117 section r – information...

117 SECTION R – INFORMATION SYSTEMS

118 R.1

Part Two: Technical Proposal

Section R: Information Systems

Section R: Information Systems (Section §16 of RFP)

R.1 Describe your approach for implementing information systems in support of this RFP, including:

● Capability and capacity assessment to determine if new or upgraded systems, enhanced systems functionality and/or additional systems capacity are required to meet contract requirements;

● Configuration of systems (e.g., business rules, valid values for critical data, data exchanges/interfaces) to accommodate contract requirements;

● System setup for intake, processing and acceptance of one-time data feeds from the State and other sources, e.g., initial set of CCN enrollees, claims/service utilization history for the initial set of CCN enrollees, active/open service authorizations for the initial set CCN enrollees, etc.; and

● Internal and joint (CCN and DHH) testing of one-time and ongoing exchanges of eligibility/enrollment, provider network, claims/encounters and other data.

● Provide a Louisiana Medicaid CCN-Program-specific work plan that captures:

- Key activities and timeframes and

- Projected resource requirements from your organization for implementing information systems in support of this contract.

● Describe your historical data process including but not limited to:

- Number of years retained;

- How the data is stored; and

- How accessible is it.

The work plan should cover activities from contract award to the start date of operations.

Aetna Better Health® and its affiliates have been implementing Medicaid managed care information systems for over 25 years. We recently implemented three new encounter systems for Medicaid managed care programs in Florida, Pennsylvania and Illinois and expanded our Missouri Medicaid managed care program into two large regions. Today, Aetna Better Health administers or manages Medicaid health plans providing coverage to over 1.3 million members in 10 states. Our implementations leverage a proven methodology that is rigorous, yet accommodating to the unique needs of any given contract. We initiate certain preliminary implementation activities prior to contract award, creating an infrastructure that expedites subsequent implementation activities. Foremost among these preliminary activities is formation of a Lead Team comprising personnel from every operating division, including any division involved in information systems implementation. Twenty (20) staff members in the following roles/departments will coordinate implementation of the Coordinated Care Network (CCN) Program, providing the direction and prompt, consensus-based, decision-making necessary to keep implementation on task and on schedule. The Lead Team is chaired by the Aetna Better Health Chief Operations Officer (COO).

Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic Service Areas A, B and C Section R – Requirement §16

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Louisiana Lead Team Regional Vice President VP of Business Development Finance – CFO Medical Director Information Management and Systems Director Implementation Director Compliance Officer Enrollment/Disenrollment Manager Encounter Management Finance – TPL & COB Provider Payment & Reimbursement Human Resources Information Technology (IT) Reporting Member Services Network Management OPKM/Claims Audit/BAM/Claims Provider Data Services Provider Services Appeals/Grievance Training

Capability and Capacity Assessment Aetna Better Health’s IT solution is provided by its affiliate, Aetna Medicaid, an Aetna company. Aetna Medicaid’s IT systems have evolved along with the Medicaid managed care environment, and thus currently exhibit the functionality necessary to accommodate the diverse requirements of Medicaid in 10 states. Expert in legacy and state-of-the art MMIS systems alike, Aetna Medicaid’s IT personnel have a proven record of assisting state agencies in transitioning from Medicaid fee-for-service to Medicaid managed care. We have efficiently implemented required HIPAA transactions with every Medicaid single-state agency where we have contracts. All implementations and expansions have come up on-time and in accordance with each Medicaid single-state agency’s expectations and requirements.

Aetna Better Health and Aetna Medicaid have reviewed every systems requirement in the CCN-P RFP, its appendices, attachments and systems guide and determined that our systems currently possess the functionality to support them all; not one information system upgrade, functionality enhancement or capacity expansion will be required to meet the needs of the CCN Program. The design phase of our systems implementation will not require any new development, but merely configuration of existing systems functionality to the specific needs of this Contract. Our Lead Team will see to it that the core business applications responsible for provider enrollment and data management, member eligibility and enrollment, claims processing and service authorization are configured per Contract requirements, then coordinate and conduct the rigorous and exhaustive unit and end-to-end testing necessary to verify and validate implementation of the desired functionality. In keeping with requirement 16.3.10 of this RFP, Aetna Better Health and Aetna Medicaid personnel will complete and return to the Department of Health and Hospitals (DHH) an Information Systems Capabilities Assessment (ISCA) documenting our systems functionality no later than thirty (30) days from the date Aetna Better Health signs the Contract with DHH.

Systems Configuration Aetna Better Health’s implementation methodology leverages our Implementation Team’s knowledge and experience to see to it that our information system solutions support the most secure, effective and efficient workflow possible. Our Lead Team consolidates and coordinates the identified needs of cross-functional workgroups within a work plan supporting the configuration, testing and deployment of all required information systems functionality.


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Aetna Better Health’s core information system, QNXT™, stands unmatched as a health care delivery and support solution. Designed to encompass an "n-tier" environment and service-oriented architecture, the rules-driven, user-configurable system and its advanced .NET architecture integrate readily with Aetna Medicaid’s other key production systems. Aetna Better Health and Aetna Medicaid have jointly played an active role in QNXT™ development since the system’s infancy, merging our 25 years experience in Medicaid managed care with, first, QSCI’s and, subsequently, Trizetto’s, programming expertise to produce a flexible, scalable information system readily configurable to the unique needs of our individual health plans.

Upon contract award, Aetna Better Health will work with the appropriate DHH personnel and contractors (e.g., MMIS, PBM, behavioral health vendor) to capture detailed systems and process requirements. We will create detailed file specifications for all data exchanges including; Input/Output (I/O), purpose, sender, receiver, secure transmission method, update or full file content, frequency, dependencies, business rules, file naming, file layouts, and the accounts and control system that will serve to systematically certify data and balances. Data exchange specifications will include file transmission validation and verification procedures. Other documentation will include a benefit matrix defining covered and non-covered services, a prior authorization grid, eligibility requirements and rate code information compiled by the Implementation Team. All systems-related requirements and specifications, as well as a copy of the CCN Program Contract itself, will be forwarded to Aetna Medicaid’s Business Application Management (BAM) department, which will use the information to draft a solution document, or blue-print, of the required systems configuration. That document will then be forwarded to the VP of Business Application Management for approval and distribution to the Lead Team to facilitate compatibility with concurrent activities.

Once the systems blue-print is approved, BAM analysts will configure QNXT™ accordingly, seeing to it that the system’s respective components, including Carrier and Program Setup, Benefit Plans and Benefits, Employer/Policy, Provider Contracts, Medical Policy and basic financial information like category of expense, adjudication rules and messages (remit and explanation of benefits) reflect the associated requirements. Applicable fee tables and other associated information, including base reference data such as CPT/HCPCS codes, diagnosis codes, modifiers, CPT/modifier combinations, revenue codes, etc., are also configured by BAM.

Business Rules / Valid Values Aetna Better Health’s QNXT™ system is a relational database that already conforms to the data and document management standards and standard transaction code sets required by DHH. Data structures within and between systems are maintained through data mapping protocols and business rules that support Louisiana’s CCN program requirements and promote heightened data integrity. QNXT™, supports the configuration of multiple edits (business rules) to test claim validity, enforce valid values/formats for critical data (e.g. Medicaid ID, NPI and SSN numbers and DOB) and conduct claim determination accordingly. Applied edits include, but are not limited to: a) member eligibility; b) covered/non-covered services; c) required documentation; d) services within the scope of the providers practice; e) duplication of services; f) prior authorization; and g) invalid procedure codes.

Two applications compliment QNXT™’s applied logic. The first, iHealth, enforces select payment policies from one of the industry’s most comprehensive correct coding and medical


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policy content libraries, thereby promoting improved coding accuracy. The second, McKesson’s ClaimCheck®, expedites and sees to the accuracy of claim payments, auditing correct coding combinations based upon the following criteria:

• CPT-4 and ICD-9-CM coding definitions

• AMA and CMS guidelines and industry standards

• Medical policy and literature research

• Input from academic affiliations External Data Exchanges/Interfaces Aetna Better Health’s management information system is currently capable of supporting DHH’s required technical interfaces and complies with all applicable requirements of the Health Insurance Portability and Accountability Act (HIPAA). Detailed version migration plans provide for continued compliance with current and future HIPAA mandates, including 5010 compliance. Two systems assist us in this regard:

• Microsoft’s BizTalk with HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, enabling Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.

