WG45 External Standards Assessment, Harmonization and Implementation Guidance Meeting Minutes November 7, 2013

Transcription

1 WG45 External Standards Assessment, Harmonization and Implementation Guidance Meeting Minutes November 7, 2013 Thursday, November 7, 2013 I. Welcome and Call to Order A meeting of WG45 External Standards Assessment, Harmonization and Implementation Guidance was held in Portland, Oregon on November 7, Co-Chairs Beth Serraino of Omnicare and Mary Lynam of Argus Health Systems were present to conduct the meeting. Co-Chair Sheila Miller of DataRx was unable to attend. Beth called the meeting to order at 8:42 a.m. II. Reading of the Antitrust Statement Beth Serraino read the NCPDP Antitrust Statement to the attendees. III. Housekeeping Items and Announcements Beth Serraino introduced herself and fellow co-chair Mary. She welcomed first time attendees to the work group and asked that they introduce themselves. There were seven. She also recognized and thanked the NCPDP Buddies that were present. Beth reminded participants to sign the attendee roster and make any needed corrections to the preprinted information. She also reminded the group that cell phones and pagers should be set to vibrate or off and that individuals wishing to make comments wait for the microphone so they can be heard by all. The following announcements were made: 1. Badges must be worn at all times. 2. An update for the membership from the Board of Trustees will take place on Friday, November 8, 2013 from 7:30 8:00 a.m. (30 minutes) in Fort Worth Ballrooms Information is available for: a. August Work Group meeting schedule (sent via ; also available online) b. Work Group Attendee Roster (sent via ) c. Task Group Listing d. Calendar of Events (available online) IV. Agenda Review Beth Serraino reviewed the proposed agenda as modified by the Co-Chairs. A modification was made to remove the Strategic Planning Committee reportable as it will be given as part of the Board of Trustees presentation on Friday. She asked if there were any additional modifications there were none. A motion was moved and seconded to approve the agenda as modified. The motion carried unanimously. V. Minutes Review Beth Serraino asked the participants if they had reviewed the WG45 minutes from August 2013 and if so, whether there were any corrections or additions. There were none. A motion was made and seconded to approve the minutes. The motion carried unanimously. VI. Old Business Beth Serraino initiated Old Business by introducing the Task Group leads as they gave their reports. WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 1 November 2013

2 A. Task Group Updates Task group sign-ups are now done through the NCPDP Collaborative Workspace. If you would like information on signing up for a task group or the Collaborative Workspace, please see Sue Thompson or her at sthompson@ncpdp.org. 1. Document Revision Task Group Mary Lynam of Argus Heath Systems Task Group lead provided the report. Task Group Recap Report Date: 10/11/2013 Task Group Name: Document Revisions Task Group Date Task Group Formed: Task Group Leader(s): Mary Lynam Argus Health Systems Parent Work Group: WG45 Goal of Task Group: This task group is revising the ASC X mapping documents and the Pharmacy Reference Guide to reflect Version Task Group Meeting Dates (This Period): 9/19/2013, 10/3/2013, 10/10/2013 Business Cases Reviewed: CARC Committee agenda - - 9/19 CARC/RARC update 10/3 835 reporting non-financial D.0 paid claims whereas Payer/Provider have contractual agreement 10/3, 10/10 Task Group Decisions (bullets or text): Made recommendation to NCPDP representatives at CARC committee meeting on 9/20/2013 CARC/RARC update for November WG mtg Payer/Provider non-financial reporting for November WG mt.. Task Group Reportables (bullets or text): Update WG of recommendations made no action necessary Vote CARC/RARC document Vote Payer/Provider non-financial reporting Task Group Questions to the Work Group (bullets or text): None Task Group Action Items/Next Steps (bullets or text): Make changes as necessary to documentation. Mary provided an overview the Document Revision Task Group Functions. The task group reviews changes to the Claim Adjustment Reason Codes (CARC) and makes recommendations for the use and/or applicability to pharmacy. It then aligns the pharmacy recommended use for D. with the ASC X12 guidance and CORE Operating Rules for use on the ASC X The CARCs are maintained by the Code Committee that meets on Sunday before the ASC X12 meeting and are published by Washington Publishing see under Code Lists. These codes explain the difference between billed amount and actual paid amount. To further explain the difference the CARCs may be used in conjunction with Remittance Advice Remark Codes (RARC) which for pharmacy equate to the NCPDP Reject Codes. The task group reviewed the changes made to the CARCs at the September Code Committee meeting and found that no modification to the NCPDP mapping was needed. The new codes (highlighted) were reviewed with the work group. No changes were requested. It was moved and seconded to approve the updated mapping document. The motion carried. The task group also maintains a payment guidance document NCPDP Pharmacy Reference Guide to the ASC X12/ØØ5Ø1ØX221A1 Health Care Claim Payment/Advice (835) to assist the pharmacy sector in consistent, compliant use of the transaction in reporting claim payment. The task group looks at scenarios in pharmacy and determines the optimal way to report them on the ASC X The guidance provides examples from the claim through to the remittance advice. The guidance documents WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 2 November 2013

