Committee on Operating Rules for Information Exchange (CORE)

Committee on Operating Rules for Information Exchange (CORE)

Committee on Operating Rules for Information Exchange (CORE) Presentation to eHealth Initiatives Third Annual Connecting Communities Learning Forum Washington, DC April 10, 2006 Discussion Topics Overview of CAQH and CORE CORE Phase I Operating Rules 270/271 Data Content Acknowledgements Response Time System Availability Connectivity Companion Documents 2 Becoming CORE Phase I Certified Participating in CORE Phase II rules development

An Introduction to CAQH CAQH, a nonprofit alliance of leading health plans, networks and trade associations, is a catalyst for industry initiatives that streamline healthcare administration CAQH solutions help: Promote quality interactions between plans, providers and other stakeholders Reduce costs and frustrations associated with healthcare administration Facilitate administrative healthcare information exchange Encourage administrative and clinical data integration 3 CORE Committee On Operating Rules For Information Exchange 4 Physician-Payer Interaction Physician Activities That Interact With Payers are Primarily Administrative in Nature (with Some Clinical Interaction) Primary Physician Activities Pre-Visit Activities Patient inquiry Appt scheduling Scheduling

verification Financial review of pending appts. Encounter form/ medical record preparation 5 Office and Other Visits Registration & referral mgmt. Admin & medical record preparation Patient visit Ancillary testing Charge capture Prescriptions Inpatient Activities Scheduling & referral mgmt.

Admin & medical record preparation Inpatient care Ancillary testing Charge capture Surgical Cases Scheduling & referral mgmt. Admin & medical record preparation Surgical care Post care Follow-up care Post-Visit Follow-up Admin. Follow-up Visit orders & Utilization review Claims/bill instructions Education generation Billing

materials Prescriptions Payment Ancillary tests processing Referrals Claims follow-up Follow-up visits Admin. Responsibilities Personnel management Financial management Managed care Information systems Facilities management Medical staff affairs Key Challenges: Eligibility and Benefits HIPAA does not offer relief for the current eligibility problems Data scope is limited; elements needed by providers are not mandated Does not standardize data definitions, so translation is difficult Offers no business requirements, e.g., timely response

Individual plan websites are not the solution for providers Providers do not want to toggle between numerous websites that each offer varying, limited information in inconsistent formats 6 Vendors cannot offer a provider-friendly solution since they depend upon health plan information that is not available Vision: Online Eligibility and Benefits Inquiry Give Providers Access to Information Before or at the Time of Service... Providers will send an online inquiry and know: Which health plan covers the patient * Whether the service to be rendered is a covered benefit (including copays, coinsurance levels and base deductible levels as defined in member contract) What amount the patient owes for the service** What amount the health plan will pay for authorized services** Note: No guarantees would be provided * This is the only HIPAA-mandated data element; other elements addressed within Phase I scope are part of HIPAA, but not mandated

** These components are critically important to providers, but are not proposed for Phase I 7 Vision: Online Eligibility and Benefits Inquiry Using any System for any Patient or Health Plan As with credit card transactions, the provider will be able to submit these inquiries and receive a real-time response* From a single point of entry Using an electronic system of their choice For any patient For any participating health plan *Initiative will initially support batch and real-time 8 CORE

Industry-wide stakeholder collaboration launched in January 2005 Short-Term Goal Design and lead an initiative that facilitates the development and adoption of industry-wide operating rules for eligibility and benefits Long-Term Goal Based on outcome of initiative, apply concept to other administrative transactions 9 Answer to the question: Why cant verifying patient eligibility and benefits in providers offices be as easy as making a cash withdrawal? CORE Mission To build consensus among the essential healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between health plans and providers Build on any applicable HIPAA transaction requirements Enable providers to submit transactions from the system of their choice and quickly receive a standardized response from any participating stakeholder

