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HIPAA Collaborative of Wisconsin
2015 Spring Conference
Oconomowoc, Wisconsin April 10, 2015
© 2015 CAQH. All rights reserved.
CAQH CORE Operating Rules – Key Requirements
•
Phase I and II*
•
Phase III*
•
Phase IV – currently in draft
Implementation Framework, Challenges & Issues
•
Audience Open Discussion
*ACA Mandated
© 2015 CAQH. All rights reserved.
2
ACA Mandated and HHS Health Plan
Certification
Scope and Updates
© 2015 CAQH. All rights reserved.
1
Scope: ACA-Mandated CAQH CORE Operating
Rules and Certification Compliance Dates
HIPAA covered entities conduct these transactions
using the CAQH CORE Operating Rules
• Electronic funds transfer (EFT)
• Health care payment and remittance advice (ERA)
Proposes an
adjusted
Implementation:
December 2015
Proposes health plans certify via either CORE
certification or HIPAA Credential; applies to Eligibility/
Claim Status/EFT/ERA operating rules and underlying
standards
CAQH CORE
in Process of
drafting rules
4
• Eligibility for health plan
• Claim status transactions
Compliance in
Effect as of
January 1, 2014
HHS NPRM and
deadline
adjustment
issued 12/31/13
Mandated Requirements
available and should be
in use in market
Compliance in
Effect as of
January 1, 2013
Implement by
January 1, 2016
(Draft Rules available in Late 2014)
HIPAA covered entities conduct these transactions
using the CAQH CORE Operating Rules
Applies only to health plans and includes potential penalties for incomplete certification;
existing voluntary CORE Certification is for vendors/PMS/large providers, and health plans
•
•
•
•
•
Health claims or equivalent encounter information
Enrollment/disenrollment in a health plan
Health plan premium payments
Referral, certification and authorization
Health claims attachments (HHS Standard not yet
mandated)
© 2015 CAQH. All rights reserved.
CAQH CORE Eligibility & Claim Status Operating Rules were initially developed in two phases; for ease of
use the rules are presented here by transaction addressed and rule type rather than by phase
•
Rules Addressing the ASC X12N v5010 270/271 Eligibility & Benefits Transactions
–
Data Content Related Rules
•
•
•
–
•
CAQH CORE 154 & 260: Eligibility & Benefits Data Content Rules
CAQH CORE 258: Normalizing Patient Last Name Rule for Eligibility
CAQH CORE 259: AAA Error Code Rule for Eligibility
Infrastructure Related Rules
•
•
•
CAQH CORE 150: Batch Acknowledgements Rule for Eligibility (999)*
CAQH CORE 151: Real Time Acknowledgements Rule for Eligibility (999)*
CAQH CORE 152: Companion Guide Rule
•
•
•
•
CAQH CORE 155: Batch Response Time Rule for Eligibility
CAQH CORE 156: Real Time Response Rule for Eligibility
CAQH CORE 157: System Availability Rule
CAQH CORE 153 & CAQH CORE 270: Connectivity Rules
Rules Addressing the ASC X12N v5010 276/277 Claim Status Transactions
•
CAQH CORE 250: 276/277 Claim Status Infrastructure Rule*
*NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health
Plan and Health Care Claim Status Transaction, requirements pertaining to use of Acknowledgements are NOT
included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to
Acknowledgements, the Final Rule does note “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.”
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© 2015 CAQH. All rights reserved.
