centricity™ business hidden gems in payer connectivity sharp healthcare april 2015

Centricity™ Business Hidden Gems in Payer ConnectivitySharp HealthCareApril 2015

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Agenda

• Hospital Admission Notification (278N)

• Claim Status/Claim Acknowledgments (276/277)

• Benefit Enrollment (MCA 834)

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Hospital Admission Notification 278N

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This transaction is a request and response to a Healthcare Payer for authorization of admission for inpatient hospital services.

What are the Benefits?

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• Streamline administrative tasks and increase productivity

• Reduce administrative costs through automation

• Increase data accuracy by reducing manual errors

• Accomplish more with less – fewer phone calls, faxes or keying

What are the Requirements?

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• Enterprise Visit Management required

• Centricity Business 5.3

• Payer is receiving and responding to 278N transactions

How does it Work?

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• You can manually send a notification for a particular visit

• You can use the Notification Manager in the GE Healthcare EDI Toolkit to queue up multiple visits to have notifications automatically sent to the payer

• Responses are viewable directly from HPA

• There is the ability to Hold Bills if a claim requires notification and a response has not been received

Technical Description

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The 278 is a hierarchical structure

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• Sender•Receiver

•Subscriber•Dependent

• Patient Event• Patient Event Providers

• Services • Services Providers

Trading Partner Integration in HPA

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Trading Partner Integration in HPA continued…

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Interactive Request in HPA

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Interactive Request in HPA continued…

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Interactive Request in HPA continued…

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Background Notification Requests (BNR’s)

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Background Notification Requests (BNR’s) continued…

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Background Notification Requests (BNR’s) continued…

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Background Notification Requests (BNR’s) continued…

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Background Notification Requests (BNR’s) continued…

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Hold Bills and Follow-Up’s

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Claim Status/Claim Acknowledgement 276/277

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• The 276 transaction set is the EDI X12 health care claim status request

• The 277 is the EDI X12 health care claim status response

276

277

What are the Benefits?

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• EDI verification eliminates the need for follow up reps to go outside of Centricity Business and manually check payor websites or call for claim status.

• HPA 276/277 was originally developed as a real-time tool for users

• Batch allows for automated claim status retrieval, eliminating or reducing user interaction

276 Process

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277 Process

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Current Trading Partners

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• Aetna• Anthem Blue Cross• Blue Shield• United HealthCare• Managed Care Application

(internal Sharp payer)

Claims Overview (OV Action Code)

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Claim Status Screen (CS)

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Drill Down into Results

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X12 Results

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Insurance Follow Up Questions

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Success Factors

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Since January 1, 2015*, Sharp HealthCare has sent 9496 requests and received 7855 responses. 

That’s nearly 8,000 phone calls or website research login’s that weren’t necessary! *(Data period 1/1/15 – 3/12/15)

MCA 834 Enrollment and Covered California

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About Sharp Health PlanCovered Lives: 75,000+

• 23% of SHC Commercial Managed Care

• Best Health: 8,000 Additional Lives

High Customer and Employee Satisfaction

• Highest CAHPS Scores (2013), 88th Nat’l percentile

• Broker (97.6%)and Employer (93.9%)

• Provider (93.2%) 90th percentile (The Myers Group)

Above Market Retention (12 Month Average)

NCQA Accreditation – Status of Excellence

Sharp Health Plan and Covered California – 2014 aka Year 1

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Types of Coverage

• Individual

• Small Business Health Options (SHOP < 50 Employees)

• Employers > 50 Employees

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Off Exchange

Health plans are required to offer same coverage for off exchange as on the exchange.

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Changes to GE Healthcare Centricity Business

834 Inbound

834 Outbound

999, TA1

Premium Billing & Statements

820 Premium Billing

Capitation

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834 File Flow

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EDI 834 Inbound

• Member matching

• Contract matching

• Demographics fatal edits

• Covered California DBMS columns

• Covered California fields in Enrollment

• EDI 834I Employer Group Ruleset

• Modified REF segments in 834I specification

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Covered California Enrollment Screen

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EDI 834I Employer Group Custom Enterprise Ruleset

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REF Segments in 834

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Outbound 834

Capture the 834 Inbound data in enrollment

MCA Enrollment EDI Select Queue Ruleset

FDL application “EME” - MCA Benefit Enrollment Forms (834)

MCA.834.O application class for specification

834 Outbound Run Manager

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Enrollment EDI Select Queue

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EDI 820 Outbound

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• MCA Premium Payment EDI Select Queue Ruleset

• FDL Application “EMP”

• MCA.820.O Application Class for Specification

• New Spec 005010X306

• 820 Outbound Run Manager

Premium Billing Enhancements

• Individual Billing

• Fixed Rates based on data from inbound 834 (Yearly)

• Welcome Letters to Members via Optum prior to first payment

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Premium Billing

Turned on MCA AES MAP #156 to modify premium during compile

Modified custom direct bill statements

Created new custom activity for Covered California direct bill statements

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Covered California – Year 2

• Covered California sends multiple enrollment transactions per member/family. Many are duplicates or corrections for previous transactions

• During 2014 – Sharp worked with GE Healthcare Centricity Business to customize the 834 member and contract matching as much as possible

THEN

• Covered California introduced 14 new issues/failures with the 2015 open enrollment

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Ongoing Issues

• Who’s right? The Exchange says they are the source of truth for all demographic data but Sharp also has a Master Patient Index group

• A reconciliation process has not been established to report demographic discrepancies

• Since we don’t know if the member has paid on initial enrollment – we have to manually term members/enrollment until payment is received

• Exchange sends multiple add/change records for members that are out of sequence

• Ongoing issue with retro dates on change transactions – this is causing billing issues 49

Questions?