HIPAA Collaborative of Wisconsin

EDI Roundtable Recap

Presented by the EDI Taskforce Co-chairs:

Jacklyn Lippe, Dir. of Business Office Services at St. Joseph’s Community Hospital Janet Sanders, Principal Consultant at Siemens Medical Solutions

Suzanne Ronde, Independent Consultant

Agenda for Today’s PresentationOverview of the Addenda:

Original Presenter, Mark McLaughlin (Regulatory Policy Analyst of McKesson, Board Member/Co-chair of Education/Co-chair HIPAA Success Task Group - WEDI, Co-chair Transactions/Steering Committee Member - WEDI/SNIP, Board Member/Co-Chair Membership - AFEHCT )Today’s Reviewer: Janet Sanders

Testing and Certification: Original Presenter, Larry Watkins (Vice President and COO of Claredi, Co-Chair - ASC X12N Health Care Task Group, Co-Chair - WEDI SNIP)Today’s Reviewer: Suzanne Ronde

Code Set Overview:Original Presenter, Mark McLaughlin Today’s Reviewer: Jacklyn Lippe

Overview of the AddendaOriginal Presenter

Mark McLaughlin Regulatory Policy Analyst of McKesson, Board Member/Co-chair of Education/Co-chair HIPAA Success Task Group - WEDI, Co-chair

Transactions/Steering Committee Member - WEDI/SNIP, Board Member/Co-Chair Membership - AFEHCT

Today’s Reviewer

Janet Sanders

HIPAA COW EDI Taskforce Co-Chair

Types of Changes in the Addenda

Added loops, segments, elements Deleted loops, segments, elements Updated loops, segments, elements Updated usage notes Usage changes

Situational -> Not Used Required -> Situational

Internal code set changes

Timeframe Issues

Implement addenda as proposed? May have to change once finalized

When will the finalized addenda be mandated?

What about the trading partner matrix?

Implement pre-addenda? NDC codes and all?

Taxonomy code issues?

What about the trading partner matrix?

Trading Partner Matrix of Confusion Payers w/Extension

Payers w/o Extension

Providers w/Extension

Providers w/o Extension

Clearinghouse

Non-compliant ProprietaryNon-compliant

AddendaCompliant to the AddendaCompliant to pre-Addenda

Compliant to pre-Addenda

Data Compliant Prop.

Non-compliant Addenda

Non-compliant Proprietary

Compliant to the AddendaCompliant to pre-

Addenda

Data Compliant Prop.

Compliant to pre-Addenda

837 Claims Alone!

Discussion After the PresentationAs of Aug. 13, 2002 – only 700 entities in Wisconsin have filed for their extension. CMS is very concerned. In a poll at the Roundtable, everyone was filing for an extension.Testing the Transactions

Concern about possible log jam as the compliance date gets closer, that entities will wait until then to test.UGS has well over 2,200 Trading Partners to coordinate with, only 37 are ready to test the 837 Transaction to date.Some payers may be creating what’s known as companion guides, these are guides that define the specific elements in order for claims to process through their adjudication system. These will normally be added to the trading partner agreements between the two entities.Timelines for testing outlined by the WEDI/SNIP organization would have started long ago, but the industry is behind the curve.

Recommended Outline for Transaction Testing 837 (batch) 835 (batch) 270/271(real-time) 276/277 (real-time) 278 (real-time)

Discussion After the PresentationMoving forward with the addenda

Some payers have said that they will move forward with some of the addenda changes now, in a phased approach.

Some entities are not sure they want to implement the addenda and then have to back out of the system.

At this time, the addenda is still going through the legal process. It’s uncertain when exactly the finalized rule will come out.

One of the recommendations is to implement those addenda changes that seem highly likely or whether or not HIPAA COW could make recommendations or suggestions on what items would be good to implement or not.

270/271 Discussion At this time, the Implementation Guides requires a payer to give yes/no response to the 270 transaction.

Providers are looking for more information than just a yes/no in order to be able to get an adequate response for eligibility.

EDI Deliverable - work on the schema for the 271 response and make a recommendation to payers on what information providers would like.

Testing and CertificationOriginal Presenter

Larry Watkins Vice President and COO of Claredi, Co-Chair - ASC X12N

Health Care Task Group, Co-Chair - WEDI /SNIP

Today’s Reviewer

Suzanne Ronde

HIPAA COW EDI Taskforce Co-Chair

• Find trading partner that agrees to test with you

• Typically one that will eventually benefit from your transactions

• Send test files

• Get test report from trading partner

• Correct errors found by trading partner

• Repeat the cycle until no more errors

Testing Today

What the testing covers• Telecommunications• Security, authentication, access• Data format issues• Data content issues

• Generic HIPAA requirements

• Trading partner specific requirements

• Business rules• Some are HIPAA, some are trading partner specific

requirements

Graphical view• EDI Submitter contract• Telecom / connectivity• X12 syntax• HIPAA syntax• Situational requirements• Code sets• Balancing• Line of business testing• Trading partner specifics

1-2 days

1-2 days

2-3 weeks

3-4 weeks

Testing with multiple Trading Partners

TP Specific

TP Specific

Common in HIPAA(2-3 weeks each)

The end result of today’s method of testing• Repeat the testing for each trading partner.• Common HIPAA requirements tested again

from scratch each time.• “Statistical Testing”• Never sure of whether the testing is:

• Complete, Correct, Repeatable.