ACA-Mandated CAQH CORE Eligibility and Claim
Status Operating Rules: Requirements Scope
Current healthcare operating rules build upon a range of standards – healthcare specific
(e.g., ASC X12) and industry neutral (e.g., OASIS, W3C, ACH CCD+)
Rules
Infrastructure
Data Content
Eligibility &
Benefits
Eligibility,
Benefits &
Claims
Status
High-Level CAQH CORE Key Requirements
Respond to generic and explicit inquiries for a defined set of 50+ high volume services with:
•
Health plan name and coverage dates
•
Static financials (co-pay, co-insurance, base deductibles)
•
Benefit-specific and base deductible for individual and family
•
In/Out of network variances
•
Remaining deductible amounts
•
Enhanced Patient Identification and Error Reporting requirements
•
Companion Guide – common flow/format
•
System Availability service levels – minimum 86% availability per calendar week
•
Real-time and batch turnaround times (e.g., 20 seconds or less for real time and next
day for batch)
•
Connectivity via Internet and aligned with NHIN direction, e.g., supports plug and play
method (SOAP and digital certificates and clinical/administrative alignment)
•
Acknowledgements (transactional)*
*NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim
Status Transaction, requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring
compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important
role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH
C ORE rules we are adopting herein.” A PowerPoint overview of the Phase I & II CAQH CORE Rules is available HERE; the complete rule sets
are available HERE.
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© 2015 CAQH. All rights reserved.
2
ACA-Mandated CAQH CORE Eligibility & Claim
Status Operating Rules: Phase I & II Rules in Action
Pre- or At-time of Service
Post-Claim Submission
Eligibility Inquiry
(270)
Claim Status
Request
(276)
Health Plan
Provider
Provider
Eligibility Response
(271)
Content
Enhanced
Patient
Identification
Health Plan
Claim Status
Response
(277)
Content
Uniform Error
Reporting
Content
Robust Eligibility Data,
e.g., Patient Financials
(YTD deductibles, Co-pay,
Indicates where
a CAQH CORE
Phase I or II
Rule comes
into play
Co-insurance, in/out
network variances)
E.G.,
SOAP+
WSDL
Infrastructure Rules
Standard
Companion
Guides
10
Real-time
and Batch
Response
Times
Internet
Connectivity
and Security
Increased
System
Availability
© 2015 CAQH. All rights reserved.
ACA-Mandated CAQH CORE EFT & ERA Operating
Rules: Requirements Scope
Infrastructure
Data
Content
Rule
High-Level Requirements
•
Identifies a minimum set of four CAQH CORE-defined Business Scenarios with a
maximum set of CAQH CORE-required code combinations that can be applied to
convey details of the claim denial or payment to the provider
EFT Enrollment Data Rule
•
•
•
Identifies a maximum set of standard data elements for EFT enrollment
Outlines a flow and format for paper and electronic collection of the data elements
Requires health plan to offer electronic EFT enrollment
ERA Enrollment Data Rule
•
Similar to EFT Enrollment Data Rule
EFT & ERA Reassociation
(CCD+/835) Rule
•
Addresses provider receipt of the CAQH CORE-required Minimum ACH CCD+ Data
Elements required for re-association
Addresses elapsed time between the sending of the v5010 835 and the CCD+
transactions
Requirements for resolving late/missing EFT and ERA transactions
Recognition of the role of NACHA Operating Rules for financial institutions
Uniform Use of CARCs and
RARCs (835) Rule
Claim Adjustment Reason Code (CARC)
Remittance Advice Remark Code (RARC)
•
•
•
•
Health Care Claim
Payment/Advice (835)
Infrastructure Rule
•
•
•
Specifies use of the CAQH CORE Master Companion Guide Template for the flow
and format of such guides
Requires entities to support the Phase II CAQH CORE Connectivity Rule.
Includes batch Acknowledgement requirements*
Defines a dual-delivery (paper/electronic) to facilitate provider transition to electronic
remits
* CMS-0028-IFC excludes requirements pertaining to acknowledgements. The complete Rule Set is available HERE.
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© 2015 CAQH. All rights reserved.