3 can be found on the NCPDP WG45 webpage under the Resources Tab by selecting Guidance Documents at Login to the website is required to access the examples document located on the WG45 page. At the August WG, the ASC X Adjustments Task Group was disbanded. An outstanding scenario, the reporting of paid claims with no financial transaction was deemed not to be an adjustment and referred to the Document Revision Task Group. The task group created the NCPDP Claim Paid but No Financial Transaction Reporting on the ASC X12/005010x221A1 Health Care Claim Payment/Advice (835) which was presented to the work group for approval. It was noted that the task group determined that these transactions should not be combined with a remittance associated with a check. A motion was made and seconded to approve the recommendation document as presented. The motion carried /835 FAQ Task Group Leann Lewis of PDX, Task Group lead reported that the 834/835 FAQ Task Group did not meet since no new questions were received this quarter. The FAQ document is available on the NCPDP website. If you have questions about the use of the ASC X or 835 please them to sthompson@ncpdp.org. 3. DSMO Change Request Task Group Beth Serraino of Omnicare, Task Group lead reported the task group received no new DSMO requests during the last quarter and did not meet. 4. Provider Enrollment Task Group Nancy Bridgman with Omnicare, Task Group lead reported pending response from ASC X12 to a change request (CR1267) regarding addition or modified definition of fields to the ASC X Provider Enrollment transaction to meet identified pharmacy data requirements. To date there has been no response or request for clarification. There was also a question regarding a need for additional taxonomy codes primarily to breakout long term care into sub categories. These have not been submitted as definitions have not been provided by the requestors. The task group will have a call to determine if there is a need for additional taxonomy codes for long term care and identify a source for the business reason and definition. Other work groups can then be engaged if needed. 5. Central Pay for ASC X v5010 Task Group Mary Lynam gave the report on behalf of Patty Benjamin with HD Smith, Task Group lead who was unable to attend. The task group met once during the last quarter to review two questions arising from the presentation of the revised Business Model approved in August. The questions and discussion were as follows: 1. How do you report adjustments done outside the claim activity, e.g. the pharmacy wants to write off an amount due or wants to send the payer a check? This question is not limited to consolidated scenario and is outside the task group scope. How should the 835 report payment by check? Report per the normal TR3 guidance: Claim Overpayment Recovery If the provider chooses to remit the balance due within the specified time period with a check, the health plan will acknowledge the receipt of the check using the PLB segment of the next 835. In order to maintain a balanced 835, this is accomplished using offsetting adjustments in the PLB. PLB03-1 codes 72 (Authorized Return) and WO (Overpayment Recovery) are used. Example: A health plan sends a letter to a provider (number 1234) identifying an overpayment of $37.50.The FCN of the document is Before the specified deadline, the provider remits the overpayment to the health plan, identifying the FCN with the payment. A PLB segment in the next 835 would report this payment. PLB*1234* *WO:56473*37.5*72:56473*-37.5~ WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 3 November 2013

