Eligibility and Claim Status Operating Rules and …UnitedHealth Group: Corporate Profile OUR HEALTH BENEFITS BUSINESS: UNITEDHEALTHCARE OUR HEALTH SERVICES BUSINESS: OPTUM Helping
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• Administrative Simplification Provisions of the Affordable Care Act• Overview of UnitedHealth Group• Review of Operating Rules for Eligibility and Claim Status• UHG’s Transactions and Our Roadmap to Compliance• Moving the Industry to Adoption and Utilization• The PayerID of the Future - HPID• Future Considerations to drive Adoption and Utilization
UnitedHealthcare – Operating Rules and the Payer Experience
• CMS Announces 90-Day Period of Enforcement Discretion for Compliance with Eligibility and Claim Status Operating Rules.
• CMS will not initiate enforcement action until March 31, 2013 for health plans that are not in compliance with the operating rules adopted for Eligibility Inquiry (270/271) and Claim Status (276/277) transactions.
• The compliance date for using the operating rules remains January 1, 2013.• UHG systems were upgraded to be in compliance with these operating rules
as part of the scope of HIPAA 5010 (CORE Phase I & II Certification) but we are anxious for the industry to be aligned on these transactions.
OUR HEALTH BENEFITS BUSINESS: UNITEDHEALTHCARE OUR HEALTH SERVICES BUSINESS: OPTUM
Helping People Live Healthier Lives
UnitedHealthcare Community & State
UnitedHealthcare Employer & Individual
UnitedHealthcare Medicare & Retirement
UnitedHealthcare Military & Veterans
Making the Health Care System Work Better for Everyone
OptumInsight
OptumHealth
OptumRx
“Health in Numbers”• Serving 35 million Americans at every stage of life• Innovation-driven growth• Exceptionally well positioned to evolve and grow through
health care reform
“Good for the System”A dedicated and independent business providing services to:
6,000 hospital facilities, 250,000 health care professionals, 60 million consumers
• Health care information technology• Consumer engagement and support• Integrated care delivery• Pharmacy • Health financial services
FOUNDATIONAL COMPETENCIES
• Domain knowledge around care management and care resources • Actionable health care information and intelligence• Advanced, enabling technology
• A Phase I and Phase II v5010 CORE-certified health plan
• CAQH Board Member and CORE Transition Committee Member
• Co-Chair of the CAQH Committee on Operating Rules for Information Exchange (CORE) CORE Code Combinations Task Group
• Current CAQH Board Chair: David S. Wichmann, Executive VP, UnitedHealth Group and President, UnitedHealth Group Operations and Technology
• UnitedHealth Group is an active collaborator on industry initiatives that simplify healthcare administration for health plans and providers, resulting in better care experiences for patients and caregivers
– > 20 million Benefit/Eligibility and Claim Status calls in 2012
– > 411 million claims were processed in 2012
• Eligibility and Benefits
– Supports eligibility transactions both in real-time and batch
– >264 million EDI transactions annually
– 95% of these eligibility transactions are handled in real-time
• Claim Status
– Supports claim status transactions both in real-time and batch
– 54 million EDI transactions annually
UnitedHealthcare: Transaction Services Profile
Operational Objective: Collaborate with our provider network to transition phone calls and paper to electronic transactions, and transition batch to real-time.
Scope of CAQH CORE Operating Rules: Phase I and Phase II
*Please Note: The Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, CORE 150 and CORE 151 are not included for adoption. Although HHS is not requiring compliance with any operating rules related to acknowledgement, the Final Rule does say “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.”
• Results from an internal research analysis indicated as many as 30% (6.6 million) of call center service requests could be resolved by adopting the CORE Operating Rules for eligibility response transactions.
• Management had a strong interest in leveraging voluntary CORE Operating Rules and the CORE Certification process to gain valuable experience and insight about the benefits associated with implementing industry operating rules prior to federal and state mandates.
• United Healthcare Executive Management supported CORE certification as a critical organizational priority
• Enterprise-wide requirements were created for the HIPAA v5010 compliance project as well as for the implementation of Phase I and II CORE Operating Rules
• CORE Operating Rules implementation was managed as its own project. The timeframe for implementing CORE Operating Rules ran concurrently with the organization’s HIPAA v5010 implementation.
• Pursued Phase I and II CORE Certification concurrently
• A full understanding of CORE Operating Rules requirements and how they impact your organization’s IT systems is essential
• Upfront business/systems planning and analysis is a major component of the project
• Technical and business analyst resources must be available and work closely together throughout the full lifecycle of the project
• If you rely on vendors, make sure they are involved early-on in the planning process
• Consider early on how CORE Master Test Bed Data (for testing eligibility rule) will be loaded and used within the context of your system environment. It took approximately 8 weeks to setup the data due to complexity of the UnitedHealthcare claim platforms
• Execute the test scripts first that you have concerns with as you can run the test scripts as many times as you want and this will give you more lead time to fix any problem areas
“Adoption will allow for a higher level of automation for health care provider offices, particularly for provider processing of billing and insurance related tasks, eligibility responses from health plans, and remittance advice that describes health care claim payments.”1
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Secretary to adopt unique identifiers for each of the following:• Individuals(status: Congress delayed indefinitely)• Employers (status: EIN adopted)• Health plans (status: HPID adopted)• Health care providers (status: NPI adopted)
• Structure• 10-digit, all-numeric identifier with a Luhn check-digit as the 10th digit.• Intelligence- free identifier except for 1st digit
1Federal Register / Vol. 77, No. 172 / Wednesday, September 5, 2012 / Rules and Regulations, 54664
Controlling Health Plan (CHP) means a health plan that (1) Controls its own business activities, actions, or policies; or (2)(i) Is controlled by an entity that is not a health plan; and
(ii) If it has a subhealth plan(s), exercises sufficient control over the subhealth plan(s) to direct its/their business activities, actions, or policies.