Connectivity
Dual Delivery
Batch Acknowledgements1
• Entities must be able
to support the CAQH
CORE Connectivity
Rule Version 2.2.0 for
transmission of the
v5010 835
• A health plan that currently
issues proprietary paper claim
remittance advices is required
to continue to offer such paper
remittance advices to each
provider during that provider’s
initial implementation testing
of the v5010 X12 835 for a
minimum of 31 calendar days
from the initiation of
implementation
• Upon mutual agreement
between the provider and the
health plan, the timeframe for
delivery of the proprietary
paper claim remittance
advices may be extended
• See §4.3 for more detail
• A receiver of a v5010 X12 835 transaction
must return:
- A v5010 X12 999 Implementation
Acknowledgement for each Functional
Group of v5010 X12 835 transactions
to indicate that the Functional Group
was either accepted, accepted with
errors or rejected, and
- To specify for each included v5010
X12 835 transaction set that the
transaction set was either accepted,
accepted with errors or rejected
• A health plan must be able to accept and
process a v5010 X12 999 for a Functional
Group of v5010 X12 835 transactions
• When a Functional Group of v5010 X12
835 transactions is either accepted with
errors or rejected, the v5010 X12 999
Implementation Acknowledgement must
report each error detected to the most
specific level of detail supported by the
v5010 X12 999 Implementation
Acknowledgement
Companion Guide
• Specifies use of the
CAQH CORE Master
Companion Guide
Template for the flow
and format of such
guides for the v5010
835
1
NOTE: CMS-0028-IFC does not adopt the Batch Acknowledgement
Requirements in Section 4.2 of CAQH CORE Rule 350, as the Secretary has not
yet adopted HIPAA standards for acknowledgements.
© 2015 CAQH. All rights reserved.
3
Indicates where a
CAQH CORE
EFT/ERA Rule
comes into play
Pre- Payment: Provider
Enrollment
Claims Payment Process
Content:
Uniform Use
of CARCs &
RARCs Rule
Infrastructure
Rules
Health Plan
EFT Enrollment
Data Rule
Claims
Processing
ERA Enrollment
Data Rule
Provider
Billing &
Collections
Payment/Advice (835)
Content:
EFT & ERA
Reassociation
(CCD+/835) Rule
Content: Provider first enrolls in
EFT and ERA with Health
Plan(s) and works with bank to
ensure receipt of the CORErequired Minimum ACH CCD+
Data Elements for
reassociation
Bank
Treasury
Bank
Treasury
Electronic Funds Transfer
(CCD+/TRN)
Stage 1:
Initiate EFT
Infrastructure Rules
Real-time
and Batch
Response
Times
Standard
Companion
Guides
Increased
System
Availability
Internet
Connectivity
and Security
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© 2015 CAQH. All rights reserved.
Infrastructure
Requirement
Prior
Authorization1
Claims1
Enrollment2
Premium
Payment2
Batch OR Real Time
Required
Batch Required;
Real Time Optional
Batch Required;
Real Time Optional
Batch Required;
Real Time Optional
Batch Processing Mode
Response Time
If Batch Offered
X
X
X
Batch
Acknowledgements
If Batch Offered
X
X
X
Real Time Processing
Mode Response Time
If Real Time Offered
If Real Time Offered
If Real Time Offered
If Real Time Offered
Real Time
Acknowledgements
Processing Mode
If Real Time Offered
If Real Time Offered
If Real Time Offered
If Real Time Offered
Safe Harbor Connectivity
and Security3
X
X
X
X
System Availability
X
X
X
X
Companion Guide
Template
X
X
X
X
N/A
Include guidance for COB in
companion guide
Timeframe requirements to
process data after successful
receipt and verification of
transaction
Timeframe requirements to
process data after successful
receipt and verification of
transaction
Other
X = Required
1. Draft Rules approved by Claims/Prior Authorization Subgroup under Rules Work Group ballot.
2: Draft Rules approved by Benefit Enrollment & Maintenance/Premium Payment Subgroup under Rules Work Group review.
3: Draft Connectivity Rule approved by Connectivity & Security Subgroup under Technical Work Group ballot.
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© 2015 CAQH. All rights reserved.
Rule Applicability to Transactions
Draft Phase IV CAQH CORE
470 Connectivity Rule v4.0.0
Claims
Prior Authorizations
Benefit Enrollments
Premium Payments
HIPAA Covered
Entity
HIPAA Covered
Entity
Phase II CAQH CORE 270
Connectivity Rule v2.2.0
Eligibility Inquiry
Claim Status Inquiry
Electronic Remittance Advice
Phase I/II/III Rules Mandated under ACA
© 2015 CAQH. All rights reserved.