• Foresight’s HIPAA Validator™ InStream™ is a fully functional HIPAA editing and validation application. It validates HIPAA transactions through all seven levels of edits as defined by the Workgroup for Electronic Data Interchange and Strategic National Implementation Process (WEDI/SNIP), has all standard HIPAA code sets embedded, and can support custom, trading partner- specific companion guides and validation requirements. The application also provides descriptive error reports to submitters to facilitate quick error resolution.

Internal Data Exchange/Interfaces One aspect of application deployment particularly relevant when discussing systems implementation is Aetna Medicaid’s systemic use of one relational database technology for all core business applications. Key production systems, including QNXT™, our web-based care management business application (Dynamo™), ActiveHealth, AboveHealth®, our Actuarial Services Database (ASDB) and proprietary Encounter Management (EMS) and General Risk Model (predictive modeling) systems use Microsoft’s SQL Server 2000 Relational Database Management System (RDBMS), allowing for the virtual integration of data from physically disparate systems. This provides for consistent naming, formatting, definition and usage of data across applications. It allows us to maintain transaction and information integrity across core applications while maintaining the specialized, robust functionality each application provides. BAM, in addition to configuring QNXT™ itself, sees to it that all supported interfaces are configured and tested accordingly. Three examples of how such interoperability promotes data consistency and integrity follow:


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Provider Information from QNXT™ to our web-based care management business application (Dynamo™): Aetna Better Health’s network administration personnel use QNXT™ to build and maintain provider network information, including demographics, specialty/sub-specialty, affiliations, fee schedule and contractual arrangements. An extract of this information is automatically fed to our web-based care management business application (Dynamo™), on a nightly basis, reflecting any changes in provider network composition (additions, changes and terminations). No provider network data is input into the web-based care management business application (Dynamo™), the system of record for this information is QNXT™.

Eligibility Information from QNXT™ to our web-based care management business application (Dynamo™): Eligibility information received by Aetna Better Health is housed and maintained in QNXT™. An extract from QNXT™ is automatically created and loaded into the web-based care management business application (Dynamo™), on a regularly scheduled basis. If there is a change in a member’s demographic or eligibility data, the change is updated in QNXT™ and uploaded to the web-based care management business application (Dynamo™), during the next scheduled interface.

• QNXT™ to AboveHealth®: AboveHealth®, Aetna Better Health’s secure web portal allows authorized users to perform a number of functions, all dependent on the regularly scheduled import of data from QNXT™. These include:

• Claim/Encounter Status Inquiry — To support this operation, a periodic claims status file is exported from QNXT™ and populates AboveHealth’s® database.

• Checking authorization Status – For services requiring pre-authorization. This too, is based on data extracted daily from QNXT™.

• Member eligibility and provider directory look-up — To support these operations, a periodic extract of eligibility and provider information from QNXT™ is created and loaded into the AboveHealth® database.

The table below lists the external sources of QNXT™ data, while the chart that follows maps the exchange of data between QNXT™ and other key production systems, including:

• How each data exchange is triggered

• Direction of each data exchange

• Frequency of each data exchange

• A summary of the data exchanged


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System setup for intake, processing and acceptance Aetna Better Health, after receipt and analysis of the two years of historic claims data for members enrolled in Aetna Better Health, effective the start date of operations, will employ a stratification process that will facilitate participants’ assignment to the appropriate risk level; allowing Member Services personnel, Care and Case managers to appropriately target members with the most significant need. The Medical Management Coordinator in collaboration with the Chief Medical Officer (CMO) will be responsible for overseeing the stratification process. Information we will concentrate on includes members:

• With prior authorizations that indicate hospitalization admissions

• Who based on their claims pattern may have a chronic disease (e.g., asthma, diabetes, Congestive Heart Failure [CHF], Chronic Obstructive Pulmonary Disease [COPD])

• That are receiving or have recently (past 60 days) received home health care services

• Members with Special Health Care Needs (MSHCNs) and Children with Special Health Care Needs (CSHCNs)

• Who are recent NICU graduates

• Who have had three (3) or more ED visits in the last six (6) months

• Who have had thee (3) or more inpatient admissions in six (6) months

• With five (5) or more prescriptions from different therapeutic classes

• With a recent (last 60 days) hospital admission and readmission within fifteen (15) days

Key to our stratification process is our General Risk Model (GRM). We successfully use GRM in each of our Medicaid care management programs and it is a standard tool for our care management system solution. Through the utilization of GRM will be able to assign a Total Risk Score to each participant and determine the appropriate risk level into which the participant falls. Unlike some identification methods which are solely dependent on retrospective claims review or referrals, this tool uses innovative data-driven identification and stratification methods that includes looking at gaps in medical care and problematic participant behavior. GRM is an effective tool to accurately identify a member’s future high-cost utilization and/or those at risk of developing a serious chronic condition for whom enrollment in care management programs would result in improvements in both clinical and financial outcomes.

The analysis of the two years of historic claims data will also facilitate the identification of providers the member has frequently had encounters. We will use this data to determine:

1) The member’s Primary Care Provider (PCP)

2) The specialists the member frequently visits

3) If the member’s PCP or specialists participate with Aetna Better Health

We will use the results of this analysis to outreach to providers that we currently do have under contract and begin outreaching to those providers. This analysis will be a key tool for our network expansion efforts, we will fine tune our network to meet the needs of our members. If we are unable to reach a contractual agreement with a provider we will use our single case agreement process so that the member may continue in the provider’s care. We will be


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especially sensitive to providers used by MSHCN and CSHCN to secure continuity of care for these members. A report of any gaps in providers will be provided to the Chief Operating Officer (COO) and the Provider Services Manager as a planning tool. The Quality Management Coordinator and Grievance System Manager will also be copied on this report and be involved in any planning sessions.

Testing of One-Time and Ongoing Data Exchanges Aetna Better Health’s Lead Team bears responsibility for leading and coordinating the testing and issue/defect management of all business applications associated with any implementation. With regard to Louisiana, this includes appointing a Technology Lead to manage execution of the DHH-provided test plan and associated activities prior to Contract’s Go-Live Date. Aetna Better Health will initiate regular meetings with DHH personnel upon contract award to collaborate on a test approach that best aligns unit, end-to-end and DHH’s Readiness Review testing. Should DHH provide specific test scripts or scenarios, we will include these into our unit and/or end-to-end testing. Should the timing of DHH’s request preclude that option, DHH’s test scripts or scenarios will be executed independently. Aetna Better Health’s implementation tests comprise IT-facilitated end-to-end testing of all business and technology functions, daily status meetings, and policies and procedures providing for the prompt resolution and/or escalation of any issue. All testing issues are comprehensively tracked, managed and resolved, allowing anyone from Aetna Better Health or Aetna Medicaid’s IT or related business function to see all issues and participate in and validate their resolution. Critical and potentially show-stopping issues are escalated to Lead Team for discussion and resolution. Daily meetings see that any roadblock, issue or defect is resolved as quickly as possible.

Joint Testing Aetna Better Health-DHH Testing Upon contract award, Aetna Better Health will work with the appropriate DHH personnel to capture detailed systems and process requirements. We will create detailed file specifications for all data exchanges including; Input/Output (I/O), purpose, sender, receiver, secure transmission method, update or full file content, frequency, dependencies, business rules, file naming, file layouts, and the accounts and control system that will serve to systematically certify data and balances. Data exchange specifications will include file transmission validation and verification procedures. Our Technology Lead will coordinate the internal testing necessary to support the one-time and ongoing exchange of eligibility/enrollment, provider network, claims/encounters and other data with DHH, then work with DHH to coordinate joint testing accordingly. Should any issues arise in the course of the joint testing, Aetna Better Health will work with DHH to resolve them within allotted timeframes.