Enable stakeholders to implement CORE phases as their systems allow Facilitate stakeholder commitment to and compliance with COREs longterm vision Facilitate administrative and clinical data integration 10 What are Operating Rules? Agreed-upon business rules for using and processing transactions Encourages the marketplace to achieve a desired outcome interoperable network governing specific electronic transactions (i.e., ATMs in banking) Key components Rights and responsibilities of all parties Transmission standards and formats Response timing standards Liabilities Exception processing Error resolution Security 11 Phased Approach CORE Timeline Overview Rule Development Phase I

2005 **Market Adoption *Phase II 2006 Phase I *Future Phases 2007 *Phase II 2008 2009 *Future Phases Notes: *Scope of Phase II and Future Phases will be decided upon by CORE Membership **Not all CORE participants will meet targeted market adoption timeframes; an ongoing CORE focus will be achieving/increasing adoption of established phases. CORE will look to its founding participants to achieve target market adoption timeline. 12

Current Participants Nearly 85 organizations participating representing all aspects of the industry: 16 health plans 9 providers 6 provider associations 16 regional entities/RHIOS/standard setting bodies/other associations 26 vendors (clearinghouses and PMS) 6 others (consulting companies, banks) 5 government entities, including: Centers for Medicare and Medicaid Services Louisiana Medicaid Unisys TRICARE 13

CORE participants maintain eligibility/benefits data to nearly 125 million commercially insured lives, plus Medicare beneficiaries Current Participants Health Plans 14 Aetna, Inc. Blue Cross Blue Shield of Michigan Blue Cross and Blue Shield of North Carolina

BlueCross BlueShield of Tennessee CareFirst BlueCross BlueShield CIGNA Excellus BlueCross BlueShield Group Health, Inc. Health Care Service Corporation Health Net, Inc. Health Plan of Michigan Humana, Inc. Independence Blue Cross Kaiser Permanente UnitedHealth Group WellPoint, Inc. Associations / Regional Entities / Standard Setting Organizations

Americas Health Insurance Plans (AHIP) ASC X12 Blue Cross and Blue Shield Association (BCBSA) Delta Dental Plans Association eHealth Initiative Healthcare Financial Management Association (HFMA) Healthcare Information & Management Systems Society Maryland/DC Collaborative for Healthcare IT National Committee for Quality Assurance (NCQA) National Council for Prescription Drug Programs (NCPDP) NJ Shore Private Sector Technology Group Smart Card Alliance Council Utah Health Information Network (UHIN) Utilization Review Accreditation Commission (URAC) Work Group for Electronic Data Interchange (WEDI) Providers

Adventist HealthCare, Inc. American Academy of Family Physicians (AAFP) American College of Physicians (ACP) American College of Radiology (ACR) American Hospice, Inc. American Medical Association (AMA) Greater New York Hospital Association HCA Healthcare Laboratory Corporation of America (LabCorp) Mayo Clinic Medical Group Management Association (MGMA) Montefiore Medical Center of New York University of Wisconsin Medical Foundation (UWMF) University Physicians, Inc. (University of Maryland) U.S. Oncology Government Agencies

Louisiana Medicaid Unisys Michigan Department of Community Health Michigan Public Health Institute TRICARE United States Centers for Medicare and Medicaid Services (CMS) Current Participants Vendors

15 ACS State Healthcare Affiliated Network Services Athenahealth, Inc. Availity LLC CareMedic Systems, Inc. EDIFECS Electronic Data Systems (EDS) Electronic Network Systems (ENS) Emdeon First Data Corp. GHN-Online HTP, Inc. InterPayNet MedAvant Healthcare Solutions MedCom USA MedData Microsoft Corporation NaviMedix Passport Health Post-N-Track Quovadx RxHub

Siemens / HDX SureScripts The TriZetto Group, Inc. ViPS (a Division of Emdeon) Other ABN AMRO Accenture Data Processing Solutions Marlabs, Inc. PNC Bank PricewaterhouseCoopers LLP CORE Work Groups And Subgroups CORE Steering Committee 16 Policy Work Group Rules Work Group

