Payer Affordable Care Act End-to-End Testing Checklist

Transcription

1 Payer Affordable Care Act End-to-End Testing Checklist Overview The purpose of this checklist is to aid the payers that interact with providers, payers, and other trading partners in organizing end-to-end testing. Level 1 Timeline: months from regulation implementation date Level 1 of the end-to-end testing process includes the following Elements: Planning Review new Regulation and become educated on the requirements. Look to professional associations for information and resources to help your organization understand the impact of Affordable Care Act and how to prepare your practice. Obtain updated publications and tools with new regulation changes. Communicate changes with staff. Establish Affordable Care Act project team. Develop Affordable Care Act project plan, budget, and risk management plan. Assessment Perform an assessment of the detailed regulation changes (all transactions). Identify impact of Affordable Care Act to your organization s business processes and systems. Inventory and list all Trading Partners and Software Vendors. Review Trading Partner Agreements and make changes as necessary. Obtain and assess each vendor(s) testing plan and implementation timeline of Affordable Care Act into all systems. 1 Page

2 Payer Affordable Care Act End-to-End Testing Checklist Design Review new or update current business requirements for all affected systems and processes due to the regulation change. Include the identification changes of screen, reporting, data extract, and web-based applications or portals. Create/update data mapping and analyze required database changes. Verify and document that you have the most recent version of external codes and have updated your systems. Determine if Explanation of Benefits (EOB)/Explanation of Payment (EOP) changes for participants and/or providers will be required and how you will communicate these changes. Development Review and adjust as necessary Technical Specification. Perform necessary functions to complete needed database changes. Perform necessary functions to complete development including updated edits/audits. Following your organization's testing policies, perform unit testing: Unit testing will confirm that the updates meet the individual component requirements. Update Business Requirements and Technical Specifications as necessary. Testing Create a Quality Assurance Plan/tracking tool to coordinate your internal testing and testing with multiple Trading Partners and transactions you are testing for. Create a Test Plan that can be used for each stage of testing: Level 1 (internal testing); Level 2 (Trading Partner testing and end-to-end testing); Level 3 (end-to-end testing) Determine what percentage (%) of mission-critical external Trading Partners you will be testing with and document. Work with each Trading Partner that you have identified for testing to establish communication, plan and schedule testing, obtain a copy of the Trading Partner s Test Plan, and trade updated companion guides. Work with each Trading Partner to formulate a back-up plan in the event one party is not ready to implement by the regulatory implementation date. Create test scripts with both positive and negative tests, define successful and unsuccessful test results, and include system edit/audit testing (pass/fail). Perform Level 1 testing. 2 Page

3 Payer Affordable Care Act End-to-End Testing Checklist Transition Create an Implementation/Migration Event Plan. Determine when system/hardware changes will be finalized and evaluate against your established timeline. Develop plan for post-implementation data analysis by identifying potential code/code categories to focus on. Documentation: Develop new or update your existing procedural manuals and/or workflows; continue to update or create new training material and e-learning. Ensure staff is familiar with new upgrade and is knowledgeable with any new functionality. Level 2 Timeline: 6 12 months from regulation implementation date Level 2 of the end-to-end testing process includes the following Elements: Assessment Review and refine Trading Partner Test Plan to ensure any changes made during Level 1 are updated and included for testing. Contact application vendors (as necessary) if your software upgrade for the regulation change has not been implemented. Determine their delivery schedule(s) for the system upgrade(s). Identify the Interchange IDs, Receiver Code, any other relevant ISA information prior to entering the testing phase to avoid unnecessary file level rejections in testing or production areas. Ensure that your system is set-up with required test data meeting your Trading Partners' requirements and can accommodate their requirements. Create additional test scripts needed to meet Trading Partners' requirements. Update Test Plan as needed for results tracking. Design Create and/or update training documents such as manuals and e-learning as necessary for this regulation change. Create your post-production monitoring plan (transaction denials and rejections, transaction coding accuracy, payments including diagnosis-related groupers (DRGs), Home Health Resource Groups (HHRGs) working with your providers). Testing Perform System Integration Testing (SIT), review test results and address defects and document your test results in your test plan. 3 Page