Aetna Better Health-FI EDI Testing Upon Contract award, Aetna Better Health will submit to DHH and its MMIS vendor a plan for testing the ASC X12N 837 COB in accordance with the required three (3) tiered methodology. The plan will include the following activities:

Prior to testing, Aetna Better Health will supply DHH with documentation of provider information publicly available through the Freedom of Information Act (FOIA) from the National Provider and Plan Enumeration System (NPPES). The documentation will map each provider to the corresponding provider types and specialties provided by DHH.


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Tier I Aetna Better Health will request, complete and submit to MMIS an EDI application and approval forms necessary to obtain a Trading Partner ID .

The Technology Lead will contact the MMIS’ EDI Department to obtain EDI specifications relative to data and format requirements for EDI claims. We will use these specifications to confirm compliance with required data and format requirements prior to any testing.

Concurrent with EDI enrollment, Aetna Better Health will begin testing – at our own expense – with EDIFECS, the MMIS’ third-party vendor, to certify HIPAA compliance prior to submission of any test files through the MMIS Electronic Data Interchange (EDI). Upon successful certification by EDIFECS, we will begin submitting test encounters to MMIS’ EDI Coordinator for data and format validation, seeing to it that the following information is included in each encounter file:

• All test files will be submitted with the required 4509999 identifier

• ‘RP’ is present in X12 field TX-TYPE-CODE field

• Aetna Better Health’s Medicaid IDs is in loop 2330B segment NM1 in ‘Other Payer Primary Identification Number

• If line item CCN paid amount is submitted, ‘Other Payer Primary Identifier’ in loop 2430 segment SVD is populated with their Medicaid provider number

• If a contracted provider has a valid NPI and taxonomy code, Aetna Better Health will submit those values in the 837. If the provider is an atypical provider, we will adhere to 837 atypical provider guidelines

Aetna Better Health’s Technology Lead will work with the EDI Coordinator to resolve any submission related issues

Tier II Once more than 50% of Aetna Better Health’s encounter claims data has successfully passed the MMIS pre-processor edits, the MMIS will process the encounters through the MMIS Adjudication cycle and the Payment cycle. The Payment cycle will create an 835 transaction, which Aetna Better Health will retrieve via IDEX. Encounter analysts will examine the returned 835s, comparing them to the encounter data claims (837s) submitted to see that all claims submitted are accounted for. Should any issues arise, Aetna Better Health will use the MMIS’ new edit code reports, as well as the MMIS edit code explanation document provided, to help determine the nature of the problem. We will reach out to MMIS for assistance if necessary.

Tier III Once satisfactory test results are documented, and the MMIS moves Aetna Better Health into production, Aetna Better Health will submit encounter files on a monthly basis. We will have established procedures for recouping post-payments available for DHH’s review during the Readiness Review process. These require that we void encounters for any claim recouped in full. For recoupments that result in an adjusted claim value, we submit replacement encounters accordingly.


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Internal Testing Aetna Better Health follows the Strategic National Implementation Project’s (SNIP) recommendations for testing created by the Workgroup for Electronic Data Interchange (WEDI), providing for our continued compliance with current and future federal IT mandates. These recommendations include the seven distinct types of testing described below:

Type 1: Integrity Testing involves testing for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 syntax and compliance with X12 rules.

Type 2: Requirement Testing involves testing for HIPAA Implementation Guide-specific requirements, such as repeat counts, used and not used codes, elements and segments, required or intra-segment situational data elements (non-medical code sets as laid out in the Implementation Guide) and values noted via an X12 code list or table.

Type 3: Balancing Testing involves testing the transaction for balanced field totals, record or segment counts, financial balancing of claims or remittance advice, and balancing of summary fields.

Type 4: Situation Testing is the testing of specific inter-segment situations described in the HIPAA Implementation Guides such that: If A occurs, then B must be populated. This is considered to include the validation of situational fields given values or situations present elsewhere in the file. As an example, if the transaction is an inpatient claim, a date of admission must be present.

Type 5: Code Set Testing is testing for valid Implementation Guide-specific code set values. Examples are CPT, CDT3, NDC, and ICD-9-CM.

Type 6: Product Types/Types of Service Testing (also known as line-of-business testing) is specialized testing required by certain healthcare specialties, such as chiropractic, ambulance, durable medical equipment, etc.

Type 7: Trading Partner-Specific Testing involves edits in the HIPAA Implementation Guides that are unique and specific to a payer. Examples are edits for Medicare, Medicaid, or Indian Health Services.

In addition to the recommended testing above, Aetna Better Health utilizes two applications to validate the HIPAA compliance of any in/outbound HIPAA transaction prior to import/export.


• Microsoft’s BizTalk with HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, enabling Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Accelerator has the Washington


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Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.

Aetna Better Health currently complies with the following federally mandated HIPAA transactions:

• ASC X12N 834 Benefit Enrollment and Maintenance

• ASC X12N 835 Claims Payment Remittance Advice Transaction

• ASC X12N 837I Institutional Claim/Encounter Transaction

• ASC X12N 837P Professional Claim/Encounter Transaction

• ASC X12N 276 Claims Status Inquiry

• ASC X12N 277 Claims Status Response

• ASC X12N 278 Utilization Review Inquiry/Response

• ASC X12N 820 Payroll Deducted and Other Group Premium Payment for Insurance Products

Aetna Better Health continuously monitors the technical interfaces supporting our HIPAA transactions. Our NOC and Operation Command Centers in Windsor, Connecticut monitor systems performance 24/7/365 via state-of-the-art applications and tools. IBM’s Tivoli Monitoring (ITM) products, for example, interface with other enterprise monitoring tools to provide a comprehensive yet consolidated view of problems across the enterprise. Production outages and system issues are managed by the Production Services Department, which assembles and coordinates teams and vendors to facilitate quick resolution and provide escalation when needed. Finally, the System Platform Performance (SPP) Department provides enterprise-wide performance monitoring, tuning, trend analysis and reporting for large-scale and midrange systems/platforms and mainframe systems and applications in support of business operations. SPP aims to promote optimum throughput and efficient use of resources to meet established service level agreements and availability goals.

Louisiana Medicaid CCN Work Plan Please see Appendix X for the work plan which identifies key activities, timeframes and projected resource requirements related to systems implementation of the Louisiana CCN contract.

Historical Data Processes QNXT™, Aetna Better Health’s core information processing system, maintains a complete transaction history; no data is archived, and all data is available real-time in an online accessible format.


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119 R.2



R.2 Describe your processes, including procedural and systems-based internal controls, for ensuring the integrity, validity and completeness of all information you provide to DHH (to their fiscal intermediary and the Enrollment Broker.) In your description, address separately the encounter data-specific requirements in, Encounter Data Section of the RFP as well as how you will reconcile encounter data to payments according to your payment cycle, including but not limited to reconciliation of gross and net amounts and handling of payment adjustments, denials and pend processes. Additionally, describe how you will accommodate DHH-initiated data integrity, validity and provide independent completeness audits.

Aetna Better Health and its affiliates have been implementing Medicaid managed care information systems for over 25 years. Today, Aetna Better Health administers or manages Medicaid health plans providing coverage to over 1.3 million members in 10 states. Well aware of the role sound, reliable information plays in effective healthcare administration, Aetna Better Health maintains robust processes safeguarding the integrity, validity and completeness of the information we provide to DHH, its Fiscal Intermediary and Enrollment Broker.

Integrity, Validity and Completeness of Information Encounter Transactions We have efficiently implemented required HIPAA transactions with every state agency with which we have contracted since the Act’s inception. We currently maintain HIPAA compliant technical interfaces supporting the information needs of 10 state agencies, their Fiscal Intermediaries and Enrollment Brokers. The following table describes the procedural and systems-based controls we have implemented to safeguard the integrity, validity and completeness of the information we provide to DHH and its Fiscal Intermediary:

17.5.4 Encounter Data-Specific Requirement Procedural Control Systems-based Control

17.5.4.1 - The CCN’s system shall be able to transmit to and receive encounter data from the DHH FI’s system as required for the appropriate submission of encounter data. We have developed encounter implementation strategies and approaches that facilitate the timely, accurate and complete submission and receipt of encounter information. These strategies and approaches support the efficient and effective identification, categorization and accounting for encounter specifications to design, test and implement the encounter management system.

