CAQH CORE and Edifecs with Humana: Voluntary CORE Certification

Transcription

1 CAQH CORE and Edifecs with Humana: Voluntary CORE Certification Planning for conformance with EFT & ERA Operating Rules through voluntary CORE Certification October 23, :30pm 4pm ET

2 Participating in Today s Interactive Event Download a copy of today s presentation HERE The phones will be muted upon entry and during the presentation portion of the session At any time throughout today s session, you may communicate with our panelists via the web Submit your questions on-line at any time by entering them into the Q&A panel on the right-hand side of the WebEx desktop On-line questions will be addressed first There will be an opportunity for the audience to submit questions through the telephone during today s presentation When directed by the operator, press * followed by the number one (1) on your keypad 2

3 Session Topics Welcome and Introduction ACA-mandated EFT & ERA Operating Rules Timeline and Compliance Requirements Voluntary CAQH CORE Certification Step-By-Step Process Phase III Voluntary CORE Certification Testing About Edifecs: An Independent, CORE-authorized Testing Vendor Overview of Testing Site and Test Scripts Operating Rule Implementation Perspective Humana Project Planning for implementation and certification testing Best practices and lessons learned Q&A 3

4 Amrita Kalkura, Senior Product Analyst, Edifecs As a Product Analyst, Amrita Kalkura, is responsible for Operating Rules at Edifecs. Her responsibilities include defining the business requirements and product features and capabilities for the Operating Rules Solution. Amrita has over 12 years of experience working in various areas within Edifecs Shruti Ramamurthy, Senior Business Analyst, Edifecs Shruti is a Senior Business Analyst at Edifecs. She is responsible for implementing the combined CORE Phase I/II 5010 and the CORE Phase III EFT/ERA Edifecs testing Portal along with another colleague. She has been working with Edifecs for over 10 years. Kim Peters, HIPAA EDI Program Manager, Humana Today s Panelists With over 31 years of healthcare experience, Kim is responsible for HIPAA transaction and code set enforcement, all compliance issues and review of ongoing Affordable Care legislation for impacts to Humana s varied systems. Omoniyi Adekanmbi, Senior Project Associate, CAQH CORE Omoniyi is a Senior Project Associate with CAQH CORE. In addition to assisting implementing entities in completing voluntary CORE Certification, she supports CORE rules development and the CAQH CORE request process. She has been working with CAQH CORE for over three years. 4

5 ACA Section 1104 Compliance Requirements: CAQH CORE EFT & ERA Operating Rules 5

6 ACA Mandated Operating Rules Compliance Dates: Required for all HIPAA Covered Entities Operating rules encourage an interoperable network and are therefore vendor agnostic Compliance in Effect as of January 1, 2013 Eligibility for health plan Claims status transactions HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules Implement by January 1, 2014 Electronic funds transfer (EFT) transactions Health care payment and remittance advice (ERA) transactions HIPAA covered entities will need to conduct these transactions using the CAQH CORE Operating Rules Implement by January 1, 2016 Health claims or equivalent encounter information Enrollment and disenrollment in a health plan Health plan premium payments Referral certification and authorization Health claims attachments Rule requirements available. 6

7 EFT Standard and EFT & ERA Operating Rules: Required of All HIPAA Covered Entities EFT & ERA Operating Rules: April 2013 CMS announces CMS-0028-IFC should be considered the Final Rule and is now in effect Adopts Phase III CAQH CORE Operating Rules for the Electronic Funds Transfer (EFT) and Health Care Payment and Remittance Advice (ERA) transactions except for rule requirements pertaining to Acknowledgements* CMS also confirms that the CORE Code Combinations maintenance process updates are immediately effective. Healthcare EFT Standard: July 2012 CMS announces CMS-0024-IFC is in effect Adopts the NACHA ACH CCD plus Addenda Record (CCD+) and the X12 v TR3 TRN Segment as the HIPAA mandated Healthcare EFT Standard Compliance date for both the Healthcare EFT Standard and EFT & ERA Operating Rules is January 1, * CMS-0028-IFC excludes requirements pertaining to acknowledgements.