Subgroups Contracting Certification/Enforcement Long-Term Vision Subgroups Functional Responsibilities Definitions Identifiers Acknowledgements & Reporting Technical Work Group Subgroups Connectivity/Security Testing CORE Leadership POSITION COMPANY INDIVIDUAL Chair BCBSNC Harry Reynolds, Vice President

Vice Chair HCA Eric Ward, CEO of Financial Services Policy Work Group Chair Humana Bruce Goodman, Senior Vice President & CIO Rules Work Group Chair PNC Bank J. Stephen Stone, SVP & Director of Product Management Technical Work Group Chair Siemens Mitch Icenhower, Director, HDX At Large Members: Health Plan 1 Aetna Paul Marchetti, Head of Network Contracting, Policy and Compliance

At Large Members: Health Plan 2 BCBSMI Deborah Fritz-Elliott, Director, Electronic Business Interchange Group At Large Members: Vendor Org. TriZetto Dawn Burriss, Vice President, Constituent Connectivity At Large Members: Montefiore J. Robert Barbour, JD, Vice President, Finance for MD Services and Technical Development HIMSS H. Stephen Lieber, President & CEO Provider Organization At Large: Other Organization Other (Ex-officio or Advisor): CAQH: Robin Thomashauer, Executive Director; CMS: Stanley Nachimson, Senior Technical Advisor, Office of E-Health Standards and Services; ASC X12: Donald Bechtel, Co-Chair, X12 Healthcare Task Group (also with Siemens); WEDI: Jim Schuping, Executive Vice President; NACHA: Elliott McEntee, President and

CEO 17 CORE Phase I Operating Rules 18 Phase I Scope Pledge, Strategic Plan, including Mission/Vision Certification and Testing (conducted by independent entities) Connectivity -- HTTPS Safe harbor Response Time -- For batch and real-time System Availability -- For batch and real-time

Content Patient Responsibility (co-pay, deductible, co-insurance levels in contracts not YTD) Service Codes (9 for Phase I) 19 Acknowledgements Companion Guide (flow and format standards) 270/271 Data Content Rule The CORE Data Content Rule 20 Specifies what must be included in the 271 response to a Generic 270 inquiry or a nonrequired CORE service type Response must include The status of coverage (active, inactive)

The health plan coverage begin date The name of the health plan covering the individual (if the name is available) The status of nine required service types (benefits) in addition to the HIPAA-required Code 30 1-Medical Care 33 - Chiropractic 35 - Dental Care 47 - Hospital Inpatient 50 - Hospital Outpatient

86 - Emergency Services 88 - Pharmacy 98 - Professional Physician Office Visit AL - Vision (optometry) 270/271 Data Content Rule CORE Data Content Rule also Includes Patient Financial Responsibility 21 Co-pay, co-insurance and base contract deductible amounts required for 33 - Chiropractic

47 - Hospital Inpatient 50 - Hospital Outpatient 86 - Emergency Services 98 - Professional Physician Office Visit Co-pay, co-insurance and deductibles (discretionary) for 1- Medical Care 35 - Dental Care 88 - Pharmacy AL - Vision (optometry)

30 - Health Benefit Plan Coverage If different for in-network vs. out-of-network, must return both amounts Health plans must also support an explicit 270 for any of the CORE-required service types Real World Impact Data Content Patient Financial Responsibility 22 Enables providers to inform patients of basic financial responsibility prior to or at time of service Gives providers a mechanism to better manage revenue and cash

flow Enables plans to better utilize call center staff to provide higher levels of service to providers while reducing operational costs Enables vendors to differentiate themselves to offer improved products Acknowledgements Rule Specifies when to use TA1 and 997 Real time Submitter will always receive a response Submitter will receive only one response Batch Receivers include Plans, Intermediaries Providers Will always return a 997 to acknowledge receipt for Rejections Acceptances