Aetna Better Health’s proprietary Encounter Management System (EMS) provides for the accurate, timely and complete submission and receipt of encounter data –including all billed and paid units and charges, as well as the National Provider Identifier (NPI) – in HIPAA compliant 837(I/P) format. Developed with the functionality to manage encounter data across the encounter submission continuum – including preparation, review, verification, certification, submission, and reporting – the system consolidates required claims data from multiple sources (e.g. QNXT™ and contracted service providers) for all services eligible for processing.


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17.5.4.2 - Within sixty (60) days of operation in the applicable geographic service area, the CCN’s system shall be ready to submit encounter data to the FI in a provider-to-payer-to-payer COB format. The CCN must incur all costs associated with certifying HIPAA transactions readiness through a third-party, EDIFECS, prior to submitting encounter data to the FI. Data elements and reporting requirements are provided in the CCN-P Systems Companion Guide. • All encounters shall be submitted electronically in the standard HIPAA transaction formats, specifically the ANSI X12N 837 provider-to-payer-to-payer COB Transaction formats (P - Professional, and I - Institutional). Compliance with all applicable HIPAA, federal and state mandates, both current and future is required. We have developed encounter implementation strategies and approaches that facilitate the timely implementation of our encounter reporting capabilities. These strategies and approaches support the efficient and effective identification, categorization and accounting for encounter specifications to design, test and implement the encounter management system. In fact we have recently implemented three new encounter systems for Medicaid managed care programs (Florida, Pennsylvania and Illinois), meeting each state’s requirements and specifications for the development and submission of encounters. One of our encounter system implementation best practices is the early, frequent and consistent meetings with the state’s encounter management agent to establish a sound working relationship. This sound working relationship is a method to avoid unnecessary and costly errors often caused by misunderstandings or miscommunication. We will incur all costs associated with this activity. We have met the testing protocols for each of our ten states; including the most recent implementations of Illinois, Pennsylvania and Florida.

We have reviewed the data elements and reporting requirements in the CCN-P Systems Companion Guide and will meet all specifications and requirements, including but not limited to: 1. Submitting encounters electronically in the standard HIPAA transaction formats, specifically ANSI X12N 837. 2. We will comply with all HIPAA, federal and state mandates – current and future – as such requirements/specifications are implemented; provided that there is adequate time to test transmission protocols with DHH and its FI.

17.5.4.3 - The CCN shall provide the FI with complete and accurate encounter data for all levels of healthcare services provided. Aetna Better Health has encounter system implementation and submission best practices to validate data validity for all levels of healthcare services provided (ancillary, acute, and institutional services) prior to submitting encounter data to DHH.

Aetna Better Health has encounter system implementation and submission best practices to validate data validity for all levels of healthcare services provided (ancillary, acute, and institutional services) prior to submitting encounter data to DHH: 1. The QNXT™ system verifies that all necessary claims fields are populated with values of the appropriate range and type prior to the encounter information being loaded onto the EMS.


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2 .Encounter data files from vendor sources go through a staging process. The staging process consists of automated and manual verification, to validate that files have the proper layout and the appropriate fields populated. In this staging process, correct files are allowed to pass; pended files are corrected if there are correctable errors, or are rejected if the errors cannot be corrected. This staging process results in only the cleanest files being imported into the EMS. 3. After data from QNXT™ and vendor sources are loaded into the EMS, they must pass the EMS Scrub Edits, which are customized based on DHH’s requirements for clean encounters. Files that are unlikely to pass the DHH’s edits are not submitted until they are corrected. Encounter Unit analysts take responsibility for the correction. This proactive approach to identifying and correcting errors prior to the submission of data to the Commonwealth expedites review and adjudication.

17.5.4.4 - The CCN shall have the ability to update CPT/HCPCS, ICD-9-CM, and other codes based on HIPAA standards and move to future versions as required. We have protocols to thoroughly test these modifications to see to transitional accuracy.

Aetna Better Health has updated CPT/HCPCS, ICD-9-CM and other codes in accordance with HIPAA standards and the Medicaid agencies’ requirements and specifications. In addition, we continually meet the requirements of these Medicaid agencies’ to update fee schedules and other system modifications. We have designed our controls, processes and standards to modify CPT/HCPCS, ICD-9-CM, including protocols to thoroughly test these modifications to verify transitional accuracy.

17.5.4.5 - In addition to CPT, ICD-9-CM and other national coding standards, the use of applicable HCPCS Level II and Category II CPT codes are mandatory, aiding both the CCN and DHH to evaluate performance measures. Aetna Better Health has uniform written policies and procedures and system protocols that we apply to maintain compliance with these encounter reporting requirements. We also have written policies and procedures that require informing our provider network of CPT/HCPCS coding modifications that are effective as of a date-of-service to avoid unnecessary delays, confusion or problems in submitting complete, accurate and timely encounters to DHH and other Medicaid agencies.

Aetna Better Health maintains strict compliance with updates regarding Current Procedural Terminology (CPT), the Healthcare Procedural Coding System (HCPCS) (CPT/HCPCS), and ICD-9-CM and other codes in accordance with HIPAA standards so that claims and resulting encounters are processed in an orderly and consistent manner


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17.5.4.6 - The CCN shall have the capability to convert all information that enters its claims system via hard copy paper claims to electronic encounter data, to be submitted in the appropriate HIPAA compliant formats to DHH’s FI. All paper claims are converted to electronic images we have

the capability and capacity to convert all the claim informationreceived via hard copy “paper” claims to electronic claims using Optical Character Recognition (OCR) technology. All paper claims are converted to electronic images by our vendor (EMDEON – using their Alchemy program). If the claim cannot be translated into an electronic data record by the OCR process, then the paper claims is sent directly to our claims department for data entry. Each claim is assigned a unique claim number and an electronic file of the claim is created. This file is uploaded into QNXT™ to be accessed by the claims team. The paper claim is in the QNXT™ system within 1 to 3 business days from its receipt. Additionally, the scanned image of the paper claim is stored in an image repository and is viewable to Aetna Better Health personnel, as needed. Aetna Better Health uses Microsoft BizTalk with HIPAA Accelerator™ (a data transformation application) to translate data to and from the full spectrum of HIPAA Transactions sets in a highly customizable, flexible, and robust server-based environment. Moreover, Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the Transactions sets are updated over time.

17.5.4.7 - The FI encounter process shall utilize a DHH-approved version of the claims processing system (edits and adjudication) to identify valid and invalid encounter records from a batch submission by the CCN. Any submission which contains fatal errors that prevent processing, or that does not satisfy defined threshold error rates, will be rejected and returned to the CCN for immediate correction. Encounter system implementation and submission best

practices validate data validity for all levels of healthcare services provided (ancillary, acute, and institutional services) prior to submitting encounter data to DHH: 1. The QNXT™ system verifies that all necessary claims fields are populated with values of the appropriate range and type prior to the encounter information being loaded onto the Encounter Management System. 2 .Encounter data files from vendor sources go through a staging process. The staging process consists of automated and manual verification, to validate that files have the proper


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layout and the appropriate fields populated. In this staging process, correct files are allowed to pass; pended files are corrected if there are correctable errors, or are rejected if the errors cannot be corrected. This staging process results in only the cleanest files being imported into the EMS. 3. After data from QNXT™ and vendor sources are loaded into the EMS, they must pass the EMS Scrub Edits, which are customized based on DHH’s requirements for clean encounters. Files that are unlikely to pass the DHH’s edits are not submitted until they are corrected. Encounter Unit analysts take responsibility for the correction. This proactive approach to identifying and correcting errors prior to the submission of data to the Commonwealth expedites review and adjudication

17.5.4.8 - DHH and its FI shall determine which claims processing edits are appropriate for encounters and shall set encounter edits to “pay” or “deny”. Encounter denial codes shall be deemed “repairable” or “non-repairable”. An example of a repairable encounter is “provider invalid for date of service”. An example of a non-repairable encounter is “exact duplicate”. The CCN is required to be familiar with the FI exception codes and dispositions for the purpose of repairing denied encounters. Aetna Better Health will obtain documentation from the FI regarding the approved processing edits and specifically design our encounter submission process to transmit timely, accurate and complete encounters consistent with these requirements to avoid confusion and unnecessary cost. Our best practice is to meet frequently with the Medicaid agency and the FI to fully understand design, intent and application of these edits and the adjudication process during the system design and testing phase. We will validate our compliance during readiness review and system testing activities.