8 EFT & ERA Operating Rules Effective January 1, 2014 Indicates where a CAQH CORE EFT/ERA Rule comes into play Pre- Payment: Provider Enrollment Claims Payment Process EFT Enrollment Data Rule ERA Enrollment Data Rule Health Plan Claims Processing Infrastructure Rules Content: Uniform Use of CARCs & RARCs Rule Payment/Advice (835) Provider Billing & Collections 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 Treasury Bank Content: EFT & ERA Reassociation (CD+/835) Rule Bank Electronic Funds Transfer Stage 1: (CCD+/TRN) Initiate EFT Treasury Infrastructure Rules 8 Standard Companion Guides Real-time and Batch Response Times Internet Connectivity and Security Increased System Availability

9 Mandated EFT & ERA Operating Rules: January 1, 2014 Requirements Scope Data Content Infrastructure Rule Uniform Use of CARCs and RARCs (835) Rule Claim Adjustment Reason Code (CARC) Remittance Advice Remark Code (RARC) Rule 360 EFT Enrollment Data Rule Rule 380 ERA Enrollment Data Rule Rule 382 EFT & ERA Reassociation (CCD+/835) Rule Rule 370 Health Care Claim Payment/Advice (835) Infrastructure Rule Rule 350 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 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 Similar to EFT Enrollment Data 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 v and the CCD+ transactions Requirements for resolving late/missing EFT and ERA transactions Recognition of the role of NACHA Operating Rules for financial institutions 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 9 * CMS-0028-IFC excludes requirements pertaining to acknowledgements.

10 Polling Question #1: EFT & ERA Implementation Challenges Which CAQH CORE EFT & ERA Operating Rule does your organization anticipate requiring the greatest amount of resources to implement? a) CAQH CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule b) CAQH CORE 360 Uniform Use of CARCs and RARCs (835) Rule c) CAQH CORE 370 EFT & ERA Reassociation (CCD+/835) Rule d) CAQH CORE 380/382 EFT & ERA Enrollment Data Rules e) Not applicable (not a HIPAA covered entity) 10

11 Voluntary CORE Certification Step-By-Step Process Phase III CORE EFT & ERA Operating Rules 11

12 About Voluntary CORE Certification Since its inception, CAQH CORE has offered a voluntary CORE Certification to health plans, vendors, clearinghouses, and providers Voluntary CORE Certification provides verification that your IT systems or product operates in accordance with the federally mandated operating rules CORE Certification is stakeholder-specific Each entity completes testing specific to their stakeholder type in order to become CORE Certified CAQH CORE Certification is available for the following transactions Eligibility and Claim Status (Phase I and Phase II) EFT and ERA (Phase III) Key Benefits Provides all organizations across the trading partner network useful, accessible and relevant guidance in meeting obligations under the CAQH CORE Operating Rules Encourages trading partners to work together on data flow and content needs Offers vendors practical means for informing potential and current clients on which of their products by versions - follow operating rules, including Practice Management Systems Achieves maximum ROI because all entities in data exchange follow the operating rules; once CORE-certified need to follow operating rules with all trading partners Means for voluntary enforcement dialog and steps 12 Note: Learn more about voluntary CORE Certification here

13 Voluntary CORE Certification: A Step-by-Step Process Step 1: Pre-certification Planning & Systems Evaluation Understand requirements of the CORE Operating Rules and scope your internal efforts to adopt and implement the operating rules CORE has free Gap Analysis Tool Step 2: Step 3: Step 4: Sign and Submit CORE Pledge CORE Certification Testing Apply for CORE Certification Seal Formally communicate your intent to pursue CORE Certification for a given phase of CAQH CORE Operating Rules An entity seeking CORE Certification works with a CORE-authorized testing vendor to perform tests based upon CORE Phase III testing criteria specific to that entity s stakeholder type Entities successfully achieving CORE Certification will receive a CORE Seal from CAQH that corresponds with the CORE Phase and stakeholder-type 13

14 Voluntary CORE Certification Completion Timeline Average Start to Finish: 2-6 months* Step1: Pre-Certification Planning & Evaluation Step 2: Submission of CORE Pledge Step 3: CORE Certification Testing Step 4: Submission of CORE Certification Seal Application Application Approval & CORE Certification Seal Distribution Conducted internally by certifying entity; time to complete depends on internal resources After submitting pledge, entities have 180 days to complete certification testing NOTE: CORE Pledge** can be submitted at any time (e.g., after testing has been completed) On average testing takes some hours over business days. Time to complete depends on amount of adjustments needed to bring system(s) into conformance with applicable CAQH CORE Rules & level of resources entity commits to certification testing effort Completed application must include: CORE HIPAA Attestation Form** CORE Certification Seal Application & appropriate Seal Fee (one-time fee per phase of certification) Health Plan IT System Exemption Form (if applicable)** CORE reserves 30 business days from receipt of complete application to review and approve 14 *Timeframe varies by stakeholder type and by individual organization. **Must be signed by an authorized executive.