23 Remember when you didnt know if your fax went through? Real World Impact Acknowledgements 24 Enables prompt, automated error identification in all communications, reducing provider and plan calls to find problems Industry no longer required to program a multiplicity of different proprietary error reports thus simplifying and reducing the cost of administrative tasks

Eliminates the black hole of no response by confirming that batches of eligibility inquiries have been received without phone calls Response Time Rule Real time Maximum: 20-second round trip Batch Receipt by 9:00 p.m. Eastern Time requires response by 7:00 a.m. Eastern Time the next business day 25 CORE participants in compliance if they meet these measures 90 percent of time within a calendar month System Availability Minimum of 86 percent system availability Publish regularly scheduled downtime Provide one week advance notice on non-routine downtime Provide information within one hour of emergency downtime

26 Real World Impact Response Time & System Availability 27 Enables providers to reliably know when to expect responses to eligibility inquiries and manage staff accordingly Encourages providers to work with practice management vendors, clearinghouses and plans that are CORE-certified and thus comply with the rules Identifies to the industry that immediate receipt of responses is important and lets all stakeholders know the requirements and expectations

Enables vendors to differentiate themselves to offer improved products Connectivity Rule CORE-certified entities must support HTTP/S 1.1 over the public Internet as a transport method for both batch and real-time eligibility inquiry and response transactions Real-time requests Batch requests, submissions and response pickup Security and authentication data requirements Response time, time out parameters and re-transmission

Response message options & error notification Authorization errors Batch submission acknowledgement Real-time response or response to batch response pickup Server errors 28 Real World Impact Connectivity 29 Like other industries have done, supports healthcare movement towards at least one common, affordable connectivity platform. As a result, provides a minimum safe harbor connectivity and transport method that practice management vendors, clearinghouses and plans that are COREcertified can easily and affordably implement Enables small providers not doing EDI today to connect to all clearinghouses and plans that are CORE-certified using any COREcertified PMS

Enables vendors to differentiate themselves to offer improved products cost-effectively Companion Documents Rule CORE-certified entities will use the CORE Companion Document format/flow for all their 270/271 companion documents CORE participants would not be asked to conform to standard Companion Guide language 30 Best Practices Companion Guide format developed by CAQH/WEDI in 2003 Real World Impact Companion Documents 31 Provides a consistent format to the industry for presenting a health plans requirements for the 270/271 Eligibility Transactions

Enables the industry to minimize need for unique data requirements Promotes industry convergence of multiple formats and requirements into a common companion document that will reduce the burden of maintaining a multiplicity of companion documents Phase I Rules Impact: Health Plans 32 Increase in electronic eligibility inquiries and a commensurate decrease in phone inquiries Reduced administrative costs More efficient process for providing eligibility and benefits

information to providers May need to change IT capabilities to meet rules and data relationships with vendors Will need to sign CORE pledge and prove systems compliance by seeking CORE certification Phase I Rules Impact: Providers All-payer eligibility solutions from CORE-certified vendors Because the data will be sourced directly from the relevant health plan(s), providers can be assured of data accuracy Improved Customer Service to Patients/Subscribers: redundant registration interviews eliminated advance notification of potential financial liability, e.g., non-covered services, out of network penalties prior authorization/referral requirements met in advance claims filed to right payer and paid, patients not caught in middle

33 Data entry and errors diminished through integrated 271 Reduced staff time in confirming eligibility and benefits Reduced bad debt related to eligibility issues Reduced claim denials due to eligibility Phase I Measures of Success: Tracking ROI CAQH will track and report Phase I Measures of Success Volunteers are being sought in each key stakeholder category Measures will allow CAQH to publish impact by stakeholder category Examples of metrics