Aetna Better Health will configure our Encounter Management System (EMS) to differentiate between “repairable” and “non-repairable” encounters. The systems workflow management functionality provides for the routing and disposition of encounters based upon the associated exception code.

17.5.4.9 - As specified in the CCN-P Systems Companion Guide, denials for the following reasons will be of particular interest to DHH:

● Denied for Medical Necessity including lack of documentation to support necessity; ● Member has other insurance that must be billed first; ● Prior authorization not on file; ● Claim submitted after filing deadline; and ● Service not covered by CCN.

Aetna Better Health monitors denial reasons as a tool to determine if our training, processes, protocols or operations require performance improvement. We also monitor denial reasons to determine if a provider may need with assistance with filing claims appropriately or in following our established protocols.


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We train and inform providers of our claims requirements and specification in the Provider Manual, Provider Newsletters and initial/on-going provider training events. We use the PDSA approach to monitor and adjust our processes and procedures. Establishing a positive working relationship with participating and non-participating providers is a priority. Aetna Better Health has never, nor will we ever, use deliberate claims mishandling or claim denials as a method to delay or avoid payment of claims. 17.5.4.10 - The CCN shall utilize DHH provider billing manuals and become familiar with the claims data elements that must be included in encounters. The CCN shall retain all required data elements in claims history for the purpose of creating encounters that are compatible with DHH and its FI’s billing requirements. Aetna Better Health’s expert team of claims system developers and encounter system design specialists have already reviewed DHH’s system guide and compared it to similar guides from other Medicaid agencies.

Aetna Better Health has standard operating procedures related to the retention and storage of claims and encounter history and data. Our expert team of claims system developers and encounter system design specialists have already reviewed DHH’s system guide and compared it to similar guides from other Medicaid agencies. .

17.5.4.11 - Due to the need for timely data and to maintain integrity of processing sequence, the CCN shall address any issues that prevent processing of an encounter; acceptable standards shall be ninety percent (90%) of reported repairable errors are addressed within thirty (30) calendar days and ninety-nine percent (99%) of reported repairable errors within sixty (60) calendar days or within a negotiated timeframe approved by DHH. Failure to promptly research and address reported errors, including submission of and compliance with an acceptable corrective action plan may result in monetary penalties. Aetna Better Health currently meets DHH’s requirements in each of the ten states in which we do business. We will apply the management principles and administrative discipline that support our record of excellence in this area to the Louisiana CCN program.

17.5.4.12 - For encounter data submissions, the CCN shall submit ninety-five (95%) of its encounter data at least monthly due no later than the twenty-fifth (25th) calendar day of the month following the month in which they were processed and approved/paid, including encounters reflecting a zero dollar amount ($0.00) and encounters in which the CCN has a capitation arrangement with a provider. The CCN CEO or CFO shall attest to the truthfulness, accuracy, and completeness of all encounter data submitted. Aetna Better Health currently meets DHH’s requirements in each of the ten states in which we do business. We will apply the management principles and administrative discipline that support our record of excellence in this area to the Louisiana CCN program.


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17.5.4.13 - The CCN shall ensure that all encounter data from a contractor is incorporated into a single file from the CCN. The CCN shall not submit separate encounter files from CCN contractors. Business Application Management (BAM) personnel will

configure EMS such that all encounter data attributable to a given contractor is incorporated within a single file prior to submission.

17.5.4.14 - The CCN shall ensure that files contain settled claims and claim adjustments or voids, including but not limited to, adjustments necessitated by payment errors, processed during that payment cycle, as well as encounters processed during that payment cycle from providers with whom the CCN has a capitation arrangement. Aetna Better Health’s written policies and procedures and operating manuals are specifically designed to support this requirement. Furthermore, we require each capitated or delegated provider to meet these requirements and will test compliance during readiness review. We recommend that DHH develop encounter testing protocols to include examples of these requirements to assure itself that Aetna Better Health meets this stipulation.

17.5.4.15 - The CCN shall ensure the level of detail associated with encounters from providers with whom the CCN has a capitation arrangement shall be equivalent to the level of detail associated with encounters for which the CCN received and settled a fee-for-service claim. Aetna Better Health’s written policies and procedures and operating manuals are specifically designed to support this requirement. Furthermore, we require each capitated or delegated provider to meet these requirements and will test compliance during readiness review. We recommend that DHH develop encounter testing protocols to include examples of these requirements to assure itself that Aetna Better Health meets this stipulation.

17.5.4.16 - The CCN shall adhere to federal and/or department payment rules in the definition and treatment of certain data elements, such as units of service that are a standard field in the encounter data submissions and will be treated similarly by DHH across all CCNs. Business Application Management (BAM) personnel will

configure EMS in accordance with all federal and/or department payment rules pertaining to the definition and treatment of certain data elements.

17.5.4.17 - Encounter records shall be submitted such that payment for discrete services which may have been submitted in a single claim can be ascertained in accordance with the CCNs applicable reimbursement methodology for that service. Business Application Management (BAM) personnel will

configure EMS such that encounter records display the level of detail necessary to differentiate between discrete services


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Provider Data Aetna Better Health will provide the Enrollment Broker a Provider Directory in two formats: an electronic file and a hard copy, abbreviated version. To expedite such activities, we maintain data on all contracted providers and all non-participating providers having filed a claim within QNXT™, our core information processing system. For participating, contracted providers, we establish a provider record during the credentialing process or through data received from our vendor relationships. For non-participating providers, we input demographic information in the provider management system when we receive notification that a claim has been filed and there are no records for the billing provider anywhere in the system. Provider records are updated continually as new information is received. The majority of provider information, however, comes from network providers who submit updated demographic information by contacting our provider call centers and network representatives or access our secure Website for physicians, hospitals and other healthcare professionals. To see to it that the provider data we submit to the Enrollment Broker is as sound, valid and complete as possible, we have implemented automated processes that coordinate Aetna Better Health’s provider enrollment records with the published list of Louisiana Medicaid provider types, specialty, and sub-specialty codes at www.lamedicaid.com on a regular basis. Policies and procedures provide for the prompt reconciliation of any inconsistencies. Should circumstances ever necessitate a member’s disenrollment, these same processes see to it that the documentation submitted is as sound, valid and complete as possible.

Reconciliation of Encounter Data to Payments Aetna Better Health provides for the integrity, validity and completeness of our encounter data through the regular reconciliation of claims payments to submitted encounters, seeing to it that the dollars paid in any given payment cycle match the corresponding dollars submitted via the encounter file. As illustrated in the following diagram, encounter unit analysts reconcile encounter data to financial expenditures on a weekly basis. In addition, monthly and quarterly processes reconcile encounters to our claims lag report.


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Handling of Payment Adjustments, Denials and Pends As illustrated by the flow chart on the following page, Aetna Better Health has a clearly defined process for handling encounters relative to claims payment adjustments, denials or pends. Beginning in the upper left corner, source data comprising Aetna Better Health or Aetna Better Health vendor claims in PAID or REVERSED status is pulled from QNXT™, Aetna Better Health’s core information processing system. That data is loaded into our proprietary Encounter Management System, where each encounter must pass a series of “scrubs” and edits en route from intermediate (or staging) to permanent data tables. EMS next applies reversal/adjustment logic specific to the requirements of the given state to each encounter having passed these internal edits. These encounters are then flagged, (T= Sent; waiting for Remit/Error/Pend file(s)), formatted and submitted to the state via HIPAA compliant 837 or NCPDP files. The states’ response files are handled as indicated.


