Encounter Data UPDATES. Industry Updates. January 19, INDUSTRY Wednesday, January 19, :00 P.M. 2:30 P.M., ET.

Transcription

1 Industry Updates January 19,

2 Industry Update Session Guidelines This is an hour and a half (1.5) long industry update for Medicare Advantage Organizations (MAOs), Prescription Industry Drug Plans Update (PDPs), and Third Session Party Submitters. Guidelines We encourage participation during the session. When asking questions, clearly state your name, organization, and title, in case follow-up correspondence is required. This session is divided into 2 distinct topics and time has been allotted at the end of each of these topics for questions and answers. 2

3 Introduction The purpose of this industry update is to provide information to MAOs, PDPs, and Third Parties regarding the progress of encounter data implementation and updates to risk adjustment payment. The goal for today s session is to provide updates to the industry regarding decisions made for: implementation, and Risk Adjustment processing 3

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5 Overview The following topics will be discussed regarding : Purpose of Plan Requirements Update Testing Plan Objectives Summary of Work Groups 5

6 Purpose of The primary use of is to correctly price an encounter according to Fee- For-Service (FFS) pricing methods. The priced encounter will be used for risk adjustment payment calibration. 6

7 Updates Since the National Meeting During the National Meeting in October 2010, MAOs were provided with the Top Ten Requirements for implementation of Encounter Data. The following information provides plans with updates regarding those Requirements. 7

8 Requirement 1 MA Organizations must enter into an EDI Agreement with the Customer Service and Support Center (CSSC). CSSC provides EDI authorization paperwork, assigns the Submitter ID, and only accepts data in the 5010 X12 format. A new submitter package for EDS will be required for new and existing MAOs/Submitters Update: CSSC will post the Submitter Packets no later than March 15, 2011 on Plans must provide the completed documents to CSSC prior to testing. Front-End testing begins March 30,

9 Requirement 2 MA Organizations will establish connectivity through Multi Protocol Label Switching. Update: MAOs may use any of the following CMS approved connections to transmit 5010 X12 encounter data transaction files to the Encounter Data Front-End System (EDFES). These include: Connect:Direct (NDM) Secure File Transfer Protocol (SFTP) Hypertext Transfer Protocol Secure (HTPPS) Gentran 9

10 Requirement 3 MA Organizations will submit only adjudicated claims. CMS will process data received through modified FFS CEM and/or CEDI modules. Update: CMS currently expects MAOs to submit adjudicated claims for those claims that follow an adjudicated process. For those non-paid or capitated claims, CMS expects MAOs to submit claims with 0.00 populated in the paid amount fields. 10

11 Requirement 4 MA Organizations are required to submit data monthly. Plans may submit more frequently. As in current risk adjustment practice, payment is calculated three times a year during data sweep dates. CMS will closely monitor and enforce this requirement. Update: This requirement remains the same. 11

12 Requirement 5 MA Organizations must submit data within 12 months of the date of service. Update: Section 6404 of PPACA amended the timely filing requirements to reduce the maximum time period for submission of all Medicare FFS claims to one calendar year after the date of service. CMS has heard the Industry comments and is maintaining compliance with PPACA for Risk Adjustment. 12

13 Requirement 6 MA Organizations will follow HIPAA 5010 as the industry standard. Update: MAOs will use the 5010 Errata version for HIPAA compliance per the Federal Register (Vol. 75, No. 197, October 13, 2010, [ ] found at: ). MAOs can find a list of the 5010 Errata at: re_fee-for-service_systems.asp#topofpage 13

14 Requirement 7 Systems will only collect HIPAA compliant 5010 data. 837 I (Institutional) 837 P (Professional) 276 (Claim status inquiry) Update: Systems will accept the following 5010 X12 formats: 837 I (Institutional) 837 P (Professional) 837 D (Dental) 276 (Claim status inquiry) 14

15 Requirement 8 MAOs will submit all data from all types of service. Update: This requirement remains the same. 15

16 Requirement 9 MA Organizations must submit data by 8 p.m. EST for that day. Update: This requirement remains the same. 16

17 Requirement 10 MA Organizations will submit Institutional and Professional test files to the front-end beginning in March MA Organizations will submit Institutional and Professional test files to the Processing and Pricing System by October Test Certification for Institutional and Professional claims must be received by November Test Certification for DME claims must be received by March Update: Testing requirements are described fully on the next slides. 17