4 If the provider chooses (or is instructed) to not remit the overpayment by the established deadline, then the health plan will recoup the funds in an appropriate 835. This is accomplished using the PLB segment, and NOT the reversal and correction procedure. Reversal and correction is not appropriate since the provider's system has already been updated manually to reflect the adjudication changes. PLB code WO (Overpayment Recovery) is used to effect the recovery. This process would also be used if the provider were to remit the funds without the payer initiating the refund. The payer would acknowledge that the funds were received using the original trace number to indicate which payment the overpayment was from WO would be used for this situation as well. Example: A health plan sends a letter to a provider (number 1234) identifying an overpayment of $ The FCN of the document is The provider does not remit the overpayment to the health plan. A PLB segment in the next 835 would report the overpayment recovery. PLB*1234* *WO:56473*37.5~ 2. Would a PSAO send the ASC X reporting the negative balance if they were not sending a check, i.e. there was no claim activity for any provider in the group? This Question was answered by adding three additional statements to the document goals. For all scenarios, all information on the ASC X to the consolidator is to be sent to the corresponding provider regardless of the financial impact. For a provider who owes money and does not have any financial activity, the ASC X should report money owed for that provider regardless of the financial impact to the consolidator. To support the above, three assumptions were added to the Business Model Task Group Goals as follows: For all scenarios, all information on the ASC X to the consolidator is to be sent to the corresponding provider regardless of the financial impact. For a provider who owes money and does not have any financial activity, the ASC X should report money owed for that provider regardless of the financial impact to the consolidator. The consolidator could receive a $0.00 ASC X if all providers have no financial activity. A motion was made and seconded to approve the responses and changes to the Business Model. The motion carried. To refer other business use cases for the task group to address, please to sthompson@ncpdp.org. B. HPID Update Margaret Weiker of the Weiker Group provided the presentation. See the WG45 November Presentations available on the WG45 webpage along with the minutes. Margaret explained the rationale for the addition of the other entity identifier (OEID). Use of the OEID is voluntary and may be used to identify atypical providers as well as payers/plans that do not qualify for an HPID. HPID and OEID are not in the same database as the provider NPIs. She provided an overview of the analysis of NCPDP standards done by WG3 Standard Identifiers to determine where payer/processor identifiers were used. No business case was identified to necessitate 2 qualifiers for HPID and OEID. The work group then identified where WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 4 November 2013

5 changes were needed and created the necessary DERF (details are available in the presentation and the DERF download). Margaret reviewed the changes by standard. The DERF will be modified, based on the WG3 Task Group deliberation, to remove the change to Telecommunication Plan ID(524-FO) to expand the field length from 8 to 10 unless a business reason if presented at MC during the DERF review. The changes for the XML standard are included in the current SCRIPT ballot (WG110037). As part of the next steps NCPD SNIP will create a white paper on the changes and NCPDP will review and comment as needed on the changes proposed for the ACS X12 standards. Margaret then provided an overview of the changes proposed by ASC X12 concentrating on those affecting the ASC X It was also noted that they allowed for dual use in the claim and payment advice. The other transaction sets follow the same format. It has been determined that rule making is not required so OESS will be issuing a notification once the changes are approved at the ASC X12 S5tanding Meeting in January. Although not yet adopted the attachment guides ASC X12 275s have also been reviewed and updated as well in preparation for the impending rule. WEDI will be making recommendation for implementation and communication using the identifiers. The WG45 DSMO Task Group will review the changes for the ASC X12 prior to the WG3 HPID Task Group review and comment submission C. Industry Updates 1. WEDI Report Ashley Maples with Express Scripts, WEDI liaison provided the following report: Liaison: Ashley Maples Parent Work Group: Work Group 45 WEDI Liaison Report Out Date: 10/17/2013 1) HPID Work Group Continued work on HPID Dual Use White Paper 9/16/13, 9/25/13 meeting notes: Health ID Card Sub-Workgroup: o H.R. 2828& SB 612 removal of SSN from Medicare cards continued review of papers, moving towards finalizing o H.R. 324 Medicare Common Access Card Act of 2013 began draft analysis of the bill o Discussion surrounding meaning and possible use of electronic signatures for provider attestation of the correctness of the primary diagnosis or treatment 2) ICD-10 Final ICD-9-CM Code Set Update The final updates to ICD-9-CM codes will take effect on October 1, These updates will be in effect until the ICD-10 transition takes place on October 1, You can find the last official ICD-9-CM code titles, both full and abbreviated, posted on the CMS website. Resources and Tools to Help Prepare for ICD-10 CMS has released a new Online ICD-10 Guide. This web-based tool includes an overview of ICD-10 as well as information on how to transition to ICD-10 for small/medium practices, large practices, small hospitals, and payers. 3) CAQH CORE Additional Resources Webpage Dedicated to the CORE Code Combinations Maintenance Process for CAQH CORE 360 Rule: To use as one-stop-shop in assisting organizations with ongoing maintenance related to the CORE Code Combinations for CAQH CORE 360: Uniform Use of CARCs and RARCs Rule. WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 5 November 2013