4 Payer Affordable Care Act End-to-End Testing Checklist Before moving to end-to-end testing, you should complete a minimum of two (2) complete internal tests working though any major defects. If you have a "mock" production environment, you should plan on conducting "mock" production moves to ensure that your code moves go smoothly. Perform Connectivity Testing with Trading Partners, update results in Test Plan. For each Trading Partner identified for testing, perform end-to-end (E2E) testing against your test plan and document results, take corrective action as necessary. Obtain documentation that you have completed and passed testing with each of your Trading Partners. This documentation needs to be retained in your documentation. Transition Formulate your production move timeline and update your project timeline. Communicate this both internal and externally. Plan your migration with timing that will allow you to handle unforeseen obstacles. Identify what system upgrades need to be in place before the production move, schedule the upgrades as needed. Meet with project team to review final plans and lessons learned. Complete all identified staff training as needed and finalize plans for future training for new staff, new Trading Partners, new customers, etc. Plan your post-implementation audit process to ensure compliance and monitor impact. Level 3 Timeline: 1 3 months from regulation implementation date Level 3 of the end-to-end testing process includes the following Elements: Planning Revisit Implementation Plan to ensure all systems are ready and Contingency Plan is up-to-date and document post-implementation plans. Communicate transition and post-implementation plans. Finalize project documentation and budget. Testing Determine if there are any Erratas that need to be included that you have not previously accommodated. 4 Page

5 Payer Affordable Care Act End-to-End Testing Checklist Continue to complete testing with Trading Partners. Document and communicate your results using your Test Plan and refine your Implementation Plan making necessary changes and retesting as needed. For each Trading Partner you have tested with, obtain documentation that you have completed and passed testing. Retain these documents in your records. Transition Perform any Production Readiness Testing. Perform internal testing/post implementation/migration before opening up systems to ensure the code move was successful and the system is operating as expected. Move to post-implementation plan to follow-up with any major issues. Implement post-production monitoring plan; taking corrective action as necessary including system adjustments and additional training. Analyze and identify the impact of implementation of this regulation. 5 Page

6 Payer Administrative Simplification End-to-End Testing Checklist Overview The purpose of this checklist is to aid the payers that interact with providers, payers, and other trading partners in organizing end-to-end testing. Level 1 Timeline: months from regulation implementation date Level 1 of the end-to-end testing process includes the following Elements: Planning Review new Regulation and become educated on the requirements. Look to professional associations for information and resources to help your organization understand the impact of Administrative Simplification and how to prepare your practice. Obtain updated publications and tools with new regulation changes. Communicate changes with staff. Establish Administrative Simplification project team. Develop Administrative Simplification project plan, budget, and risk management plan. Assessment Perform an assessment of the Administrative Simplification Regulation (all transactions). Identify impact of Administrative Simplification to your organization s business processes and systems. Inventory and list all Trading Partners and Software Vendors. Review Trading Partner Agreements and make changes as necessary. Obtain and assess each vendor(s) testing plan and implementation timeline of Administrative Simplification into all systems. 1 Page

7 Payer Administrative Simplification End-to-End Testing Checklist Design Review new or update current business requirements for all affected systems and processes due to the regulation change. Include the identification changes of screen, reporting, data extract, and web-based applications or portals. Create/update data mapping and analyze required database changes. Verify and document that you have the most recent version of external codes and have updated your systems. Determine if Explanation of Benefits (EOB)/Explanation of Payment (EOP) changes for participants and/or providers will be required and how you will communicate these changes. Development Review and adjust as necessary Technical Specifications. Perform necessary functions to complete needed database changes. Perform necessary functions to complete development including updated edits/audits. Following your organization's testing policies, perform unit testing: unit testing will confirm that the updates meet the individual component requirements. Testing Update Business Requirements and Technical Specifications as necessary. Create a Quality Assurance Plan/tracking tool to coordinate your internal testing and testing with multiple Trading Partners and transactions you are testing for. Create a Test Plan that can be used for each stage of testing: Level 1 (internal testing); Level 2 (Trading Partner testing and end-to-end testing); Level 3 (end-to-end testing) Determine what percentage (%) of mission-critical external Trading Partners you will be testing with and document. Work with each Trading Partner that you have identified for testing to establish communication, plan and schedule testing, obtain a copy of the Trading Partner s Test Plan, and trade updated companion guides. Work with each Trading Partner to formulate a back-up plan in the event one party is not ready to implement by the regulatory implementation date. Create test scripts with both positive and negative tests, define successful and unsuccessful test results, and include system edit/audit testing (pass/fail). Perform Level 1 testing. Transition Create an Implementation/Migration Event Plan. 2 Page