18 Pilot Testing The purpose of the Pilot Testing is to receive data from submitters/plans to determine which data will be accepted or rejected during processing and to identify any issues to resolve prior to front-end testing beginning in March

19 Pilot Testing Participants A sample population of six (6) plans will be recruited for the pilot according to the following criteria: Fee-for-Service experience, Participation in the National Meeting and Work Groups, Use of capitated arrangement with providers, and Level of preparedness to submit files in the 5010 format. Test data will consist of 10 encounter claims: One (1) Inpatient Institutional, One (1) Outpatient Institutional, One (1) Inpatient Professional, and Remaining seven (7) can be any combination of the above. 19

20 Date January 21, 2011 January 31 - February 25, 2011 February 28 March 11, 2011 Pilot Test Schedule Event Send Pilot Test package to participants Participants submit Pilot Test Data Review Pilot Test results By the end of the Pilot Test, CMS will be able to determine edits that will be turned on or off in preparation for industry front-end testing beginning March 30. CMS will share information learned from the pilot prior to the front-end testing. 20

21 Front-End Testing The goal for industry testing of the Front-End System (EDFES) is to successfully submit data through the COTS translator. Date March 30, 2011 June 30, 2011 Event Front-End Testing Schedule Front-End testing of the Commercial Off-the-Shelf (COTS) Electronic Data Interchange (EDI) Translator and the Encounter Common Edits Module (CEM) will begin for both Institutional and Professional services. MAOs must submit Institutional and Professional test files to the Front-End System. 21

22 Institutional and Professional Processing Testing The goal for industry testing of the Processing and Pricing System (EDPS) is to ensure accurate pricing of encounters according to FFS rules so that the priced data can be used for risk adjustment model calibration for Plan payment. Date Institutional and Professional Processing Testing Schedule July 18, 2011 September 12, 2011 October 2011 Event Institutional Processing and Pricing System endto-end testing begins. Professional Processing and Pricing system endto-end testing begins. MA organizations must certify their data by October 2011 in order to submit production data by January

23 Date February 6, 2012 May 7, 2012 DME Testing DME Processing Testing Event MAO front-end testing of DME CEDI module and DME Processing and Pricing system begins. DME Processing and Pricing system Goes- Live. MAOs must send production files for DME by this date. 23

24 Work Groups There are a total of 13 Work Groups scheduled from December 2010 to June The Work Groups are similar to focus groups. The purpose of these working sessions is for CMS to gather information from the industry regarding specific needs and issues with the implementation of Encounter Data that leads to resolutions and decisions regarding best practices. Three encounter data work groups have been conducted thus far in the following areas: Third Party Submitters (December 8, 2010) Chart Reviews & Data Submission for Chart Audits (December 15, 2010) Editing & Reporting (January 12, 2011) 24

25 Third Party Submitters Work Group Work group participants discussed possible solutions and challenges MAOs face in transitioning to the collection of encounter data. Issues discussed included: Differences in the submission of paper claims and the 5010 format, Plans can reference for a crosswalk of data from the UB04 to Plans can reference for a crosswalk of data from the CMS-1500 to The required use of the National Provider Identification (NPI), Plans can reference age for more information on the industry standard use of NPI. Select EMRs that only allow up to four (4) diagnosis codes. *Not an all inclusive list 25

26 Types of Data Only adjudicated claims, those either paid or denied, will be submitted. One encounter is equal to one claim. Adjustment claims will be processed as they are in Fee-for-Service. The adjustment will supersede the previous encounter. 26

27 Chart Reviews & Data Submission for Chart Audits Work Group Work group participants discussed: Processes currently used to collect and submit chart review data and the impact of this data on plan payments, Potential options for encounter data submission of chart review data: Utilization of the PWK01 Segment Report Type Code, Utilization of the CAS Segment, or Development of a separate format for submission of chart review data. Value of identification of Chart Review Data in the Reporting Process. 27

28 Editing and Reporting Work Group Front-End Reports MA Organizations will receive front-end reports from the EDFES. These include: TA1 = Rejected Interchange ISA/IEA envelope, 999R = Rejected Functional groups/transaction sets, 999E = Accepted Functional groups/transaction sets, and 277CA = for Rejected and Accepted Claims with claim number returned. 28

