Delivering Value Through

Electronic Healthcare Attachments

BY LeAnn Morris, DentalXChange Moderator/Clearinghouse

Nicole Smith, NEA, Vendor

Ted Rendahl, CIGNA, Payer

Introduction – LeAnn Morris

u  LeAnn Morris, Vice President of Business Development, with DentalXChange since 2008 with over 30 years of industry experience.

u  DentalXChange has been working with payers and third party vendors in support of the 275 transaction for attachments. This, along with web based provider solutions designed to manage the customization of validation rules by specialty and by provider, helps to assure improved claim processing.

Introduction to Harley & Louie

As they say never leave cash on the table or in my world never leave the door open!

Introduction – Ted Rendahl, CIGNA

u Ted Rendahl is currently a Business Project Specialist at CIGNA focusing on EDI and Digital Solutions.  Ted has 11 years of experience in the healthcare industry, all with CIGNA, concentrating on EDI and Digital Solutions for the past 6 years.

CIGNA celebrates being LIVE with the 275

u  Cigna went LIVE in 2016

u  CIGNA was the first known national payer to support the 275 transaction

u  Payers? Who’s next?

u  Who is working on their 275?

Being First and was it a Challenge u  CIGNA choices?

u  Portal, Partner vs. 275?

u  Availability, Quality, additional benefits?

u  How long did it take to go live?

u  2 Years+ between, development, testing and production pilots

u  What where the hurdles along the way? u  Formatting of BIN Segments and claim/attachment matching logic

u  File size limitations

u  Image quality, both of text as well as x-rays and perio-charting

u  Provider adoption

u  Kathy Weintraub shared “value of enhanced validations by plan level and specialty are something we have never supported”

It was NO Challenge, just benefits!

u  Lower cost for both payer and provider

u  Per 2017 CAQH Index Health Plan savings are $1.64 and Provider savings are $0.51 for electronic attachments

u  Faster turn around times for claim processing and payment

u  Ability to define scenarios/codes up front that always require an attachment, resulting in reduced claim pends

u  How is Cigna doing today?

u  In production with multiple Clearinghouses for the dental 275 unsolicited transaction

u  Currently piloting the medical 277RFAI and Solicited 275 transaction with plan to eventually rollout to Dental

Introduction to Nicole Smith, NEA

u  Vice President of Payer and Partner Services

u  Executive leadership team member responsible for architecting the strategic growth and management of NEA powered by Vyne's Payer and Partner Services. Responsible for leveraging NEA's businesses, products and services to address emerging market opportunities and the challenges posed by healthcare reform and the rapidly evolving technology landscape. Accomplished sales, marketing and management executive with over 15 years experience in the healthcare industry.

NEA solutions and Services Vyne By the Numbers 2019

u  Years in Business: More than 20 years

u  Number of Clients:

u  Medical = over 900 u  500+ Trace hospitals / health systems

u  400+ FastAttach hospitals / health systems

u  Dental = over 70,000 dental practice offices / over 110,000 dental providers

u  Number of Plans & Payers:  

u  Medical = 50+ (Commercial & Medicare)

u  Dental = 750+    

u  Number of Images & Attachments Transmitted:    

u  Medical = Over 4M images per month

u  Dental u  Over 3M images per month

u  Over 2M attachments per month

Current State

•  Industry lacks a 275 mandate – numerous delays, rule not finalized

•  Once mandated – two years to comply

•  Dental payers are not asking NEA for a 275 transaction

•  Entered agreement with Cigna for medical 277 RFAI / /275 pilot

• Claim created

Provider alerted of payer specific attachment

requirements by procedure code.

• Attachment created and submitted

Payer accesses NEA PayerWeb • Claim Reviewed

and approved or denied for additional information

Provider Reimbursed

Unsolicited Workflow

Solicited Workflow

• Claim denied or pended for additional information

Payer rejected claim requests additional

information via mail, phone call, 277 or

NEA payer messaging

• Requested images are submitted with or without a new claim

Provider submits requested images

electronically • Payer reviews claim and associated images

Payer accesses NEA PayerWeb to

view images

• Final adjudication, claim approved

Released for payment

• Reimbursement received

Remittance advice

277/275 Workflow

• Provider generates the claim

837 file

• Payer receives the claim, solicits additional information via structured transaction

277 RFAI

• Provider prepares attachment response

275 transaction

• Payer receives 275, stores and acknowledges file

277 ACK • Provider receives Acknowledgement

Improving Attachment Services in coming years

u  Driving the ability to control provider validations down to the plan level. (i.e. - FEP programs that have different rules)

u  Provider Improvements?

u  Validations by provider/specialty

u  Validations by credentialing and or naughty list

u  Payer Improvements?

u  How do we get there as an industry?

Open to Questions from the NDEDIC attendees