15 CAQH CORE Master Test Suite Phase III CORE EFT & ERA Operating Rules 15

16 Phase III CORE EFT & ERA Operating Rules Voluntary CORE Certification Testing Step 3: CORE Certification Testing An entity seeking CORE Certification works with a CORE-authorized testing vendor to perform tests based upon CORE Phase III testing criteria specific to that entity s stakeholder type Activities Key Points a) Pre-Testing Review Testing Policy and Master Test Suite Upgrade all affected internal systems as previously defined in Step 1 Complete your internal testing of CORE-ready systems Note: This step may be performed prior to submitting CORE Pledge b) Testing Register and schedule your testing with a CAQH CORE-authorized testing vendor CORE Certification testing is conformance-based and, as such, is not exhaustive The CAQH CORE Test Suite must be used by all stakeholders in order to maintain standard and consistent test results Testing must be successfully completed within 180-days of pledge c) Post-Testing Remediate all systems/software issues identified by testing process and, if necessary, repeat CORE Certification Testing 16

17 Voluntary Phase III CORE Certification Testing: Roles and Responsibilities All parties essential to the success of the electronic exchange of the EFT* and ERA transactions will be addressed in the CORE Certification Process: Health plans Providers Clearinghouses Vendors CORE Certification Testing is performed by the applicant The applicant s systems must be up-to-date and compliant with CAQH CORE EFT and ERA Operating Rules prior to testing Each testing applicant going through CORE testing will be responsible for their own specific CORE Certification Testing process and related resources Independent CAQH CORE-authorized testing vendor, provides an approved CORE Certification Testing platform 17 *Voluntary CORE Certification does not test your organizations ability to send or receive payments using the EFT Standard (ACH CCD+) over the ACH Network. The ACH Network has a governance model that is acknowledged by CAQH CORE given the CORE rules support the use of the ACH CCD+ standard. For more information on the ACH Network, please contact your financial institution or learn more about the ACH Network by visiting the NACHA website.

18 Phase III CORE EFT & ERA Operating Rules Voluntary Certification: About the Master Test Suite CORE EFT & ERA Operating Rules Master Test Suite Contains requirements to achieve voluntary CORE Certification Must be used by all stakeholders undergoing the voluntary CORE Certification process Provides guidance to help stakeholders better understand which EFT and ERA Operating Rules apply to various stakeholders CORE Guiding principles apply to the entire set of rules The Master Test Suite includes scenario-based testing and expected outcomes CORE Certification Testing is not exhaustive and does not use production-level testing (CORE participants determining how to do such in future rules) Structure of Test Scenarios for All Rules Key Operating Rule Requiremens Certification Conformance Testing Requirements By Rule Test Assumptions by Rule Detailed Step by Step Test Scripts 18 See Phase III CORE EFT & ERA Operating Rules Voluntary CORE Certification Master Test Suite : Each rule requirement is provided in a numbered list.

19 Edifecs, an Independent CORE-authorized Testing Vendor 19

20 About Edifecs Who We Are Founded in 1996 headquartered in Bellevue, WA. Edifecs 4-yr ( ) average growth rate over 50% Employee-owned (no outside investors), Debt-free, Profitable Worldwide Associates Seasoned Leadership Team, executive experience at Microsoft, Hewlett Packard, Oracle, GE Healthcare, WellPoint and other leading healthcare and technology companies. What We Do Edifecs products streamline the processing and exchange of transactions in real-time at the edge-of-the-enterprise Industry leading solutions for healthcare information management, compliance and enrollment processing Customer Momentum 46 Blue plans out of total commercial plans 70+ providers 31 State Medicaid programs out of Fastest Growing Companies in WA Inc5000 fastestgrowing private companies in the US 100 Best Places to work for in WA

21 Edifecs and CAQH CORE Partnership Edifecs is a designated CAQH COREauthorized Testing vendor for Phase I and II The CORE Phase III EFT/ERA Certification Testing Portal is currently open for registrations Helping healthcare organizations with voluntary CORE certification testing since 2006 Provides free testing service based upon the CORE-approved Phase I and II Test Suites Dedicated web portal available 24/7 Has on-line and live support for quick issue resolution Edifecs has enabled: 61 health care organizations to complete Voluntary CORE Certification Testing for Phase I 51 health care organizations to complete Voluntary CORE Certification Testing for Phase II 21