4
CAQH CORE Connectivity Rule Versions
Graphical View and Comparison
Phase II CORE Connectivity Rule
Draft
Phase IV CORE Connectivity Rule
to be adopted under the ACA
Mandated under the ACA
Payload(s)
X12 Administrative Transactions
NCPDP, HL7 V2.x or V3 Messages
Other
X12 Administrative Transactions
NCPDP, HL7 V2.x or V3 Messages
Other
Submitter
(Client)
Authentication
Username/Password (WS-Security Token)
X.509 Digital Certificate
X.509 Digital Certificate over SSL/TLS
Processing
Mode/Message
Interactions
Required: Real Time
Optional: Batch
Required: Batch, Generic Push and Pull
Optional: Real Time
Message
Envelope
Metadata
CORE Specified Message Envelope Metadata
CORE Specified Message Envelope Metadata
MIME Multipart
SOAP+WSDL (MTOM for Batch only)
Message
Envelope(s)
Communications
Channel Security
Secure Sockets Layer - (SSLv3 required with optional
use of TLS1.0 or higher)
Transport
HTTP over TCP
Network
Public Internet
SOAP+WSDL
(MTOM for both Real Time and Batch)
Secure Sockets Layer
(SSLv3.0 with optional use of TLS1.1 or higher. Entities
needing higher security can use TLS1.1 in lieu of SSLv3.0)
HTTP over TCP
Public Internet
=Revised from the previous phase
Implementation Framework & Steps
A Real World Approach by a State
Medicaid
© 2015 CAQH. All rights reserved.
14
Planning
• Phase I and II planning kicked off September 24, 2012
• Phase III planning kicked off May 7, 2013
• Identified and engaged appropriate resources across teams
– EDI, Eligibility, Claims, Financial, Banking, Reference, Enrollment
• Coordinated with other priority projects
© 2015 CAQH. All rights reserved.
5
Planning
Gap Analysis
• Subject matter experts completed gap analysis worksheets
from CAQH Analysis & Planning Guide
• Attended CAQH education events and submitted questions
• Reviewed FAQs on CAQH website
• Emailed CAQH our questions
• Attended workgroup sessions and discussed with other states
16
© 2015 CAQH. All rights reserved.
Planning
Gap Analysis
Design
• Developed solution based on gap analysis and rule requirements
• Chose to implement generic response option for Safe Harbor
connection (Rule 270 § 4.3.1.3 Batch Response Pickup)
– Allows trading partners to view a list of available files for retrieval
17
© 2015 CAQH. All rights reserved.
Planning
Gap Analysis
Design
Implementation
• Project schedule was developed
– Phases I and II were implemented on August 22, 2013 (11 months)
– Phase III was implemented on December 27, 2013 (8 months)
• Provider outreach activities began two months ahead of golive date, whenever possible
© 2015 CAQH. All rights reserved.
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6
All Phase III Operating Rules
Challenge: Difficulty understanding specific rule requirements,
or determining if a requirement was applicable to our business
Solution:
•
Attended CAQH education events and submitted questions
•
Reviewed FAQs on CAQH website
•
Emailed CAQH our questions
•
Attended workgroup sessions and discussed with other states
© 2015 CAQH. All rights reserved.
19
All Phase III Operating Rules
Challenge: Difficulty understanding specific rule requirements,
or determining if a requirement was applicable to our business
Solution:
•
Attended CAQH education events and submitted questions
•
Reviewed FAQs on CAQH website
•
Emailed CAQH our questions
•
Attended workgroup sessions and discussed with other states
© 2015 CAQH. All rights reserved.
20
Rule 360: Uniform Use of CARCs and RARCs
Challenge: Difficulty determining if an existing code
combination was in one of the CORE-defined Business Scenarios
Solution:
•
Generated listing of current and proposed code mapping
•
Mapping changes were reviewed and approved by subject
matter experts across various teams
© 2015 CAQH. All rights reserved.
21
7
Rule 360: Uniform Use of CARCs and RARCs
Challenge: Difficulty determining if an existing code
combination was in one of the CORE-defined Business Scenarios
Solution:
•
Generated listing of current and proposed code mapping
•
Mapping changes were reviewed and approved by subject
matter experts across various teams
© 2015 CAQH. All rights reserved.