8 Payer Administrative Simplification End-to-End Testing Checklist Determine when system/hardware changes will be finalized and evaluate against your established timeline. Develop plan for post-implementation data analysis by identifying potential code/code categories to focus on. Documentation: Develop new or update your existing procedural manuals and/or workflows; continue to update or create new training material and e-learning. Ensure staff is familiar with new upgrade and is knowledgeable with any new functionality. Level 2 Timeline: 6 12 months from regulation implementation date Level 2 of the end-to-end testing process includes the following Elements: Assessment Review and refine Trading Partner Test Plan to ensure any changes made during Level 1 are updated and included for testing. Contact application vendors (as necessary) if your software upgrade for the regulation change has not been implemented. Determine their delivery schedule(s) for the system upgrade(s). Identify the Interchange IDs, Receiver Code, and any other relevant ISA information prior to entering the testing phase to avoid unnecessary file level rejections in testing or production areas. Ensure that your system is set-up with required test data meeting your Trading Partners' requirements and can accommodate their requirements. Create additional test scripts needed to meet Trading Partners' requirements. Update Test Plan as needed for results tracking. Design Create and/or update training documents such as manuals and e-learning as necessary for this regulation change. Create your post-production monitoring plan (transaction denials and rejections, transaction coding accuracy, payments including diagnosis-related groupers (DRGs), Home Health Resource Groups (HHRGs) working with your providers). Testing Perform System Integration Testing (SIT); review test results and address defects and document your test results in your Test Plan. Before moving to end-to-end testing, you should complete a minimum of two (2) complete internal tests working though any major defects. If you have a "mock" production environment, you should plan to conduct "mock" production moves to ensure that your code moves go smoothly. 3 Page

9 Payer Administrative Simplification End-to-End Testing Checklist Perform Connectivity Testing with Trading Partners; update results in your Test Plan. For each Trading Partner identified for testing, perform end-to-end (E2E) testing against your test plan and document results, take corrective action as necessary. Obtain documentation that you have completed and passed testing with each of your Trading Partners. This needs to be retained in your documentation. Transition Formulate your production move timeline and update your project timeline. Communicate this both internally and externally. Plan your migration with timing that will allow you to handle unforeseen obstacles. Identify what system upgrades need to be in place before the production move; schedule the upgrades as needed. Meet with project team to review final plans and lessons learned. Complete all identified staff training, as needed, and finalize plans for future training for new staff, new Trading Partners, new customers, etc. Plan your post-implementation audit process to ensure compliance and monitor impact. Level 3 Timeline: 1 3 months from regulation implementation date Level 3 of the end-to-end testing process includes the following Elements: Planning Revisit Implementation Plan to ensure all systems are ready and Contingency Plan is up-to-date and document post-implementation plans. Testing Communicate transition and post-implementation plans. Finalize project documentation and budget. Determine if there are any Erratas that need to be included that you have not previously accommodated. Continue to complete testing with Trading Partners. Document and communicate your results using your Test Plan and refine your Implementation Plan making necessary changes and retesting as needed. For each Trading Partner you have tested with, obtain documentation that you have completed and passed testing. Retain these documents in your records. 4 Page

10 Payer Administrative Simplification End-to-End Testing Checklist Transition Perform any Production Readiness Testing. Perform internal testing/post implementation/migration before opening up systems to ensure the code move was successful and the system is operating as expected. Move to post-implementation plan to follow-up with any major issues. Implement post-production monitoring plan. Take corrective action as necessary including system adjustments and additional training. Analyze and identify the impact of implementation of this regulation. 5 Page

11 Payer ICD-10 End-to-End Testing Checklist Overview The purpose of this checklist is to aid the payers that interact with providers, payers, and other trading partners in organizing end-to-end testing. Level 1 Timeline: months from regulation implementation date Level 1 of the end-to-end testing process includes the following Elements: Planning Review new Regulation and become educated on the requirements. Look to professional associations for information and resources to help your organization understand the impact of ICD-10 and how to prepare your practice. Obtain updated publications and tools with new regulation changes. Communicate changes with staff. Establish ICD-10 project team. Develop ICD-10 project plan, budget, and risk management plan. Assessment Evaluate CMS and National Center for Health Statistics (NCHS) General Equivalence Mappings (GEMs) and reimbursement crosswalks and mapping tools. Identify impact of ICD-10 to your organization s business processes and systems. Inventory and list all Trading Partners and Software Vendors. Obtain and assess each vendor(s) testing plan and implementation timeline of ICD-10 into all systems. Identify contracts that need to be modified to comply with changes, determine who will be making changes and the date the modifications need to be completed by. 1 Page