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DHH-initiated Data Integrity and Validity Studies Aetna Better Health maintains a Quality Improvement Program whereby we continually evaluate opportunities to adopt and implement procedural and systems-based controls providing improved data integrity, validity and completeness. As part of our ongoing quality improvement efforts, claims and EDI experts, clinical quality assurance and reporting and data analytics personnel will cooperate with DHH’s own Continuous Quality Improvement Program initiatives. We will use quality improvement tools, such as root cause analysis, to investigate and evaluate data quality issues identified by DHH, then present those findings during a quarterly site visit (or as needed). As data issues are discussed, Aetna Better Health quality assurance personnel will incorporate corrective action steps into a quality improvement report, and then implement corrective measures accordingly. If for any reason an issue is not resolved in a timely manner, we will provide DHH a Corrective Action Plan (CAP) listing issues, responsible parties, and projected resolution dates.

Provision of Independent Audit Results QNXT™ maintains audit trails facilitating the auditing of individual claims in accordance with, at a minimum, the guidelines and objectives of the American Institute of Certified Public Accountants (AICPA) Audit and Account Guide, The Auditor’s Study and Evaluation of Internal Control in Electronic Data Processing (EDP) Systems. Aetna Better Health will maintain an internal EDP Policy and Procedures (P&P) manual mirroring AICPA guidelines and will make the manual available to DHH and both state and independent auditors upon request. The manual will, at a minimum, describe all accessible screens used throughout the system and attest to the system’s adherence to not only the same Graphical User Interface (GUI) standards, but programmers’ adherence to the highest industry standards for the coding, testing, execution and documentation of all system activities.

Aetna Better Health has engaged KPMG, LLC since 2000 to perform SOC I Type II audits of our claims processing and related general computer controls. These have consistently indicated positive, unqualified opinions. We will contract with KPMG – or a similar independent firm subject to the written approval of DHH – to perform audits in full compliance with AICPA Professional Standards for Reporting on the Processing of Transactions by Service Organizations. These will include:

1) Conduct limited scope EDP audits on an ongoing and annual basis using DHH’s audit program specifications at the conclusion of the first twelve (12) month operation period and each twelve (12) month period thereafter, while the Contract is in force with DHH and at the conclusion of the Contract; and

2) Conduct a comprehensive audit on an annual basis to determine the CCN’s compliance with the obligations specified in the Contract and the Systems Guide.

The auditing firm will deliver to the Aetna Better Health and to DHH a report, prepared in accordance with generally accepted auditing standards for EDP application reviews, of findings and recommendations within thirty (30) calendar days of the close of each audit. In addition, an exit interview will be conducted at the conclusion of the audit and a yearly written report of all findings and recommendations submitted to Aetna Better Health and DHH by the independent auditing firm. These finding will be incorporated within our EDP manual following DHH’s


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review. Aetna Better Health will deliver to DHH a corrective action plan addressing any deficiencies identified during the audit within ten (10) business days of receipt of the audit report.


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120 R.3



R.3 Describe in detail how your organization will ensure that the availability of its systems will, at a minimum, be equal to the standards set forth in the RFP. At a minimum your description should encompass: information and telecommunications systems architecture; business continuity/disaster recovery strategies; availability and/or recovery time objectives by major system; monitoring tools and resources; continuous testing of all applicable system functions, and periodic and ad-hoc testing of your business continuity/disaster recovery plan.

Identify the timing of implementation of the mix of technologies and management strategies (policies and procedures) described in your response to previous paragraph or indicate whether these technologies and management strategies are already in place.

Elaborate, if applicable, on how you have successfully implemented the aforementioned mix of technologies and management strategies with other clients.

Aetna Better Health and its affiliates have been implementing Medicaid managed care information systems for over 25 years. As a result, we are aware of the importance state agencies, network providers and members place on uninterrupted access to our information and telecommunication systems. Our information and telecommunication systems are configured accordingly, incorporating the multiple levels of redundancy necessary to provide members’ and providers’ access to internet and/or telephone-based and information functions 24 hours a day, seven days a week (except during periods of scheduled system unavailability mutually agreed upon with DHH). All other system functions and information are available to applicable system users between, at a minimum, the hours of 7 a.m. and 7 p.m. (CST), Monday through Friday. Redundant technical interfaces provide for the uninterrupted exchange of data, such as that which will be required between Aetna Better Health and DHH’s FI and/or Enrollment Broker.

Information and Telecommunications Systems Architecture Aetna Better Health’s key production and telecommunication system include the following Aetna Better Health-owned and outsourced system/applications. All key information system are housed at Aetna Medicaid’s primary and secondary (DR/BC) data centers in Windsor and Middleton, Connecticut (respectively), while telecommunications services (Avaya) are based out of Blue Bell, Pennsylvania1. Technical support is provided through an agreement between Aetna Better Health and the Aetna Medicaid Business Unit, affording Aetna Better Health access to Aetna Medicaid’s expansive technical support. Disaster Recovery and Business Continuity (DR/BC) Plans are maintained at three levels: Aetna Medicaid manages and maintains DR/BC Plans providing for uninterrupted access to corporate resources. Individual health plans, in turn, are required to maintain detailed DR/BC Plans relative to their respective geographic location and associated risks. Finally, all outsourced system/application vendors are required to maintain their own DR/BC plans, which they are contractually required to validate on an annual basis.

1 An Avaya switch will also be installed on-site in Louisiana.


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CONFIDENTIAL CONFIDENTIAL CONFIDENTIAL



Owned systems/Applications:

• QNXT™ – Core information processing system responsible for:

− Claims data, adjudication and COB/TPL processes

− Demographic, eligibility and enrollment data

− Provider contract configuration,

− EDI processes

− QM/UM, Prior Authorizations and concurrent reviews

• EMS – Encounter Management system

• General Risk Model (GRM) – Risk stratification system

• ASDB – Actuarial Database

• Grievance and Appeals Database – Issue management tracking

• Avaya – Communications (telecommunications) management platform Outsourced systems/Applications: • Dynamo™ - Web -based care management business application

• ActiveHealth® Care Engine - Clinical support/messaging

• AboveHealth® – Secure Web portal (member/provider)

Business Continuity/Disaster Recovery Strategies Aetna Medicaid’s disaster backup and recovery strategy is to provide and maintain an internal disaster recovery capability. This strategy leverages the internal computer processing capacity of two state-of-the-art, hardened computer centers located in Middletown and Windsor, Connecticut. Both facilities have extensive fire suppression systems, dual incoming power feeds, UPS, and backup diesel generators supporting 24/7/365 operation. Physical access is strictly controlled and monitored, and access to vital areas is segregated by floor and business function as appropriate. The two data centers house Aetna Medicaid’s computer processing capabilities on three major platforms, mainframe (Z/OS), mid-range (Various UNIX versions), and LAN (Windows on X86 processors). The data centers are load balanced and supplemented by quick-ship and capacity-on-demand contracts, permitting each center to back the other up in the event of disaster. We maintain contracts with national vendors providing for replacement equipment and supplemental capacity as needed, further promoting compliance with Recovery Time Objectives (RTO).

In the event of a data center disaster, the RTO to resume most production processing is four days from disaster declaration for all mainframe and mid-range system and five days for LAN systems. Portfolios of highly available applications, such as web and pharmacy, have RTO’s of four hours or less. These applications utilize mirroring and/or load balancing technologies between the data centers to make certain that the reduced RTOs can be met. Aetna Medicaid’s voice and data network backbones are fully redundant using SONET ring technology and are recovered within 1-4 hrs hours of a data center outage. In short, Aetna Medicaid’s data center recovery strategy and its application RTO’s are consistent with or better than industry standards.