22
Rule 370: EFT & ERA Reassociation
Challenge: Coordination with our financial institution during
testing and implementation
Solution:
•
Engaged banking operations to act as a liaison between
development team and financial institution
•
Completed end-to-end testing prior to implementation
© 2015 CAQH. All rights reserved.
23
Rule 370: EFT & ERA Reassociation
Challenge: Coordination with our financial institution during
testing and implementation
Solution:
•
Engaged banking operations to act as a liaison between
development team and financial institution
•
Completed end-to-end testing prior to implementation
© 2015 CAQH. All rights reserved.
24
8
Rule 380/382: EFT & ERA Enrollment Data
Challenge: “Account Number Linkage to Provider Identifier”
•
Provider preference for grouping claim payments on an EFT or ERA;
however, we do not use either option (NPI or Tax ID)
Solution:
•
Provided both options during enrollment and store
information
•
Did not change how claim payments are grouped on EFT and ERA
transactions
25
© 2015 CAQH. All rights reserved.
Rule 380/382: EFT & ERA Enrollment Data
Challenge: “Account Number Linkage to Provider Identifier”
•
Provider preference for grouping claim payments on an EFT or ERA;
however, we do not use either option (NPI or Tax ID)
Solution:
•
Provided both options during enrollment and store
information
•
Did not change how claim payments are grouped on EFT and ERA
transactions
26
© 2015 CAQH. All rights reserved.
Communication is Critical!
Education is key
–
Get executive buy-in early
–
Just Getting
Started
Fully understand your business
processes and the mandates
Among payers and their trading
partners, penalties for noncompliance help make this a priority
Engage Trading Partners Early
and Often
–
It’s important to contact your
trading partners early in the
implementation process, clarify
roles and responsibilities, and
coordinate a timeline for
completion
Analysis and
Planning
Systems
Design
Determine Scope of Project
–
Identify the affected departments,
processes, systems and trading
partners
Treat like any major business
project
–
–
Identify staff resources, e.g.
Realistic timelines, e.g. don’t
underestimate the complexity of the
systems and adjustments involved
Systems
Implementation
TEST, TEST, TEST!
–
Test your compliance with
your trading partners and
with your clients
Integration &
Testing
Get Involved with CAQH
CORE
Deployment/
Maintenance
–
Give input on rule maintenance,
and stay up-to-date on
implementation developments
© 2015 CAQH. All rights reserved.
9
Appendix
Additional Resources
28
© 2015 CAQH. All rights reserved.
CAQH CORE Free Resources

Master the CAQH CORE Operating Rules

If your implementation efforts/your vendor(s) are just getting started access CAQH
CORE Analysis & Planning Guides for Eligibility & Claim Status Operating Rules and
EFT & ERA Operating Rules

If your implementation/your vendor(s) is fully underway or nearing completion:


Education Sessions: CAQH CORE holds frequent sessions with partners such as ASC
X12, NACHA, Medicaid workgroups, etc.

FAQs: CAQH CORE has a list of FAQs to address typical questions regarding the
operating rules; updated FAQs being loaded to website on a regular basis

Request Process: Contact technical experts as needed at CORE@caqh.org
If your implementation/your vendor(s) is complete or nearly complete, and/or you
are testing readiness with trading partners:

Consider Voluntary CORE Certification: Phase I & Phase II
–
If testing your implementation of operating rules with trading partners, then, take 5
minutes and tell others about your readiness at CORE Operating Rule Readiness:
•
Voluntary CORE Certification provides verification that your IT systems or product
operates in accordance with the federally mandated operating rules
© 2015 CAQH. All rights reserved.