29 Edits Translator Implementation Guide CEM Error Edits Examples File Processing File level (format edits) Batch and claim (format edits) Claims (validation edits) Example File: ISA12 Interchange Control Version Number, must have a value of Otherwise a TA1 Acknowledgement Report will be sent indicating Invalid Interchange Version ID value. File: IEA01 Interchange Control Number, must be present and equal to the value in ISA13. Otherwise, a TA1 Acknowledgment Report will be sent indicating The Interchange Control Number in the Header and Trailer Do Not Match. Data Element: 2320.AMT02, must be equal to 0 and <= 99,999, Otherwise a 999 Reject Acknowledgement will be sent indicating the Data Element too Long. Data Element: 2320.AMT02, must be the sum of all 2430.SVD02 payer paid amounts for the same payer. Otherwise, a 277CA Acknowledgement will be sent indicating Acknowledgement Rejected for Invalid Information, Other Payer s payment information is out of balance., and Other payer s Explanation of Benefits/payment information. 29

30 Front-End Reports TA1 30

31 Front-End Reports transaction data:( line numbers included for reference only in this document): ) ISA*00* *00* *28*00520 *28*E9999 1a) *100907*1201*^*00501* *0*T*:~ 2) GS*FA*00520*E9999* * *1*X*005010X231~ 3) ST*999*1001*005010X231 ~ 4) AK1*HC* *005010X222A1~ 5) AK2*837*PA92430xx*005010X222A1~ 6) AK9*A*1*1*1~ 7) SE*5*1001~ 8) GE*1*1~ 9) IEA*1* ~ 31

32 Front-End Reports 277CA 277CA transaction data:( line numbers included for reference only in this document): ) ISA*00* *00* *ZZ*00520 *ZZ*E9999 1a) *100907*1219*^*00501* *0*P*:~ 2) GS*HN*00520*0* *121922*11*X*005010X214~ 3) ST*277* *005010X214~ 4) BHT*0085*08*10250* * *TH~ 5) HL*1**20*1~ 6) NM1*PR*2*MEDICARE SERVICES******46*00520~ 7) TRN*1* ~ 8) DTP*050*D8* ~ 9) DTP*009*D8* ~ 10) HL*2*1*21*1~ 11) NM1*41*2*CMSMD******46*E9999~ 12) TRN*2*PA92430XX.SVD02~ 13) STC*A1:19:PR* *WQ*50~ 14) QTY*AA*1~ 15) AMT*YY*50~ 16) HL*3*2*19*0~ 17) NM1*85*2*LOVING CARE SOUTH-HOME-APPLES ROCK******XX* ~ 18) TRN*1*0~ 19) STC*A8:496:85**U*50~ 20) QTY*QC*1~ 21) AMT*YY*50~ 22) SE*20* ~ 23) GE*1*11~ 24) IEA*1* ~ 32

33 Question & Answer Session 33

34 Risk Adjustment Risk Adjustment 34

35 CY 2011 Submission Schedule Dates of Service Initial Submission Deadline First Payment Date Final Submission Deadline 10 1/1/09 12/31/09 3/5/10 7/1/10 1/31/ /1/09 6/30/10 9/3/10 1/1/11 N/A 11 1/1/10 12/31/10 3/4/11 7/1/11 1/31/ /1/10 6/30/11 9/2/11 1/1/12 N/A 35

36 Risk Adjustment Risk Adjustment Question & Answer Session 36

37 Risk Adjustment Questions Please submit any additional questions regarding risk adjustment to: 37

38 Training Schedule Dates for the Technical Assistance Training Program will be announced by the end of this quarter. Risk Adjustment ICD-10/RADV Enrollment & Payment Prescription Drug Expected schedule for training is between June and August Regional Trainings will be held in Chicago, San Diego, and Orlando. 38

39 CMS: Resources CSSC Operations: HPMS Notices: Industry Updates: Ask Risk Adjustment: RADV Mailbox: 39

40 Resources (continued) X12 Version 5010 Standards: CEM/CEDI Technical Reporting Formats: _TechnicalDocumentation.asp TA1, 999, 277CA Reports Information: _National_Presentation_ _final.pdf Washington Publishing Company: ICD-10 Information: 40

41 Q & A Question & Answer Session 41

42 Evaluation Your feedback is important! Please take a moment to give us your feedback regarding the Industry Update and provide recommendations for future discussion topics. Please complete the Evaluation Form sent via after the close of the Industry Update session. THANK YOU! 42