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Data Backup Infrastructure and application data is secured and stored offsite on a daily basis. Backed-up data is cross vaulted between the two computer centers, with mainframe backups stored primarily on disk media and mid-range/LAN backups stored primarily on tape. Additionally, all mainframe disk data is mirrored to the alternate data center providing a simplified and timelier recovery for that piece of the environment. Any customer data lost as a result of a data center catastrophe will be recovered through re-submittals by service providers and/or recovery reconciliation teams. To provide for ready access to off-site storage, Aetna Better Health maintains remote back-ups of operating instructions, procedures, reference files, system documentation, and operational files. These include:

• Descriptions of the controls for back-up processing, including how frequently back-ups occur

• Documented back-up procedures

• The location of data that has been backed up (off-site and on-site, as applicable)

• Identification and description of what is being backed up as part of the back-up plan; and

• Any change in back-up procedures in relation to a change(s) in technology

Aetna Better Health will provide DHH with a list of all back-up files to be stored at remote locations and the frequency with which these files will be updated upon request.

Contingency Plans Aetna Better Health maintains, and is continually ready to invoke, contingency plans protecting the availability, integrity, and security of data during unexpected failures or disasters, providing for the continued function of essential application or system functions. In keeping with best practice, our contingency plans include both a Disaster Recovery Plan (DRP) and a Business Continuity Plan (BCP). The following scenarios are addressed:

• The central computer installation and resident software are destroyed or damaged;

• The system interruption or failure resulting from network, operating hardware, software, or operations errors that compromise the integrity of transaction that are active in a live system at the time of the outage;

• System interruption or failure resulting from network, operating hardware, software or operations errors that compromise the integrity of data maintained in a live or archival system;

• System interruption or failure resulting from network, operating hardware, software or operational errors that does not compromise the integrity of transactions or data maintained in a live or archival system, but does prevent access to the system, such as it causes unscheduled system unavailability; and

For each instance, our contingency plans specify projected recovery times and anticipated data loss for mission-critical system in the event of a declared disaster.

Disaster Recovery Plan The Aetna Medicaid’s Disaster Recovery Plan is the high level plan for recovery of a data center and its critical components. The plan is derived from over 50 detailed IT infrastructure plans which are maintained by each critical support area. The plans contain processes and procedures


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to recover all functions, services, and equipment which are needed to recover either data center. These plans are centrally maintained by our disaster recovery group, are stored both locally and offsite and are updated semi-annually or as needed by the respective infrastructure area.

Application recovery (DBAR) plans document technical and management contacts, application recovery specifics, application dependencies, integrated system synchronization, and checkout procedures. The plans are maintained routinely and utilize automated recovery processes to insure appropriate data resilience. These DBAR plans are validated annually with the application owners and business users with periodic integrated tabletop simulations.

Escalation and notification procedures are contained within disaster recovery plans to verify recovery team members, affected partners and business unit owners are activated in a timely manner. AIS’s role during a disaster is to lead, manage, and staff the various recovery teams, which will also be augmented by additional vendor specialists under contract for certain supplemental recovery technologies, which AIS will coordinate.

Each one of Aetna Better Health’s health plans is responsible for maintaining its own DR Plan, as each local plan must contain detailed instructions relative to its geographic location and associated risks.

Business Continuity Plan Aetna Medicaid maintains and implements a detailed business continuity program, with over 300 plans to address its critical business work group operations. In the event of an office outage, processing is transferred to surviving offices within Aetna Better Health’s network with little or no disruption to service levels. The detailed business continuity plans are maintained on a quarterly basis and in-depth tests, including CMP and BCP simulations, building evacuations, or call tree tests, are conducted periodically.

The Aetna Medicaid is responsible for the coordination of Aetna Medicaid’s DR/BC activities. Similarly, each Aetna Better Health’s plan maintains a local version of the Disaster Recovery/Business Continuity Plan specific to its respective operations and local resources. The Plan contains a listing of key customer priorities, key factors that could cause disruption, and the timelines within which each anticipates resumption of critical customer services (e.g. providers’ receipt of prior authorization approvals and denials), including the percentage of recovery at certain hours, as well as key activities required to meet those timelines. Recovery Time Objectives (RTOs) for key information and telecommunication systems are provided below:

Availability and/or Recovery Time Objectives (RTOs) by Major System Aetna Medicaid Business Unit’s Chief Operating Officer (COO) bears responsibility for maintaining the continuity of Aetna Better Health’s information system, seeing to our continued compliance with required RTOs. As demonstrated in the table below, Aetna Better Health’s RTOs provide for the recovery of required Tier 1 functionality (eligibility/enrollment and claims processing) within zero to four hours, exceeding DHH’s RTO of seventy-two (72) hours.

The COO will notify designated DHH personnel via phone, fax and/or electronic mail within sixty (60) minutes upon discovery of any problem within or outside Aetna Better Health’s span of control that may jeopardize or is jeopardizing availability and performance of critical system functions and the availability of critical information, including any problems impacting scheduled exchanges of data with DHH or DHH’s FI. The notification will provide details as to


28




the related impact to critical path processes such as enrollment management and encounter submission processes. Similarly, should Aetna Better Health discover a problem that results in delays in report distribution or problems in on-line access to critical system functions and information during a business day, we will notify designated DHH personnel via phone, fax, and/or electronic mail within fifteen (15) minutes, in order for the applicable work activities to be rescheduled or handled based on system unavailability protocol. In either case, we will provide DHH, at a minimum, hourly updates (via phone and/or electronic mail) regarding the nature of the event(s), as well as a status on its resolution.

Aetna Better Health will resolve and implement system restoration within sixty (60) minutes of any official declaration of unscheduled system unavailability of critical functions caused by the failure of system and telecommunications technologies within our span of control. Unscheduled system unavailability to all other system functions caused by system and telecommunications technologies within our span of control will be resolved, and the restoration of services implemented, within eight (8) hours. Cumulative system unavailability caused by system and/or IS infrastructure technologies within our span of control will not exceed twelve (12) hours during any continuous twenty (20) business day period.

Within five (5) business days of the occurrence of a problem with system availability, Aetna Better Health will provide DHH with full written documentation including a corrective action plan describing what measure we will implement to prevent a recurrence.


29


Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Key I

nfor

mat

ion

and

Telec

omm

unica

tion

Syst

ems’

Reco

very

Tim

e Obj

ectiv

es (R

TOs)

Appl

icatio

n De

scrip

tion

DBAR

Pr

iorit

y*

QNXT

™

Core

infor

matio

n pro

cess

ing sy

stem

- Cl

aims d

ata, a

djudic

ation

and C

OB/T

PL pr

oces

ses

- De

mogr

aphic

, elig

ibility

and e

nroll

ment

data

- Pr

ovide

r con

tract

confi

gura

tion,

- ED

I pro

cess

es

- QM

/UM,

Prio

r Auth

oriza

tions

and c

oncu

rrent

revie

ws

Tier 1

Dyna

mo™

2 W

eb-b

ased

care

man

agem

ent a

pplic

ation

Tie

r 1

Avay

a Ca

ll man

agem

ent s

ystem

Tie

r 1

EMS

Enco

unter

Man

agem

ent s

ystem

Tie

r 2

Pred

ictive

Mod

eling

Ri

sk st

ratifi

catio

n Tie

r 2

Actua

rial S

ervic

e Data

base

(ASD

B)

Pred

ictive

mod

eling

/ Stat

istica

l outl

ier an

alysis

Tie

r 2

Activ

eHea

lth C

are E

ngine

Cl

inica

l sup

port

/ mes

sagin

g Tie

r 2

Griev

ance

s and

App

eals

Issue

man

agem

ent

Tier 2

Ab

oveH

ealth

®

Secu

re W

eb P

ortal

(Mem

ber/P

rovid

er)

Tier 2

*Rec

over

y tim

e ob

ject

ives

for

tier

-one

app

lica

tion

s ar

e 0-

4 hr

s; R

TO

for

rem

aini

ng a

ppli

cati

ons

is 1

-4 w

eeks

.