22 Edifecs Voluntary CORE Testing Site Getting Started 22

23 Overview of the Certification Testing Site 23 These slides will be removed from presentation; Audience will see testing site

24 Overview of the Certification Testing Site 24 These slides will be removed from presentation; Audience will see testing site

25 Registration/Setting up a Test Account 25 These slides will be removed from presentation; Audience will see testing site

26 Voluntary CORE Certification Testing Test Scripts 26

27 Operating Rule Conformance Testing: Test Scripts CORE Certification Testing is comprised of stakeholder-specific test scripts for each CAQH CORE Operating Rule Conformance Test Requirement Types Type Description System Transaction Conduct the actual transaction for which you are testing with the CORE-certified testing vendor Upload Upload specified document to the testing site as proof of compliance Attestation Along with other specified documentation, an entity must sign an attestation signifying their current or planned compliance 27

28 CAQH CORE EFT & ERA Operating Rules: ERA Infrastructure Rule - Connectivity Rule Types Rule References Rule Areas Infrastructure Health Care Claim Payment/Advice (835) Infrastructure Rule Rule 350 Support Connectivity Requirements Dual Delivery of Paper and Electronic ERA Flow and Format of Companion Guides Entities must be able to support the Connectivity Rule Version for transmission of the v ; they must follow: Real-time and/or batch request submission and response pickup guidelines Security and authentication requirements Response message options and error notification Response time, time out parameters and re-transmission guidelines Prescriptive submitter authentication, envelope specifications, etc. Payload-agnostic, can use to send any type of data For more detail, see CORE Rules 153, and *Specifically designed to align with key Federal efforts, e.g., NHIN.

29 CAQH CORE 350 Rule Test Script: System Transaction Type Connectivity Conformance Detailed Step-By-Step Test Script See Phase III CORE Certification Test Suite. Each Rule requirement is provided in a numbered list. 29

30 CAQH CORE EFT & ERA Operating Rules: EFT Enrollment Data Rule Rule Types Rule References Rule Areas Infrastructure EFT Enrollment Data Rule Rule 380 Requirement to offer Electronic EFT Enrollment Maximum set of Standard Enrollment Data elements Flow and Format for Collection of Enrollment Data Elements A Health Plan (or its agent or vendors offering EFT Enrollment) are required to: Collect the CORE-required Maximum EFT Enrollment Data Set; includes some optional data elements* Use the format, flow, and data element descriptions without modification in the EFT Enrollment Data Set Make available to the provider (or its agent) specific written instructions/guidance to the provider for enrollment and the specific procedure to accomplish a change in/cancellation of their enrollment Additional requirements specific to electronic and paperbased enrollment noted in the rule For more detail, see CORE Rules 380 and *The CAQH CORE 380 Rule does not prohibit health plans and their agents from adding capabilities to the electronic EFT enrollment method designed to improve functionality and ensure data integrity and comprehensiveness

31 CAQH CORE 380 Rule Test Script: Attestation Type Enrollment Data Set Conformance Detailed Step-By-Step Test Script See Phase III CORE Certification Test Suite. Each Rule requirement is provided in a numbered list. 31

32 Voluntary CORE Certification Applying for CORE Certification Seal 32

33 Phase III CORE EFT & ERA Operating Rules Voluntary CORE Certification Seal Application Step 4: Apply for CORE Certification Seal Entities successfully achieving CORE Certification will receive a CORE Seal from CAQH that corresponds with the CORE Phase and stakeholder-type 33 Activities a) Determine your CORE Seal fee b) Complete appropriate CORE Seal Application c) Bundle together all required application paperwork d) Submit the CORE Seal Application package Key Points A one-time application fee for each phase of the CAQH CORE Operating Rules is assessed based upon a stakeholder-specific fee scale Phase III CORE Certification Seal Application Package includes: Documentation of successful certification testing from CORE-authorized testing vendor HIPAA Attestation Form(s) for Phase IIII which must be signed by an authorized executive If applicable, file Health Plan IT Exemption Request Form or notify CAQH CORE of potential Out of Scope systems/products Forward CORE Seal Application Package with the CORE Seal fee to: CORE, c/o CAQH 601 Pennsylvania Avenue, NW South Building, Suite 500 Washington, DC 20004