6 CORE Code Combinations v3.0.3 Updated Versions An updated version of the CORE-required Code Combinations for the CORE-defined Business Scenarios (CORE Code Combinations) is now available for use with CAQH CORE 360: Uniform Use of CARCs and RARCs Rule. CAQH CORE Rule 360 enables more uniform use of the Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) by targeting a minimum set of common or problematic Business Scenarios along with a maximum specified set of code combinations for each of these Scenarios. The CORE Code Combinations must be updated to align with the current published CARC and RARC lists which are maintained by code committees and updated at least three times per year. 4) ONC and the OCR Release Model Notices of Privacy Practices The Office of the National Coordinator for Health Information Technology (ONC) and the Office for Civil Rights (OCR) have collaborated to develop three model Notices of Privacy Practices for health care providers and health plans to use to communicate with their patients and plan members. 5) P&C ebilling Workgroup Survey Results The auto and workers compensation industry has been moving towards ebilling technology, including alignment with the ASC X12 electronic standard transactions and CAQH CORE operating rules over the past several years.. 6) CMS Releases Basic Health Program Proposed Rule (CMS-2380-P) The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule establishing the standards for the Basic Health Program (CMS-2380-P) which provides states the option to establish a health benefits coverage program for low-income individuals who would otherwise be eligible to purchase coverage through the Health Insurance Marketplace. This proposed rule sets forth a framework for Basic Health Program eligibility and enrollment, benefits, delivery of health care services, transfer of funds to participating states, state administration and federal oversight. Public comments on the proposed rule are due November 25, For more information about how to submit comments, please refer to the instructions in the Federal Register. The proposed rule can be found online at the Federal Register s website: For more information on this rule please visit: 7) Meaningful Use Data White Paper: CMS released a white paper with data on year one of the Electronic Health Record (EHR) Incentive Programs. The report focused on five areas of Stage 1 of meaningful use: Quality, Safety, Efficiency, and Health Disparity Reduction; Patient and Family Engagement; Care Coordination; Population and Public Health Improvement; and Privacy and Security. The meaningful use data is analyzed by state and specialty type for eligible professionals and eligible hospitals who participated in the 2011 Medicare EHR Incentive Program. 8) FDA issues final guidance on mobile medical apps FDA will exercise enforcement discretion, meaning it will not enforce requirements under the Federal Drug & Cosmetic Act, for the majority of mobile apps because they pose minimal risk to consumers. However, they will target a subset of mobile medical apps that pose a greater risk to patients if they do not work as expected. Mobile Medical Apps under FDA scrutiny could include: Diagnose abnormal heart rhythm Mobile ultrasound devices Central Command for blood glucose meters/monitoring 9) NUCC Releases Updates to 08/05 and 02/ Instruction Manuals WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 6 November 2013