Health plans Change in call center volume related to eligibility/benefit inquiries; average number and percentages of calls per week (per 1,000 members) before CORE adoption versus average number and percentage change after implementing Phase I CORE Providers 34 Measure change in usages of the following methods of eligibility transactions: Phone, Fax, Real-time EDI, Batch EDI, DDE Becoming CORE Phase I Certified 35 Achieving the CORE Seal 36 CORE Pledge 37 CORE certification is voluntary

Binding Pledge By signing Pledge, CORE entities agree to adopt, implement and comply with Phase I eligibility and benefits rules as they apply to each type of stakeholder business The Pledge will be central to developing trust that all sides will meet expectations Organizations have 180 days from submission of the Pledge to successfully complete CORE certification testing CORE Certification 38 Recognizes entities that have met the established operating rules requirements

Entities that create, transmit or use eligibility data in daily business required to submit to third-party testing (within 180 days of signing pledge); if they are compliant, they receive seal as a CORE-certified health plan, vendor (product specific), clearinghouse or provider Entities that do not create, transmit or send sign Pledge, receive CORE Endorser Seal Certification Testing Based on Phase I CORE Test Suite For each rule there is standard conformance requirements by stakeholder Suite outlines scenarios and stakeholder-specific test scripts by rule Not testing for HIPAA compliance, only Phase I CORE; however, entities must attest that, to the best of their knowledge, they are HIPAA compliant Phase I testing is not exhaustive, (e.g. does not include production data or volume capacity testing) Testing conducted by CORE-authorized certification testing entities

RFI issued in Summer 2005 RFP issued in November 2005 Authorized companies will have market products by early Q2 2006 Cost of testing determined by authorized companies; RFI responses indicated free to low-cost goal would be reached 39 Real World Impact Informs the industry that COREcertified entities not only support their stakeholder-specific rules but have also implemented the required capabilities Provides a reasonable building block towards industry-wide conformance testing (and validation) for administrative transactions Testing 40 CORE Certification Seals

41 CORE Seal Fees Health Plans Below $75 million in net annual revenue $4,000 fee $75 million and above in net annual revenue $6,000 fee Vendors Below $75 million in net annual revenue $4,000 fee $75 million and above in net annual revenue $6,000 fee Providers

Up to $1 billion in net annual revenue $ 500 fee $1 billion and above in net annual revenue $1,500 fee Endorser (only for entities that do not create, transmit or use eligibility data) 42 No fee Real World Impact Pledge, Certification & Enforcement Policy 43 Provides mechanism to identify practice management vendors, clearinghouses and plans that are CORE-certified and, thus, to the best of COREs knowledge compliant with

the rules Sends a clear signal that compliance with administrative transactions is important and that there is a process to remove non-compliant organizations Enables vendors to differentiate themselves to offer improved products Publicly communicates the seriousness of this voluntary effort Phase II: Areas Under Consideration Patient identification logic* More detailed components of eligibility transactions not addressed in Phase I, including: Estimated patient responsibility (e.g., YTD member financials) What amount the health plan will pay for authorized services

(procedure code needed?) Financial data on additional service type codes, such as carve-outs Enhancements to other aspects of Phase I Faster response time Greater system availability HTTPS message format standards 44 Initial set of rules for another transaction type, e.g. 835 *Research is already underway Participating in CORE Phase II Rules Development CORE is developing the operating rules that will govern the exchange of information as it relates to eligibility and benefits, and potentially other administrative transactions It is critical that there is engagement from stakeholders throughout the healthcare system By participating, your organization will be contributing to a

solution that addresses the complexity found in todays healthcare system Download application and join us today http://www.caqh.org/ben_join.html 45 Contact Gwendolyn Lohse at [email protected] for more information on CORE In Closing The work of CORE is not something that one company or even one segment of the industry can accomplish on its own. We will all benefit from the outcome: an easier and better way of communicating with each other. -- 46 John W. Rowe, M.D., Executive Chairman of Aetna www.CAQH.org 47

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