34 Key Health Plan Considerations: Exemption vs. Out of Scope Public list on CORE website Exemptions: Allows a health plan seeking CORE Certification to request that a scheduled migration of an existing IT system(s) or recent mergers at the time of CORE Certification be exempt from CAQH CORE Conformance for a specific timeframe. Health plan exemptions will be granted only if: Exempted system affects no more than 30% of the health plan s membership or total electronic remittance advice plus electronic payment transactions and Remainder of the health plan's IT systems is in conformance with all applicable CAQH CORE Operating Rule requirements. Documented plan is in place for exempted IT system(s) to be brought into conformance with the CAQH CORE Operating Rules NOTE: CAQH CORE Exemption Policy requires that within 12 months of the health plan's CORE Certification all exempt systems must be remediated to operate in conformance with the applicable CAQH CORE Operating Rules Out of scope: Applies when claims are fully owned and processed by another organization and, therefore, the CAQH CORE Operating Rules cannot be applied by the certifying health plan (i.e., member data for the product is wholly owned by the external organization). The health plan that owns the processing needs to become CORE-certified if they want to demonstrate that their processing complies with the CORE rules. An Out of Scope Designation does not apply if a health plan touches the administrative data in any way - but outsources some processing to a Business Associate(s) these health plans must coordinate with their BA to gain CORE-certification Health plan-ba coordination on health plan CORE certification is a frequent occurrence, and in many instances, the BA/vendor needs to also get CORE-certified 34

35 Applying for the CORE Certification Seal: Considerations Expedite application review by asking key questions before submitting application: Stakeholder-specific questions For all: Did I coordinate with my Business Associates? Do they need to be certified? For health plans: If applicable, have I submitted an IT Exemption Form or notification of Out of Scope system? For vendors & clearinghouses: Have I accurately identified the market name and version number (if applicable) for the product/service to be CORE-certified? Have all forms requiring signature by an authorized executive been appropriately signed? Have all materials been submitted, including appropriate CORE Certification seal fee? Complete Phase III application including: Phase III CORE Certification Pledge (if not previously submitted) Phase III CORE HIPAA Attestation Form Phase III CORE Certification Seal Application & appropriate Phase III CORE Certification Seal Fee CORE authorized-testing vendor documentation of successful Phase III CORE Certification testing Phase III CORE Health Plan IT Exemption Form (if applicable) If completing multiple phases of CORE Certification concurrently, complete set of materials must be submitted for each phase 35 NOTE: CAQH CORE review cannot begin until all application materials have been received.

36 Polling Question #2: Voluntary CORE Certification True or False: My organization needs to complete CORE Certification for phases I and II prior to becoming certified for phase III. a) True b) False Answer: BOTH ARE RIGHT! 1. This is dependent on your stakeholder type (i.e. Vendors can become certified for only one section of the Phases and, therefore, don t have to abide by any sequence) 2. Although it is true for all entities seeking certification for each phase in its totality (i.e. Health Plans) that they must be certified for the previous Phase before achieving certification for any subsequent phase, your organization can elect to participate in the certification process for all three phases concurrently 36

37 Success Stories in Implementing Operating Rules for EFT/ERA Operating Rules Certification and Compliance Kim Peters October 23, 2013

38 Humana s Introduction HIPAA/EDI compliance and legislation representative Kim Peters HIPAA EDI Program Manager Integrated Provider Process/ICD 10 Implementation Program Team; Humana, Inc. Responsible for HIPAA transaction and code set enforcement, all compliance issues and review of ongoing Affordable Care legislation for impacts to our varied systems. Joined Humana in 1986 as an IT programmer progressing to project manager focusing exclusively on claims processing systems. Worked extensively with the original HIPAA implementation and all Healthcare Reform projects related to X12 Transactions. 38

39 Who is Humana? Longevity: Celebrating 50 years Lifelong Well-being: Dedicated to providing solutions to enhance the wellness of each employee no matter what stage of life Financially Stable: 79 on Fortune 500 with revenues of $34 billion; total assets of approximately $18 billion Multi-faceted: Commercial, Individual, Medicare, Specialty Benefits and Well-being Solutions Personal: Dedicated to providing personalized and exceptional service at every level 39