12 Payer ICD-10 End-to-End Testing Checklist Design Develop plan to handle claims received with dates of service incurred before October 1, 2014, which will be coded with ICD-9 codes and for claims received with dates of serviced incurred after October 1, 2014, which need to run concurrently. Review new or update current business requirements for all affected systems and processes due to the regulation change. Include the identification changes of screen, reporting, data extract, and web-based applications or portals. Create/update data mapping and analyze required database changes. Verify and document that you have the most recent version of external codes and have updated your systems. Determine if Explanation of Benefits (EOB)/Explanation of Payment (EOP) changes for participants and/or providers will be required and how you will communicate these changes. Development Verify all fields within your system(s) and documentation that holds ICD codes are now at the proper length and type to accommodate ICD-10 changes. Perform necessary functions to complete needed database changes. Perform necessary functions to complete development including updated edits/audits. Following your organization's testing policies, perform unit testing: Unit testing will confirm that the updates meet the individual component requirements. Testing Update Business Requirements and Technical Specifications as necessary. Create a Quality Assurance Plan/tracking tool to coordinate your internal testing and testing with multiple Trading Partners and transactions you are testing for. Create a Test Plan that can be used for each stage of testing: Level 1 (internal testing); Level 2 (Trading Partner testing and end-to-end testing); Level 3 (end-to-end testing) Determine what percentage (%) of mission-critical external Trading Partners you will be testing with and document. Work with each Trading Partner that you have identified for testing to establish communication, plan and schedule testing, obtain a copy of the Trading Partner s Test Plan, and trade updated companion guides. Work with each Trading Partner to formulate a back-up plan in the event one party is not ready to implement by the regulatory implementation date. Create test scripts with both positive and negative tests, define successful and unsuccessful test results, and include system edit/audit testing (pass/fail). 2 Page

13 Payer ICD-10 End-to-End Testing Checklist Perform Level 1 testing. Transition Create an Implementation/Migration Event Plan. Determine when system/hardware changes will be finalized and evaluate against your established timeline. Develop plan for post-implementation data analysis by identifying potential code/code categories to focus on. Documentation: Develop new or update your existing procedural manuals and/or workflows; continue to update or create new training material and e-learning. Ensure staff is familiar with new upgrade and is knowledgeable with any new functionality. Level 2 Timeline: 6 12 months from regulation implementation date Level 2 of the end-to-end testing process includes the following Elements: Assessment Review and refine Trading Partner Test Plan to ensure any changes made during Level 1 are updated and included for testing. Contact application vendors (as necessary) if your software upgrade for the regulation change has not been implemented. Determine their delivery schedule(s) for the system upgrade(s). Identify the Interchange IDs, Receiver Code, any other relevant ISA information prior to entering the testing phase to avoid unnecessary file level rejections in testing or production areas. Ensure that your system is set-up with required test data meeting your Trading Partners' requirements and can accommodate their requirements. Create additional test scripts needed to meet Trading Partners' requirements. Update Test Plan as needed for results tracking. Design Create and/or update training documents such as manuals and e-learning as necessary for this regulation change. Create your post-production monitoring plan (transaction denials and rejections, transaction coding accuracy, payments including diagnosis-related groupers (DRGs), Home Health Resource Groups (HHRGs) working with your providers). 3 Page

14 Payer ICD-10 End-to-End Testing Checklist Testing Perform Level 2 testing, review test results and address defects and document your test results in your test plan. Before moving to end-to-end testing, you should complete a minimum of two (2) complete internal tests working though any major defects. If you have a "mock" production environment, you should plan on conducting "mock" production moves to ensure that your code moves go smoothly. Perform Connectivity Testing with Trading Partners, update results in your Test Plan. For each Trading Partner identified for testing, perform End-to-End (E2E) testing against your test plan and document results, take corrective action as necessary. Obtain documentation that you have completed and passed testing with each of your Trading Partners. This documentation needs to be retained in your documentation. Transition Formulate your production move timeline and update your project timeline. Communicate this both internally and externally. Plan your migration with timing that will allow you to handle unforeseen obstacles. Identify what system upgrades need to be in place before the production move, schedule the upgrades as needed. Meet with project team to review final plans and lessons learned. Complete all identified staff training, as needed, and finalize plans for future training for new staff, new Trading Partners, new customers, etc. Plan your post-implementation audit process to ensure compliance and monitor impact. Level 3 Timeline: 1 3 months from regulation implementation date Level 3 of the end-to-end testing process includes the following Elements: Planning Revisit Implementation Plan to ensure all systems are ready and Contingency Plan is up-to-date and document post-implementation plans. Communicate transition and post-implementation plans. Finalize project documentation and budget. 4 Page

15 Payer ICD-10 End-to-End Testing Checklist Testing Determine if there are any Erratas that need to be included that you have not previously accommodated. Continue to complete testing with Trading Partners. Document and communicate your results using your Test Plan and refine your Implementation Plan making necessary changes and retesting as needed. For each Trading Partner you have tested with, obtain documentation that you have completed and passed testing. Retain these documents in your records. Transition Perform any Production Readiness Testing. Perform internal testing/post implementation/migration before opening up systems to ensure the code move was successful and the system is operating as expected. Move to post-implementation plan to follow-up with any major issues. Implement post-production monitoring plan. Take corrective action as necessary including system adjustments and additional training. Analyze and identify the impact of implementation of this regulation. 5 Page

