Receiver NM104 First Info Receiver REF02 TRN02 TRN03 NM103 Last or Info Receiver Addn identification Info receiver provider info Subscriber Trace Number Subscriber Trace Number Subscriber NM104 First Subscriber REF02 REF01 TRN02 TRN04 NM104 Last or Subscriber add identification Provider Information Subscriber add info Dependent Trace Number Dependent Trace Number Dependent NM105 First Dependent REF02 REF02 ISA11 ISA12 GS01 GS08 BHT02 BHT06 Interchange Control standards ID Interchange Control Version No Functional Identifier Version/ Release/ Industry identifier code Transaction Set Purpose Transaction Type Dependent Add Provider Information Dependent Additional Info Interchange Control Interchange Control Functional Group Functional Group Beginning of hierarchical transaction Beginning of hierarchical transaction

6 HIPAA 5010 Changes Identifier Description Segment Description Database Changes Business Logic External Interface UI Reports Data Migration / Update Value Added/ Deleted Added PRV02 NM108 REF01 Info receiver provider info Subscriber Subscriber add identification PRV01 Provider Provider Information DTP01 EQ01 EQ03 EQ04 III01 Date Time Service Type Coverage Level Insurance Type list Subscriber Date Benefit add enquiry Info III02 Industry Benefit add enquiry Info DTP01 DTP03 REF01 Date/Time Date Time Period Benefit Date Benefit Date Dependent Add PRV01 Provider Provider Information PRV02 DTP01 EQ EQ03 EQ04 III01 DTP01 DTP03 Date/Time Service Type Coverage Level Insurance Type List Date Time Date Time Period Provider Information Dependent Date Benefit add enquiry Info Benefit Date Benefit Date III01 Industry Benefit add enquiry Info

7 HIPAA 5010 Changes Identifier Description Segment Description Database Changes Business Logic External Interface UI Reports Data Migration / Update Added Usage Change ST03 NM112 NM112 N407 NM112 N407 DMG10 Implementation Convention Ref Last or Last or Country Subdivision Last or Country Subdivision List Transaction Set Information Source Info Receiver Info receiver city/ state/ zip code Subscriber Subscriber city/ state/ zip code Subscriber Demographic Information DMG11 Industry Subscriber Demographic Information EQ02-08 EQ05 NM112 N407 DMG10 Product/ Service ID Composite Diagnosis Pointer Last or Country Subdivision List Dependent Dependent State/ City/Zip Dependant Demographic Information DMG11 Industry Dependant Demographic Information EQ02-8 EQ05 NM103 NM103 N402 Product/ Service ID Composite Diagnosis Pointer Last or Last or State or province code Information Source Info Receiver Info receiver city/ state/ zip code N403 Postal Info receiver city/ state/ zip code

8 HIPAA 5010 Changes Identifier Description Segment Description Database Changes Business Logic External Interface UI Reports Data Migration / Update Usage Change Change PRV02 Info receiver provider info Info receiver provider info N401 City Subscriber receiver city/ state/ zip code PRV02 EQ04 AMT02 Insurance Type Monetary Amount Provider Information Provider Information Subscriber spend down amount N401 City Dependent City/ State/ Zip code PRV01 Provider Provider Information PRV02 EQ03 EQ04 ISA11 Coverage Level Insurance Type Interchange Control standards ID Provider Information Provider Information Interchange Control BHT04 Date Beginning of hierarchical transaction INS INS06 Subscriber Relationship Medicare Plan Subscriber Relationship Subscriber Relationship HCL has a complete knowledge base of impacted policies, processes, applications and the impacted entities in a health plan. This knowledge will enable faster understanding of the existing landscape and transition to desired TO-BE state meeting the federated timelines.

9 Why HCL? HCL edit TM 5.1 solution covers methodologies for Enterprise discovery, Impact Analysis, System enhancements, Testing and Transition Support for HIPAA 5010 and NCPDP D.0 Solution architects and consultants experienced in X12N 4010A1/5010 and NCPDP D.0 standards Existing knowledge base for impacted policies, business processes, work flows, people, entities and fields Testing toolkit READY; compliance and trading partners Center of Excellence for leading B2B and EDI platforms Subject matter experts in Payer and Provider business processes Dedicated HIPAA security and privacy (GRC) consulting practice HCL has a HIPAA security and privacy consulting practice Certified consultants in HIPAA from HIPAA Academy, USA Certified HIPAA Professional Footprint across major healthcare Clients including: One of the largest Blue Cross Conglomerates, Regional Health Plan, Leading Diagnostic Company, Leading HMO Authors Narender Dureja is Practice Director Healthcare at HCL Technologies Ltd. He is a certified professional in hospital information management systems. Narender had been involved in crafting solutions for different industry verticals for the last 20 years. He currently drives the HIPAA 5010 solution at HCL. Mahima Bahri is Senior Consultant Healthcare at HCL Technologies Ltd. She is a Certified HIPAA Professional. She has worked on multiple areas within healthcare domain and is currently engaged in building HIPAA 5010 solution for HCL.

10 10 ABOUT HCL HCL Technologies HCL Technologies is a leading global IT services company, working with clients in the areas that impact and redefine the core of their businesses. Since its inception into the global landscape after its IPO in 1999, HCL focuses on transformational outsourcing, underlined by innovation and value creation, and offers integrated portfolio of services including software-led IT solutions, remote infrastructure management, engineering and R&D services and BPO. HCL leverages its extensive global offshore infrastructure and network of offices in 26 countries to provide holistic, multiservice delivery in key industry verticals including Financial Services, Manufacturing, Consumer Services, Public Services and Healthcare. HCL takes pride in its philosophy of Employee First which empowers our 55,688 transformers to create a real value for the customers. HCL Technologies, along with its subsidiaries, had consolidated revenues of US$ 2.5 billion (Rs. 11,833 crores), as on 31st December 2009 (on LTM basis). For more information, please visit About HCL Enterprise HCL is a $5 billion leading global Technology and IT Enterprise that comprises two companies listed in India - HCL Technologies & HCL Infosystems. Founded in 1976, HCL is one of India s original IT garage start-ups, a pioneer of modern computing, and a global transformational enterprise today. Its range of offerings spans Product Engineering, Custom & Package Applications, BPO, IT Infrastructure Services, IT Hardware, Systems Integration, and distribution of ICT products across a wide range of focused industry verticals. The HCL team comprises over 60,000 professionals of diverse nationalities, who operate from 26 countries including over 500 points of presence in India. HCL has global partnerships with several leading Fortune 1000 firms, including leading IT and Technology firms. For more information, please visit