40 Humana and CORE Certification Why become CORE Certified Customer service Industry acceptance Provider satisfaction Standardized delivery and testing on future projects Certification at Humana March 4, 2009 (CORE) Phase I compliant January 1, 2012 Humana HIPAA 5010 successful go live March 20, 2013 CORE Phase II Certification October 9, 2013 CORE Phase III certification 40

41 EFT & ERA Usage at Humana Percentage of Total Payments by Type Percentage of Total Remits by Type 41

42 Project Planning and Resources Get the right staff committed to implementation and strategy Humana Services Operations and IT executive leadership committed to CAQH CORE strategy early and supported the IT/Business design. Possible cost of penalties for non-compliance are a great motivator Identify necessary resources Humana s Annual capital budget process included project funding for completing CORE Operating Rule implementation; 2007 Today. Allocated IT resources and SME s as required to support projects. Established a dedicated team for EDI operations and day-to-day transaction management. Established an Administrative Simplification Program aligned to Corporate Healthcare Reform CORE objectives. Understand capabilities, roles and responsibilities of Trading Partners Does your software vendor have products or solutions that can directly help with CORE Operating Rule implementation? Larger Software vendors tend to have solutions to aid in implementation, which can help smaller payers that may not have the technological or human resources available for a more efficient and streamlined implementation process Communicate and coordinate with your Financial Institutions Identify all systems that are impacted by the CORE Rules 42

43 Achieving Voluntary CORE Certification Working with Trading Partners Working with Vendors and Clearinghouses Humana has had a long-term relationship with Availity Availity was originally created by Humana and BCBS of Florida Availity conducts all Remittance transactions for Humana Including paper and electronic remittance advices On a monthly basis, Humana receives a summary report* from Availity showing information on the amount of claims, remits and payments collected or sent by Humana Humana also partners with Emdeon, through their relationship with Availity, to conduct EFT & ERA transactions for some of their subsidiaries Identify the role these vendors/clearinghouses play in achieving CORE Certification Depending on the services a trading partner provides for your organization, you may have to rely on them to complete certain aspects of testing before you can be CORE Certified and they may need to get CORE-certified Example Meeting CAQH CORE Connectivity Requirements: Because Availity receives all claims and delivers all remits and payments for Humana and its subsidiaries**, we relied on them to complete all testing involved in conformance with the Connectivity requirements outlined in the CORE Operating Rules *An example of this report can be found in the appendix of this presentation **Except for CarePlus Health Plans, inc. which works with Emdeon for those transactions so Emdeon needed to be involved 43

44 Achieving Voluntary CORE Certification Working with Trading Partners Working with Financial Institutions It is best to communicate with your banks early and often Humana works with multiple banking institutions in varied ways based on their types and complexity (i.e. self-funded, legal entities) Humana has actively worked with their banks, in conjunction with an inhouse 835 Implementation workgroup, to coordinate implementation of the CAQH CORE Operating Rules We have also worked with our banks to identify changes that needed to be made due to the NACHA Operating Rules update and how those changes affect their relationship and processes 44

45 Considerations and Challenges System Impact Analysis Identify systems that will be impacted Humana uses two systems for all EFT/ERA Transactions: ehub and Paypilot ehub Humana s centralized electronic data interchange and database Built when HIPAA was originally implemented Houses all X12 transactions and helps manage Compliance and translation. Paypilot PayPilot is a software vendor Humana uses this system to manage and create EFT payments to any trading partners Coordination of these two systems is key for Certification testing and overall successful compliance with the CORE Operating Rules Example Meeting CAQH CORE Reassociation Rule Requirements: Our Paypilot system interfaces directly with claims platforms so an 835 can only be generated after an EFT is created and key data from the EFT is transferred to the 835 In order to make sure that we meet the 3-day time lapse requirement in the CORE Reassociation Rule, we had to adjust our process to ensure that the EFT is released 0-1 days after creation to allow for delivery with the

46 Considerations and Challenges Subsidiaries and Affiliated Entities All Subsidiaries MUST be Compliant to Achieve Certification Identify all subsidiary companies and products that use the transactions for which you are seeking certification Do any of these subsidiaries/products qualify for Exemptions and/or Out of Scope Designations? Exemption - Humana s CarePlus Health Plans, Inc. CarePlus Health Plans, Inc., a Humana subsidiary, will be remediated to be Phase III CORE-certified by Q This product covers less than 30% of Humana's total ERA and EFT transactions. It works with Emdeon and ERA use is extremely low. Out of Scope Entities Humana Puerto Rico Considered Out of Scope because it is a Non-US entity Humana Military Healthcare Services (Tricare Contractor) Considered Out of Scope because processing of the ERA and EFT are wholly owned and maintained by a separate entity through a contractual relationship 46