16 Admin Simplification General Yes No N/A NCPDP Acknowledgement Level Task Steps/Definitions Lessons Learned/Notes Gen Element: General Information, HIPAA Compliance Gen G.1 Determine if you are HIPAA compliant You are required to be HIPAA compliant if you conduct any of the following electronic business transactions. (list transactions) If you do not conduct any of these transactions, you are most likely not covered by HIPAA and do not need to continue with this checklist. Gen G.2 Do you, or a third party billing company or clearinghouse, conduct any one of the following business transactions electronically? Gen G.2.a Claims or equivalent encounter information Gen G.2.b Payment and remittance advice Gen G.2.c Claim status Gen G.2.d Inquiry/response Gen G.2.e Eligibility inquiry/response Gen G.2.f Referral authorization inquiry/ response Gen G.2.g If Yes, continue with the checklist. Gen G.2.h IF NO, YOU DO NOT NEED TO COMPLETE THE CHECKLIST. Gen G.3 Has your organization completed implementation of ASC X12 Version XXXX for HIPAA transactions? Gen G.4 Has your organization completed implementation of NCPDP Version X.X for HIPAA transactions? Gen G.4.a Mark the types of transactions that you submit or receive shown to the right. TA CA Proprietary Links Gen G.4.b Mark the types of transactions that you will test shown to the right. Page 1 of 48

17 Administrative Simplification LEVEL 1 The Level 1 Testing is the period during which entities perform all of their internal readiness activities in preparation for testing the new versions of the standards with their Trading Partners. When an entity has attained Level 1 compliance, it has completed all internal readiness activities and is fully prepared to initiate testing of the new versions in a test or production environment, pursuant to its standard protocols for testing and implementing new software or data exchanges. 1 1 Element: Planning Following your company's project management procedures establish governance and implement a project plan and Project Charter including project milestones, compliance dates, tasks, and deadlines. Identify Stakeholders, project manager, sponsors, and project team members. Continue to refine and update project plan throughout all levels. Ensure that your project sponsors and/or management team understands the breadth and potential impact of regulation change to your organization Review new Regulation and become educated on the requirements. Obtain updated information on regulation change from CMS. Start identifying all areas within your organization that could be impacted by this regulation change Obtain updated EDI publications and tools such as Technical Report Type TR3 (formerly known as Implementation guides) including EDI Transaction Sets as needed Create and follow a Project Timeline that meets your organization's needs keeping the implementation deadline in mind. Communicate timeline internally and externally keeping up-to-date with changes Establish risk management identification, documentation, and mitigation strategies. As part of your Risk Management Plan, include how you will coordinate communication and decision making between the governance team and the implementation team; as well as have clear decision making process defined for issue resolution Implement Issue Tracking with mitigation strategies Develop a Communication Plan and establish communication risk and mitigation strategies. During regulation review, look to professional for information and resources to help your Guidance/Regulations-and-Guidance.html organization understand the impact of this regulation and how to prepare your practice. One source is Washington Publishing (See Links). There are many resources available in the industry to provide guidance and information for the implementation of Administrative Simplification. Risks should include anything that could negatively affect this implementation as well as all other projects that may be going on in your organization that may impact or compete with your project for resources. Communication plans should include communication with internal staff, Trading Partners, providers, contractors, vendors, etc as well as web-based communication if you have a website. Page 2 of 48

18 Administrative Simplification Include a section in your Communication Plan for situations identified during your gap analysis and Business Requirement Phase as well as your Budget. Identify if the communication applies to your Partners and/or customers, devise a communication vehicle to keep everyone apprised of the change. Simple Project Dashboards are a simple and effective communication tool Create a project documentation repository where all project documents are kept and project team and sponsors have access Create a Project Budget which should be comprehensive and include all costs from planning phase to final transition and ongoing support including a Cost Benefit Analysis, if necessary. Secure your funding for this project. Determine what artifacts are to be produced at the end of each phase or level prior to entering the next phase or level and who is responsible for those artifacts. Maintain project documentation as required by your organization, these are valuable tools for the next change. Ensure all materials are updated by end of each phase of the project. Assess your budget needs and start the budget process, there are many things to consider for your budget: Hardware and software upgrades; Server upgrades; Software development and modifications; Staffing: new or temporary staff; Education and training; Resource material; Testing and/or certification costs; Other costs Element: Assessment Identify potential impact to organization by conducting a complete inventory of your business process, areas, policies, vendors and systems to determine what will be affected by this regulation change Identify and list all Trading Partners (TPs) and identify what type of transaction are traded with that TP, make sure you have up to date contact information Review Trading Partner Agreements and make changes as necessary. Implementation of regulation may have potentially far reaching implications that could impact numerous aspects of your organization. Involve all affected areas of your organization early in the process. Page 3 of 48