• Very time consuming, expensive, wasteful, process.

• Unfair cost for the “readier” partner.• They end up debugging their trading partners.

The SNIP approach• Compliance testing

• Your own system, independent from trading partners

• Structured testing; complete testing

• HIPAA Implementation Guides

• Business to Business testing• Assume both trading partners are already compliant.

Don’t repeat the compliance testing part

• Test only peculiar TP issues

• Companion Documents

SNIP Compliance testing• “Types” of testing recommended by SNIP:

1. EDI syntax integrity2. HIPAA syntactical requirements

• Loops, valid segments, elements, codes

3. Balancing of amounts• Claim, remittance, COB, etc.

4. Situational requirements• Inter-segment dependencies

5. External Code sets• X12, ICD-9, CPT4, HCPCS, Reason Codes, others

6. Product Type, Specialty, or Line of Business• Oxygen, spinal manipulation, ambulance, anesthesia, DME, etc.

7. Trading Partner Specific (NEW)• Medicare, Medicaid, Indian Health, in the HIPAA IGs.

Compliance testing• Testing in both directions

• Outgoing transactions• Incoming transactions

• Test for all SNIP test types (“levels”)• HIPAA Compliance

• Specific requirements in the IGs

• Business requirements• Fuzzy general “industry knowledge”• Companion Documents

Certification prior to Testing with multiple Trading Partners

TP Specific

TP Specific

Common in HIPAA

Certification vs. Testing• Testing is for yourself (or between yourself and your

trading partners as done today?)

• Certification is by third party

• Certify once, use certification in many trading partner relationships

• Simplify testing, reduce to only companion document

• Reduce cost of testing phase

• Certification should be recognized by all trading partners

• Certification must be done by a neutral third party

• Certification process must be disclosed, verifiable, and accepted by industry

• Testing• Private

• For your own needs only

• Test compliance

• Test non-compliance

• Never ending? User-defined

• Certification• Public statement• Also for other

trading partners• Verify compliance• (Only positive

assertion, no such thing as “certification of non-compliance”)

• Well defined end point

Certification vs. Testing

Discussion After the PresentationSome of the entities did mention that they were heavily reliant on their vendors. Whether it’s for the vendor to give them information or what changes were in the future.It was clearly stated that providers and payers must be involved in the vendor process. This is not an IT problem; a great amount of the impact is going to be on operations.Under HIPAA, it will be unavoidable not to be trading partner specific due to business requirements in EDI.Claredi mentioned that they would be willing to post companion documents onto their website for certified entities.

Discussion After the Presentation The following is a breakdown of attendees. Please note, that some of the organizations had multiple attendees:

Payer Reps: 20

Provider Reps: 21

Clearinghouse Reps: 6

Vendor Reps: 6

Attorney Reps: 1

A poll was taken on the following: How many payers are going to require certification: about 5 hands

How many providers are going to get certification: about 5 hands

How payers are going through certification: about 17

Code Set OverviewOriginal Presenter

Mark McLaughlin Regulatory Policy Analyst of McKesson, Board Member/Co-chair of Education/Co-chair HIPAA Success Task Group - WEDI, Co-chair

Transactions/Steering Committee Member - WEDI/SNIP, Board Member/Co-Chair Membership - AFEHCT

Today’s Reviewer

Jacklyn Lippe

HIPAA COW EDI Taskforce Co-Chair

Rejections and Other Considerations

Rejection types File/transaction/claim Internal vs. external code sets

Validation vs. verification Trading partner considerations

Timing of Updates

Who is driving the update timing?

X12

AMA

HHS/CMS

Other outside sources

Trading partner considerations

Overlap allowing Current – 1 version?

Old re-submitted transactions

Discussion After the Presentation Timing of Code Sets

There was heavy discussion and mixed reactions on how long to maintain the code sets after they changed.In Wisconsin, an entity can file an appeal or grievance ANYTIME, therefore an organization must be able to read codes that were filed at the time of the claim to ensure processing.This also holds true for accurate fees scheduling.Some entities struggle in being able to get the code sets in time to process correctly. Often, the code sets are back ordered and the entity is at the mercy of the vendor getting them the needed code sets.

Open Discussion of the Roundtable 270/271 Discussion

There were a couple of payers who said they planned on giving a yes/no response at this time.

Some payers who are doing just the yes/no at this time do plan on updating their systems to give more information in the future. Doing this in a phased approach.

UGS and Medicaid planned on sending more than just a yes/no response.

There was a brief discussion that small providers really need assistance in regards to EDI. WEDI/SNIP does have an excellent small provider taskforce.

There was also a comment that we do not want to be reproducing what the national level organizations are doing vs. creating products at a regional level.

HIPAA COW’S EDI Taskforce EDI Workgroups were restructured due to new volunteers and new directionWorkgroups have a great blend of entities affected by HIPAAAdministration Workgroup Deliverables

Trading Partner Agreement TemplateVendor Management White PaperPossible Recommendations on Addenda Changes – Depends on Final Rule

Technical Workgroup DeliverablesIdentify and Resolve Transaction and Code Set IssuesTesting Information Regarding Covered EntitiesRecommend Format and Content for Companion Guides