•
To benefit from new EFT and ERA mandates,
ensure your provider organization has requested
the transactions from its health plans and EFT &
ERA Operating Rule implementation status
•
To maximize the benefits available through the
CAQH CORE Reassociation Rule, providers
must request delivery of the necessary data for
EFT and ERA reassociation
•
To help facilitate this request, CAQH CORE
developed the Sample Provider EFT Request
Letter
•
To help facilitate this request, CAQH CORE
developed the Sample Provider EFT
Reassociation Data Request Letter
•
Providers can use this sample letter as template
email or talking points with health plan contacts
to request enrollment in EFT/ERA and benefits
of operating rules
•
Providers can use this sample letter as
template email or talking points with bank
contacts to request delivery of the
reassociation data
•
The tool includes background on the benefits
EFT, key steps for providers, an actual letter
template, and glossary of key terms
•
The tool includes background on the benefits of the
letter, key steps for providers, an actual letter
template, and glossary of key terms
© 2015 CAQH. All rights reserved.
30
10
• HIPAA Covered Entity Charts
– Use the HIPAA Covered Entity Charts to determine whether your organization is a HIPAA
covered entity
• CMS FAQs
– Frequently asked questions about the ACA, operating rules, and other topics
• Affordable Care Act Updates
– Updates on operating rules; compliance, certification, and penalties; and engagement with
standards and operating rules
– CMS eHealth University
– What Administrative Simplification Does For You – This fact sheet explains the basics
behind how Administrative Simplification will help improve health care efficiency and lower
costs
– Introduction to Administrative Simplification – This guide gives an overview of
Administrative Simplification initiatives and their purposes
– Introduction to Administrative Simplification: Operating Rules – A short video with
information on Administrative Simplification operating rules
• Additional Questions
– Questions regarding HIPAA and ACA compliance can be addressed to:
•
Geanelle Herring, Health Insurance Specialist, Geanelle.Herring@cms.hhs.gov
44
© 2015 CAQH. All rights reserved.
•
ACH CCD+: The CCD+ format is a NACHA ACH corporate payment format used in Electronic Funds Transfers
(EFT) with a single 80 character addendum record capability. The addendum record is used by the originator to
provide additional information to the payment recipient about to the payment.
•
ACH Network: A batch processing, store-and-forward system, governed by The NACHA Operating Rules,
which provide for the interbank clearing of electronic payments for participating depository financial institutions.
•
Accredited Standards Committee (ASC) X12: Develops and maintains the X12 electronic data interchange
(EDI) standards along with XML schemas which drive business processes globally. The membership of ASC
X12 includes technologists and business process experts, encompassing health care, insurance, transportation,
finance, government, supply chain and other industries.
•
Business Associate: A person or organization that performs a function or activity on behalf of, or provides
services to, a Covered Entity that involves Individually Identifiable Health Information
•
CMS Office of E-Health Standards and Services (OESS): The U.S. Department of Health and Human
Services’ (HHS) component that enforces compliance with HIPAA transaction and code set standards, including
operating rules, identifiers and other standards required under HIPAA by the Affordable Care Act.
•
Electronic Data Interchange (EDI): The computer-to-computer exchange of business data in standard formats.
In EDI, information is organized according to a specified format set by both parties, allowing a "hands-off"
computer transaction that requires no human intervention or rekeying on either end. All information contained in
an EDI transaction set is, for the most part, the same as on a conventionally printed document.
© 2015 CAQH. All rights reserved.
•
Healthcare Provider: Any person or Organization who furnishes, bills, or is paid for healthcare in the normal course
of business.
•
Healthcare Transaction: The transmission of information between two parties to carry out financial or administrative
activities related to health care
•
HIPAA-Covered Entities: Health Plans, Healthcare Clearinghouses, and Healthcare Providers who transmit any
health information in electronic form in connection with certain transactions
•
NACHA (The Electronic Payments Association): A non-profit rule-making entity that manages the development,
administration, and governance of the ACH Network, the backbone for the electronic movement of money and data.
•
Operating Rules: the necessary business rules and guidelines for the electronic exchange of information that are
not defined by a standard or its implementation specifications
•
Transmission Media: Electronic form of transmitting information including, for example, the internet (wide-open),
extranet (using internet technology to link a business with information accessible only to collaborating parties), leased
lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media.
Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be
transmissions via electronic media, because the information being exchanged did not exist in electronic form before
the transmission.
© 2015 CAQH. All rights reserved.
11