19 Administrative Simplification Perform an assessment of the detailed regulation change including the following transaction: X (Institutional, Professional, Dental) Healthcare Payment ASC X Healthcare Payment ASC X Eligibility Request ASC X Eligibility Response ASC X Healthcare Claim Status Request ASC X Healthcare Claim Status Response ASC X Referral Certification and Authorization request and response ASC X12 277CA NCPDP D.0 and/or NCPDP 1.2 (batch) Healthcare EFT and the ERA(835) Acknowledgments; 999, TA Software Vendor: Do you currently have a software vendor? Yes - continue with a No - continue at a All - continue with a Software vendors may or may not be covered entities and may not be responsible for compliance. However, vendors are critical to provider and payer compliance and any interruption in vendor implementation of compliant products will delay end-to-end testing. Independent of your software vendor, educate you and your staff on the regulation and the requirements including implementation deadlines a Contact software vendor(s): Determine what plans they have to make sure they are in compliance with the regulation and meeting the deadline. Understand the upgrade requirements: hardware, file conversions, and implementation compatibility with the current version. Perform necessary hardware or software procurements. Determine if the vendor will support both the existing version and the new version transactions exchange concurrently (across multiple Trading Partners both in test and production modes). Page 4 of 48

20 Administrative Simplification b Working with each software vendor; obtain timeline and project plan from vendor(s) for implementation changes and obtain a copy of their Test Plan. Review and determine if it meets your needs. Work with vendor(s) to fill in gaps as needed. Confirm installation will be completed before the compliance date and there is sufficient lead time to test before compliance date. Schedule for installation, how and who will complete the installation, obtain contact information c If there is a software upgrade, determine if there is a cost and/or anticipated pricing change. Update budget and obtain funding as necessary No: Your software is developed internally and not supported by outside vendors a Perform system(s) review to determine if changes are necessary or new edit/audits need to be added including edit mappings and system translators, preparing to start business requirements All: Applies to both internally and externally supported applications a Contact clearinghouses and/or Trading Partners that you are contracted with to learn when they will complete testing and update your Trading Partner listing b Hardware Requirements: Analyze hardware requirements to ensure they support the required upgrades. Update budget as necessary c Review impact of this implementation to other computer systems, portals, reports, data extracts within your organization d Identify all transactions that could or will experience delays for both providers and/or participants, including but not limited to processing of claims, Case Management, Preauthorization, or other transactions during this transition. Develop a Contingency Plan, Mitigation Plan, and Communication Plan Page 5 of 48

21 Administrative Simplification e Business Contracts: Identify contracts need to be modified to comply with changes, determine who will be making changes and the date the modifications need to be completed by f Help-Desk: Evaluate your staffing and determine if a help-desk will need to be formed to handle customer support during implementation. Evaluate equipment needs and update budget as necessary g Contact key Vendors to learn of EDI exchange modifications (e.g., Will a new Submitter ID be required for the new version versus the current version; will telecommunication connectivity changes be required?) Education and training: Determine who in your organization will need to have training on the changes to meet your needs. The final rule indicates there are 4 levels of training: Inpatient Codes, Outpatient Coders, Physicians, and Auxiliary Staff Determine what level of training and where training is available, update budget and obtain funding. If travel is required consider the costs of travel, lodging, etc... in your budget Determine if new resource material will need to be purchased. Update budget as necessary Create and maintain a FAQ document to share with staff and customers, publish FAQs for external partners Identify your staffing needs and determine if temporary help need to be brought in to complete the implementation, provide help desk support, or provide training. Organizations may hold several national calls one could attend for free that could provide additional information on the implementation changes. Continue to update and maintain the FAQ document throughout all elements and levels, Identify staffing constraints with other commitments for the project team. If additional staffing needs have been identified, create a timeline for when the additional staffing will be needed before, during, and/or after implementation as this will help in your budget planning Element: Design Page 6 of 48