47 Considerations and Challenges Competing Priorities and Projects Competing Projects ICD-10 Healthcare Reform Other Internal Humana Priorities Multiple Ongoing Acquisitions Normal daily business 47

48 Electronic EFT & ERA Enrollment Functionality Humana only has electronic enrollment processes for EFT and ERA We do not conduct any paper enrollments Provider enrollment process is currently on-line Provider driven selection process i.e. what locations and what departments Allows new add, update, delete. Establishes EFT with automated pre-note Paperless authentication using checks with dates and amounts. Ongoing tracking and notification of enrollment status. Complexity of provider relationships discovered early in process 48

49 Certified Provider Enrollment process - Initial Enrollment Screen

50 Certified Provider Enrollment process Facility Selection Screen

51 Certified Provider Enrollment process Group Selection Screen

52 Certified Provider Enrollment process Disclaimer Page

53 Certified Provider Enrollment process ERA Enrollment

54 Certified Provider Enrollment process EFT Enrollment

55 Certified Provider Enrollment process - Confirmation Page

56 CARC and RARC process within Humana System is tied to internal reason codes which have CARC RARC associated for 835 delivery Group codes are tied to the provider contractual relation Member responsibility drives the PR group code This was all in place when we started Operating Rules and only required updates to code list 56

57 Phase III Operating Rules Lessons Learned It was helpful to have production environments operational with transactions that were stable. Getting connections and communication protocols can be tedious to get established and operational. Make sure you have multiple environments for testing and production. Ensure you are storing your transactions long enough to research production issues that arise in the near future 1-3 months. Understand your benefit structures before you start building your transaction as it is critical in the presentation and validation layer. Have key resources lined up for X12, product interpretation, and technical issues as this will save time at implementation. It is critical to have a key resource that can understand and bridge the gap between the X12 Transactions and the system configuration of the data. Develop a good line of communication with the testing and certification organizations as there will be discrepancies in what the rule is asking for and the actual delivery/format of the data content. Plan for more time than you think it will take as delays/issues are inevitable 57

58 Q&A Please submit your question: Via the Web: Enter your question into the Q&A pane in the lower right hand corner of your screen By Phone: When prompted by the operator, press * followed by the number one (1) on your keypad 58

59 Thank You for Joining Us Appendices: Additional Implementation Tools and References 59

60 Phase III CORE EFT & ERA Operating Rules: Implementation Tools Analysis and Planning Guide provides guidance for project staff to conduct systems analysis and implementation planning Request Process: Contact technical experts as needed at FAQs: CAQH CORE has a list of FAQs to address typical questions regarding all three phases of the operating rules, the ACA Mandate and CAQH CORE processes; updated FAQs being loaded to website on a regular basis Voluntary CORE Certification: A Step-by-Step Process Operating Rules Voluntary CORE Certification Master Test Suites Phase I Phase II Phase III 60

61 Trading Partner Collaboration: Trading Partner Testing CORE Certification and Trading Partner Testing are two separate processes HIPAA covered entities can quickly communicate their organization s readiness to testing their conformance with trading partners for phases I and II* by adding their company information to the CORE Partner Testing** page of the CAQH website You do not need to complete CORE Certification before you begin testing conformance with your trading partners All CORE Certified entities have their name added to the CORE Partner Testing list as they have proven their operating rule compliance and readiness to test with trading partners If you are ready to test with trading partners, take 5 minutes and add your organization to the CAQH CORE list! 61 *Trading Partner Testing is not yet available for Phase III **Similar to CORE Certification, the CORE Partner Testing page also includes other key IT system/service vendors that support HIPAA covered entities, such as Practice Management Systems

62 Available CMS OESS Implementation Tools: Examples 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 Additional Questions Questions regarding HIPAA and ACA compliance can be addressed to: Geanelle Herring, Health Insurance Specialist, Geanelle.Herring@cms.hhs.gov 62

63 Humana ERA and EFT Activity Report Below is an example of the summary report Humana receives from it s vendor, Availity, which outlines the vital statistics regarding Remits, Claims and Payments received and delivered by Humana for the previous month. 63