7 The National Uniform Claim Committee (NUCC) has released updates to its Version 9.0 7/13 (for the 08/05 form) and Version /13 (for the 02/12 form) 1500 Health Insurance Claim Form Reference Manuals. The changes to both manuals are minor and deal mostly with clarifications and edits that go into effect immediately. The complete list of changes made to the 08/ instructions since July 2013 is available on the NUCC s website, on the "1500 Instruction Manual Changes" page under the 1500 Claim Form tab. The complete list of changes made to the 02/ instructions since June 2013 is also available on the NUCC s website on the 02/ Claim Form page. Upcoming Industry/WEDI Events: NCVHS Full Committee Meeting: o November 13 14, 2013 AMIA Annual Symposium: o November 16 20, 2013, Washington, DC WEDI Fall Conference: The Health IT Tipping Point: Bridging Strategy & Execution o November 18 21, 2013 o Gaylord National Hotel and Convention Center, Baltimore, MD WEDI 2014 Winter Forum: The ICD-10 Survival Guide: Achieving Implementation Success o January 8 9, 2014 o The Biltmore Hotel, Miami FL HL7 Working Group Meeting o January 19 24, 2014 o Hyatt Regency San Antonio on the Riverwalk, San Antonio, TX Winter 2014 ASC X12 Standing Meeting: o January 26-30, 2014, Birmingham, Alabama Ashley noted that WEDI had submitted a document to OESS on best practices for using HPID. 2. ASC X12 Update Mary Lynam, ASC X12 liaison to NCPDP provided the report. In addition to the work on the 5010 TR3s to make the required modifications for HPID/OEID, the work groups are working on the finalization of the new business requirements to be incorporated into the next version. If you have a question about an ASC X12 Standard, send them to Sue Thompson at sthompson@ncpdp.org to determine how to engage you in the solution. 3. HIPAA/Industry Update Margaret Weiker of The Weiker Group provided the report. HIPAA Update: 1. Regulations have not moved due to government shutdown. 2. Important: Approved at Nov WG: We are recommending that an existing field, Quantity Prescribed (46Ø-ET) which is currently not used in the Telecommunication Standard be reactivated with approval from the Office of e-health Standards and Services. Note this field would be required for Part D Schedule II Controlled Substance claims; however the use of this field is not limited to Part D claims only. Refer to DERF 1097 for additional information. CMS requested this modification due to an OIG audit of 2009 PDEs and determined that 400,000 Schedule II Controlled Substance prescriptions were wrongly refilled, or about 2 percent of all Schedule II prescriptions billed under Medicare Part D in a. Telecom D.0 and all versions from that point have been updated (November 2012). b. DSMO Change Request filed (and approved). c. OESS and NCVHS have been sent information. i. NCVHS sent a recommendation letter to HHS. ii. OESS has responded approving the request to proceed however the initial response of proceeding with a Federal Register notice only has been stopped as OGC says OESS will need to publish either a Notice of Proposed Rule Making (NPRM) or an Interim Final Rule (IFR) or Interim Final Rule with Comment (IFC). a. NCPDP submitted a letter to the Secretary of HHS requesting clarification and a response. It may require a second opinion. b. NCPDP and JC White have requested an explanation of the Senate intent of section 1104 Administration Simplification of ACA. WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 7 November 2013