22 Administrative Simplification Review your Standard Operating Procedures (SOP). Develop new SOP(s) or update current SOP(s) as necessary Business Requirements: Complete new or update current business requirements for all affected systems and processes due to the regulation change. Include the identification changes of screen, reporting, data extract, and web-based applications or portals. Work with your end users during this phase to identify and implement additional changes as needed. Review business requirements in detail with project team, end users, and development staff for understanding. 3.3 Design programming changes that addresses security rules, and privacy act regulations Create/update Application Technical Specifications Create/update data mapping and analyze required database changes Determine your organizations procedures for obtaining and updating the most recent versions of the External Codes keeping your system up-todate for with all additions/ deletions/and changes. These can be obtained from Washington Publishing Company. Verify and document that you have the most recent version of external codes and have updated your systems. Claim Adjustment Reason Codes (CARC) Remittance Advice Remark Codes (RARC) Claims Status Category Codes Health Care Claim Status Codes Health Care Services Decision Reason Codes Health Care Provider Taxonomy Code Set Health Care Provider Characteristics Codes Determine if Explanation of Benefits (EOB)/Explanation of Payment (EOP) changes for participants and/or providers will be required and how you will communicate these changes Element: Development Review and adjust as necessary Technical Specification Perform necessary functions to complete needed database changes Perform necessary functions to complete development including updated edit/audits Following your organization's testing policies, perform unit testing: Unit testing will confirm that the updates meet the individual component requirements. Page 7 of 48

23 Administrative Simplification Update Business Requirements and Technical Specifications as necessary Element: Testing Create a Quality Assurance Plan and a tracking tool to coordinate your internal testing and testing with multiple Trading Partners and transactions you are testing for, you can track scheduled testing, results, and notification for productions moves Determine what percentage (%) of mission critical external Trading Partners you will be testing with and document Work with each Trading Partner that you have identified for testing to establish communication, plan and schedule testing, obtain a copy of the Trading Partner's Test Plan, and trade updated companion guides. You should also identify how many test files can be sent for each transaction and testing data sets as this can be different with each Trading Partner. Mission Critical Trading Partners could be direct submit providers, clearinghouses, vendors (if purchased software), data Trading Partners. You should review your Trading Partners test plan and determine if it meets your needs. Work with vendor(s) to fill in gaps as needed. Having the ability to send multiple test files for each transaction allows you to work out any errors encountered and verify they are corrected Identify with each testing partner if you can send identifiable data or whether you must de-identify test data. This will have an impact on your test data Work with each Trading Partner to formulate a back-up plan in the event one party is not ready to implement by the regulatory implementation date Determine your options for all applicable transaction types if you or your Trading Partner are not ready by the regulatory implementation date. Document reasons why, plans you are taking to get ready, and estimated date to be ready Include in your Risk Management Plan the impact to your organization if you or any of your mission critical Trading Partners are not ready to meet the regulatory implementation date. If you can only send de-identified information, this may not allow you to test prior to early production. Page 8 of 48

24 Administrative Simplification Prepare your test system by assuring new code is migrated and test cases data is updated Create a Test Plan that can be used for each stage of testing; Level I: system testing, regression testing, performance testing, privacy-security testing, user acceptance, and Level II (including end-to-end testing for each Trading Partner you test with) Create test scripts with both positive and negative tests, define successful and unsuccessful test results, and include system edit/audit testing (pass/fail). Test scripts should include complex and simple test cases and should include transactions that require the generation of another transaction Determine if end-to-end testing will be completed in a production-like or production environment Determine if there is an adopted Errata and if and when you will be including in testing. Test Plan should track needed elements to provide a management report and testing artifact that summarizes the testing results including which items passed, and which items failed. Identify volume of success and where failure occurred, and action items to remediate testing failures. If production-like environment, verify that this environment is a complete replica of production with upto-date information such as providers, enrollment, workflows, error messages based on new code. If there is an adopted Errata, confirm with each Trading Partner you will be testing with if they have implemented Guidance/Regulations-and-Guidance.html the Errata and will the testing included the Errata changes. If not, will you be required to retest once they have implemented the Errata? Perform Level 1 testing activities; review test results, address defects, update testing plan, and communicate testing results Complete System Testing Complete Regression Testing Complete User Acceptance Testing Complete Non-functional testing such as Performance and Privacy/Security Element: Transition Errata is a list of errors and their corrections inserted, usually on a separate page or slip of paper, in a book or other publication; corrigenda. Performance testing is to ensure the changes implemented have not impacted application speed, stability, and scalability. Page 9 of 48