–
Subhealth Plan (SHP) means a health plan whose business activities, actions, or policies are directed by a controlling health plan.
–
Other Entity ID (OEID) An entity may obtain an OEID to identify itself if the entity meets all of the following:
– Needs to be identified in a transaction for which the Secretary has adopted a standard
– Is not eligible to obtain an HPID– Is not eligible to obtain an NPI– Is not an individual (defined as “the person who is the subject of
Health Plan ID (HPID) – Important Dates• Compliance Dates
• Enumeration – November 5, 2014*–
Health plans must enumerate by this date–
A Controlling Health Plan – must obtain an HPID from the Enumeration System for itself– must disclose its HPID when requested– may obtain an HPID from the Enumeration System for Subhealth
plan of the Controlling Health Plan – may direct its Subhealth plans to obtain HPIDs
–
A Subhealth plans may obtain an HPID from the Enumeration System; once enumerated, a Subhealth plan must disclose its HPID when requested
• Full Implementation – November 7, 2016–
All Covered entities must begin using HPID in the HIPAA transactions
• HPID Usage – only required when the health plan has an HPID and the Covered Entity (e.g., Provider) is identifying the health plan in standard HIPAA transactions
• We consider a health plan as ‘‘having an HPID’’ if that health plan communicates with its trading partners that it consistently uses a particular HPID, even if the HPID it uses is associated with another health plan, such as its controlling health plan.
• The phased-in approach for HPIDs, where there is lag time between when health plans are required to obtain an HPID and when covered entities are required to begin using HPIDs in the standard transactions, will allow the opportunity for dual use and sufficient time for a successful transition.
• The additional time will allow industry the opportunity to perform extensive testing of the HPID with trading partners prior to full implementation.
• This additional time and phased-in approach to compliance should reduce denied or misrouted claims during the early use of the HPID.
Health Plan ID (HPID) – UHG Considerations• UHG currently utilizes 48 PayerIDs• UHG may have 75 Controlling Health Plans (CHPs) and 5 Sub Health Plans (SHPs)• Additional Considerations:
• UHG has 224 other entities.• Other Entities do not necessarily require enumeration.• If there is a business need to have an Other Entity identified in the standard
transaction the Other Entity will need to obtain an OEID (different than HPID).• 1 PayerID may route to multiple claim platforms.• Currently, some Member ID Cards include a 10 digit PayerID (health plan ID),
this is not the same as the HPID that is being implemented so ID cards may need to be reissued
• Plan moving forward• Develop an Enumeration Strategy• Determine Governance, Implementation and Usage of HPID & OEID• Communicate and educate internal and external partners – especially physician
• During the next several years the entire revenue cycle process will experience significant transformation due to the introduction of operating rules.
• This change can drive interoperability, facilitate greater adoption of standards and generate a responsive, and adaptive, system-wide approach that aligns with other strategic initiatives.
Healthcare Administrative Data Exchange: An End-to-End Perspective
CORE-RequiredData &
Infrastructure
Vendor-Agnostic Operating Rules
ProvidersVendors and
Clearinghouses (includes TPAs)
CORE-RequiredData &
Infrastructure
HealthPlans
• All HIPAA covered entities involved in the electronic exchange of administrative transactions have a role to play in the adoption of CAQH CORE Operating Rules, i.e., providers, health plans, and/or clearinghouses
• HIPAA covered entities work together to exchange transaction data in a variety of ways. The applicability of a given CAQH CORE Operating Rule will depend upon the nature of the trading relationship between HIPAA-covered entities, e.g.,
• Non-covered entities, such as Practice Management System Vendors, also have a significant role in ensuring these processes work – but the driver is not legislation – it is economic.
Health Plans – only group penalized for non-compliance
Scheduling / Registration Workflow ~The Art of the Possible~
Patient MakesAppointment
Patient Arrives atAppointment
Objective: Build out an application to streamline the patient scheduling and registration process by matching provider and patient information to confirm eligibility and benefit coverage while ensuring authorizations are obtained prior to patient seeing the physician. The goal is to eliminate any calls a provider has to make prior to service being rendered.
Provider’s PMIS
Confirms Patient Eligibility / COB
Validates Provider Benefit Level
Validates Benefit Coverage
Determines if Auth is Required
Summarizes Product Information
Captures Patient Responsibility
Patient eligibility status and effective datesIdentify secondary coverage (COB) *
Provider’s network status with Patients plan *Determines patient’s out of pocket
Verifies coverage in general or at code levelCaptures patients lifetime / benefit max *
Determine if authorization is required *Auto links next steps to capture auth online
Identifies Patient’s plan / product informationVerifies if referral is required *Provide copy of patient’s ID card
Challenge: Providers work across multiple practice management systems that provide inconsistent tools to leverage EDI transactionspreventing providers to utilize this within their practice workflow.
UHC Systems
Prior authorizationrequests via online
Provider’s PMIS
OptumX Desktop
271
270
Ideal link betweenProvider’s PMISand OptumX Desktop
Workflow Tool
* Not provided through Core 5010 Transactions
Provider referralobtained
Goal: Simplify scheduling and registration process by capturing key information up front prior to patient arriving in the office to validate patient’s eligibility, services are covered, and financial responsibility
Did you know?Provider offices are 20% successful in collecting patient responsibility once a patient leaves the office.
Scheduling / Registration Solutions1. Link provider network status to B&E verification
2. Clarify copay / deductible information
3. Provide clearer member product information on card
4. Simplify what is provided back in a 271 response
5. Link authorization/referrals required to B&E verification