8 iii. Industry implementation January 1, 2014 Notifications to industry, in Telecom D.0 Imp Guide, in Version D Editorial that this date is on hold. 3. Health Plan ID Final Rule was released September 5, Final rule with corrections was issued October 4, a. Compliance Date for all health plans (to obtain HPID) except small health plans: November 5, 2014 b. Compliance Date for small health plans (to obtain HPID): November 5, 2015 c. Use of HPIDs in standard transactions on or after: November 7, 2016 The Health Plan and Other Entity System (HPOES) is available for obtaining an HPID or OEID. Care-Act/Health-Plan-Identifier.html for more information. 4. The Health Plan Certification (CMS-0037-P) dates have been pushed back from December 31, An NPRM will be issued to solicit industry feedback. 5. ICD-10 released with HPID Final Rule compliance October 1, a. OESS staff will work with the industry to develop more extensive outreach programs for ICD-10 including a definition of End-to-End testing. The definition is expected to include phases of testing, planned activities and deliverables for each phase, and best practices so that, upon completion, entities will be positioned for the transition. The End-to-End testing protocols and procedures are planned to be reused beyond ICD-10 for example when implementing future e-health initiatives found in the Affordable Care Act (ACA) and the Health Insurance Portability and Accountability Act (HIPAA). For more information on End-to-End testing, see Administrative-Simplification/Affordable-Care-Act/End-to-End-Testing.html Meaningful Use: 4. Operating Rules Teresa Strickland of NCPDP provided the report. See WG45 November Presentations available on the WG45 webpage along with the minutes. CORE announced last week that the Connectivity Sub work group will begin meeting on November 14, D. Inter SDO Update Mary Lynam reported that no documents were submitted in the last quarter and ASC X12 has no outstanding items from NCPDP for approval. Documents will be submitted from this meeting. E. Scope and Goals Reportable Mary Lynam presented the WG45 Scope and Goals were approved by the Board of Trustees with modifications as highlighted below: Goals: 1. Promote NCPDP membership attendance and active participation in work group meetings. 2. Contributes to the development and maintenance of the Operating Rules that impact the pharmacy industry including but not limited to Council for Affordable Healthcare Committee on Operating Rules for Information Exchange (CAQH CORE) and National Automated Clearing House Association (NACHA): The Electronic Payment Association. 3. Support Work Group 11 eprescribing & Related Transactions with the operating rule for the ASC X12 270/271 as needed. 4. Discuss and/or present the needs as reported by NCPDP members in the ongoing maintenance of non- NCPDP developed Health Insurance Portability and Accountability ACT (HIPAA) mandated and other transaction data set standards. These standards include but are not limited to the following Accredited Standards Committee (ASC) X12N HIPAA mandated transaction data set standards: a. 274 Electronic Provider Enrollment Standard b. 834 Provider/Member Enrollment Standard c. 835 Payment Reconciliation Standard d. 270/271 Health Care Eligibility/Benefit Inquiry/Response e. 278 Health Care Services Review Request/Response f. ASC X12 Acknowledgements WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 8 November 2013

9 5. Provide regular updates to Work Group 9 Government Programs regarding the implementation of the ASC X Monitor the task groups to ensure they are on track to complete their work. If appropriate, disband task groups that have completed their work. 7. Support the MC Maintenance and Control Education-Legislation and Regulation Task Group when new legislation is being introduced regarding issues relevant to the work group. 8. Review Designated Standards Maintenance Organizations Change Request System (DSMO CRS) requests as needed. 9. Review Data Element Request Forms (DERFs) and ballots pertaining to standards for which this work group is responsible. 10. Analyze, develop and execute Webinar opportunities for Work Group 45 External Standards Assessment, Harmonization and Implementation Guidance in coordination with Educational Programs Advisors Group. Three new goals were added. VII. New Business A. New DERF No DERFs were reviewed. B. Adjustments Beth Serraino reported that there have been no new adjustments submitted for review. C. Support for Activities of Other Work Groups Beth Sorrentino noted that WG45 will be working with WG3 on the response to ASC X12 HPID/OEID requests for public comment. D. The Next Quarterly Work Group Meeting The next NCPDP Quarterly Work Group Meeting will be held February 5-7, 2014 at the Hyatt Regency San Antonio, San Antonio, TX. Old Business Task Group Updates Industry Updates (HIPAA, WEDI, NCPDP SNIP, CAQH CORE, ASC X12, Health Exchanges) Inter SDO Process Operating Rules Legislation Strategic Planning Committee Deliverable New Business New DERF if applicable Member Concerns Support for Activities of Other Work Groups if needed. Request ½ day, not across from WG9 or WG1. A motion was made and seconded to approve the agenda. The motion carried. G. Submission of new DERFs Submission of new DERFs and Project Development Forms is due Monday, January 6, 2014 to Kittye Krempin (if necessary). VII. Motion to Adjourn Mary Lynam asked for a motion to adjourn the meeting. The motion was moved and seconded. The motion carried and the meeting was adjourned at 11:55 a.m. WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 9 November 2013

10 Attachments available on website or by request to Council Office: Proposed Agenda Attendee Roster Sue Thompson Staff Liaison WG45 External Standards Assessment, Harmonization and Implementation Guidance WG45 External Standards Assessment, Harmonization and Implementation Guidance Page 10 November 2013