25 Administrative Simplification Create a Implementation/Migration Event Plan and revisit it throughout all phases up to the Include in your plan time to educate all team members on Implementation/Migration Event Plan. scheduled event Determine when system/hardware changes will be finalized and evaluate against your established timeline. Make necessary adjustments Develop plan for post-implementation data analysis by identifying potential code/code categories to focus on. This will help reveal insights on how coverage policies or overall reimbursements might be affected Documentation: Develop new or update your existing procedural manuals and/or workflows; continue to update or create new training material and e-learning. Ensure staff is familiar with new upgrade and is knowledgeable with any new functionality Create/update Companion Guides as necessary. Publish Companion Guides as soon as they are completed allowing your Trading Partners time to review Review Business Associate Agreements and make changes as necessary Determine back-up plan in case there is a problem in moving code to production. 1 LEVEL 2 The Level 2 Testing is the period during which entities are preparing to reach full production readiness with Trading Partners. When an entity is in compliance with Level 2, it has completed some end-to-end testing with external Trading Partners. 2 1 Element: Assessment Review and refine Trading Partner Test Plan to ensure any changes made during Level 1 are updated and included for testing. Test Plan with your Trading Partners should include connectivity testing. You should verify Trading Partner's Interchange IDs, Receiver Code, and other relevant ISA information. Review of your test plan document will ensure that it is up-to-date before you begin Trading Partner testing. This documented should be used to communicate your testing results and shared with implementation team and Trading Partners Review Trading Partner Testing schedule against timeline and make necessary adjustments. Contact application vendors (as necessary) if your software upgrade for the regulation change has not been implemented. Determine their delivery schedule(s) for the system upgrade(s). Page 10 of 48

26 Administrative Simplification Work with your Trading Partners identified for testing; confirm testing schedule, required test scripts, and testing protocol, document; update Quality Assurance Plan (QAP) and Test Plan. meeting the requirements of vendors for testing. Determine if the entity you are testing with will require you to use the entity's test data Identify the Interchange IDs, Receiver Code, any other relevant ISA information prior to entering the testing phase to avoid unnecessary file level rejections in testing or production areas Determine if there are other Trading Partners that will require testing not previously identified Ensure that your system is set-up with required test data for each of your Trading Partner(s) that you will be testing with and that your system(s) can accommodate their requirements, make adjustments as necessary. If using test providers, confirm that all test providers records are set up to match the correct NPI, TIN, location, special Provider ID, etc. required by the Partner you testing with Create additional test scripts needed to meet Trading Partners' requirements. Update Test Plan as needed for results tracking Verify that all Level 1 testing has been completed Review your Risk Management Plan established in Level 1 to ensure you have an adequate contingency if you are unable to meet testing dates with vendors Element: Design Create and/or update training documents such as manuals and e-learning as necessary for this regulation change. Page 11 of 48

27 Administrative Simplification Create your post-production monitoring plan that should include monitoring of: Transaction denials and rejections Productivity Transaction coding accuracy System functionality and response time Payments including diagnosis-related groupers (DRGs), Home Health Resource Groups (HHRGs) working with your providers; 2 3 Element: Testing Perform Level 2 testing activities; review test results, address defects, update testing plan, and communicate testing results Perform System Integration testing, review test results and address defects and document your test results in your test plan Before moving to end-to-end testing, you should complete at minimum of two (2) complete internal tests working through any major defects If you have a "mock" production environment, you should plan on conducting "mock" production moves to ensure that your code moves go smoothly Run internal testing of test scripts created for testing with Trading Partners Perform Connectivity Testing with Trading Partners, update results in test plan For each Trading Partner identified for testing, perform End-to-End (E2E) testing against your test plan and document results, take corrective action as necessary Use your testing plan to track and provide coordination of testing with your Trading Partners Obtain documentation that you have completed and passed testing with each of your Trading Partners. This documentation needs to be retained in your documentation Make changes and retest as necessary. 2 Page 12 of 48

28 Administrative Simplification 2 3 Element: Transition Plan your migration with timing that will allow you to handle unforeseen obstacles. Example, if you have a deadline of implementation of 1/1, when can you move this to production prior to 1/1 that will allow time for roll-back or corrections before deadline? Formulate your production move timeline and update your project timeline. Communicate this both internal and externally Work with your implementation team to plan and organize how non-system changes be implemented. Determine if your system be down during normal business hours to accommodate the production move, plan communication, and update risk management as appropriate. Ensure you continue project documentation, meetings and update project sponsors Identify what system upgrades need to be in place before the production move, schedule the upgrades as needed Meet with project team to review final plans and lessons learned Formulate a back-up plan in the event there is a problem with the system migration Determine if the implementation will have an impact to your day-to-day business, formulate your contingency plan for this impact, including downtime communication plan Identify other competing system changes near the proposed production move, evaluate the impact to your implementation move Implement your migration Communication Plan including any web-based communication and FAQ Plan your post-implementation audit process to ensure compliance and monitor impact on payments, denials, coding, productivity, fraud and abuse detection, application response time and capacity, and reporting Complete training material and/or e-learning. There could also be other competing company events near the proposed production move. Communicate internally with stakeholders, customers, Trading Partners, and business associates. Page 13 of 48