2 O

ur w

eb-b

ased

car

e m

anag

emen

t bus

ines

s A

pplic

atio

n (D

ynam

o™”)


30




Monitoring Tools and Resources Aetna Medicaid’s core business system maintained a 99.99 percent uptime through the 2010 calendar year, due largely to the combined efforts of personnel at our Network Operation Center (NOC), Operation Command Center and Production Services and System Platform Performance Departments. The four share one common goal: the optimization of our core business systems’ performance. Our NOC and Operation Command Centers, for example, monitor system performance 24/7/365 via state-of-the-art applications and tools, such as IBM Tivoli Monitoring (ITM) products. ITM is an event management/problem detection tool that can monitor Windows Server system attributes and system Event logs, as well as ASCII logs. It interfaces with other enterprise monitoring tools to provide a comprehensive yet consolidated view of problems across the enterprise. Production outages and system issues are managed by the Production Services Department which assembles and coordinates teams and vendors to facilitate quick resolution and provide escalation when needed. And finally, the system Platform Performance (SPP) Department provides enterprise-wide performance monitoring, tuning, trend analysis and reporting for large-scale and midrange system/platforms and mainframe system and applications in support of business operations. SPP aims to promote optimum throughput and efficient use of resources to meet established service level agreements and availability goals

Continuous Testing of All Applicable System Functions Aetna Better Health, in conjunction with Aetna Medicaid, continuously monitors all information system functions. As described above, personnel in each of the four departments at Aetna Medicaid’s corporate data center work in concert to monitor system performance, using various quality control measures to anticipate and mitigate any potential system issue. IT personnel at the health plan level monitor performance as well and work with corporate IT personnel to resolve issues as they arise.

Business Continuity/Disaster Recovery Plan Testing Aetna Better Health and Aetna Medicaid update disaster recovery plans and procedures as necessary. Annual testing of corporate and local disaster recovery plans, employing simulated disasters and lower level failures, affords corporate and local IT personnel alike the opportunity to demonstrate and validate system recovery capabilities for DHH. Should these tests ever fail to demonstrate our ability to restore system functions, Aetna Better Health will submit a corrective action plan to DHH describing how the failure will be resolved within ten (10) business days of the conclusion of the test.

Identify the timing of implementation of the mix of technologies and management strategies (policies and procedures) described in your response to (a), or indicate whether these technologies and management strategies are already in place.

Aetna Better Health’s information system currently supports the diverse needs of Medicaid health plans in 10 states. Our Information system personnel has reviewed every system requirement in the CCN-P RFP, its appendices, attachments and system guide and determined that our system already possess the functionality to support them all. The design phase of our system implementation will not include any development, but merely clarification and configuration of existing system functionality to the specific needs of this Contract. Our COO will see to it that the core business applications responsible for provider enrollment and data


31




management, member eligibility and enrollment, claims processing and service authorization are configured accordingly, then unit and end-to-end testing conducted to verify and validate implementation of the desired functionality.

Elaborate, if applicable, on how you have successfully implemented the aforementioned mix of technologies and management strategies with other clients.

Aetna Better Health has been implementing Medicaid managed care information system for over 25 years. Today, Aetna Better Health administers or manages Medicaid health plans providing coverage to over 1.3 million members in 10 states, and each has implemented its own DR/BC Plans accordingly. All Aetna Better Health’s plan maintains their own DR/BC Plans, though each has access to Aetna Medicaid’s deep pool of DR/BC resources.

In compliance with DHH’s System Readiness Review Requirements, Aetna Better Health will submit a contingency plan comprising Disaster Recovery and Business Continuity Plans no later than 120 days prior to the Contract’s Operational Start Date.


32


121 R.4



R.4 Describe in detail:

• How your key production systems are designed to interoperate. In your response address all of the following:

o How identical or closely related data elements in different systems are named, formatted and maintained:

- Are the data elements named consistently; - Are the data elements formatted similarly (# of characters, type-

text, numeric, etc.); - Are the data elements updated/refreshed with the same frequency

or in similar cycles; and - Are the data elements updated/refreshed in the same manner

(manual input, data exchange, automated function, etc.).

o All exchanges of data between key production systems. - How each data exchange is triggered: a manually initiated

process, an automated process, etc.

- The frequency/periodicity of each data exchange: “real-time” (through a live point to-point interface or an interface “engine”), daily/nightly as triggered by a system processing job, biweekly, monthly, etc.

• As part of your response, provide diagrams that illustrate: o point-to-point interfaces, o information flows, o internal controls and o the networking arrangement (AKA “network diagram”) associated with

the information systems profiled. These diagrams should provide insight into how your Systems will be organized and

interact with DHH systems for the purposes of exchanging Information and automating and/or facilitating specific functions associated with the Louisiana Medicaid CCN Program.

Aetna Better Health through it affiliate Aetna Medicaid has access to a state-of-the-art core production system: QNXT™. QNXT™ integrates the following four primary production functions within one core application.

• Claims processing

• Eligibility and enrollment processing

• Service authorization management

• Provider enrollment and data management

This integration provides for the consistent naming and formatting of all related data elements. Data is not stored in disparate systems where it is subject to the naming and formatting conventions of each respective system, but rather within a single integrated application. QNXT™ data may be refreshed automatically (e.g. intake of HIPAA transaction code sets from our automated claims clearinghouse) or manually (e.g. daily updates by personnel), with the refresh


33



rate of any particular data element dependent on the timeliness of the data. QNXT’s™ robust interoperability provides for the mapping of “source” data elements within QNXT™ to corresponding fields in related systems. As a result, any change or edit made to a data element within QNXT™ is automatically propagated across related fields anytime it is refreshed, providing for increased data validity, integrity and accuracy. As with QNXT’s™ internal refresh rates, the refresh rate of any given data interface is determined by the nature of the respective data exchange. Refresh of claims data between QNXT™ and EMS, for example, need only occur after Aetna Better Health’s weekly check run, whereas member and provider data accessible via AboveHealth®, Aetna Better Health’s secure web portal, is refreshed daily. The process is expedited through the use of shared relational database technology, described below, that supports seamless systems interoperability.

Systems Interoperability Data Exchange between Key Production Systems One aspect of application deployment particularly relevant when discussing these data interfaces is Aetna Better Health’s systemic use of one relational database technology for all core business applications. Key production systems, including QNXT™, our web-based business application (Dynamo™), ActiveHealth, AboveHealth®, our Actuarial Services Database (ASDB) and proprietary Encounter Management System (EMS) and predictive modeling systems use Microsoft’s SQL Server 2000 Relational Database Management System (RDBMS), allowing for the virtual integration of data from physically disparate systems. This provides for consistent naming, formatting, definition and usage of data across applications. It allows us to maintain transaction and information integrity across core applications while maintaining the specialized, robust functionality each application provides. Three examples of how such interoperability promotes data consistency and integrity follow:

Provider Information from QNXT™ to our Web-based Care Management Business Application (Dynamo™)

Aetna Better Health network administration personnel use QNXT™ to build and maintain provider network information, including demographics, specialty/sub-specialty, affiliations, fee schedule and contractual arrangements. An extract of this information is automatically fed to our web-based care management business application (Dynamo™) on a nightly basis, reflecting any changes in provider network composition (additions, changes and terminations). No provider network data is input into our web-based care management business application (Dynamo™); the system of record for this information is QNXT™.

Eligibility Information from QNXT™ to our web-based care management business application (Dynamo™)

Eligibility information received by Aetna Better Health is housed and maintained in QNXT™. An extract from QNXT™ is automatically created and loaded into our web-based care management business application (Dynamo™) on a regularly scheduled basis. If there is a change in a member’s demographic or eligibility data, the change is updated in QNXT™ and uploaded to our web-based care management business application (Dynamo™) during the next scheduled interface.


34



QNXT™ to AboveHealth® AboveHealth®, Aetna Better Health’s secure web portal allows authorized users to perform a number of functions, all dependent on the regularly scheduled import of data from QNXT™. These include:

• Claim/Encounter Status Inquiry — To support this operation, a periodic claims status file is exported from QNXT™ and populates AboveHealth’s® database.

• Checking authorization Status – For services requiring pre-authorization. This too, is based on data extracted daily from QNXT™.

• Member eligibility and provider directory look-up — To support these operations, a periodic extract of eligibility and provider information from QNXT™ is created and loaded into the AboveHealth® database.

The following table summarizes the data exchange between QNXT™ and other key production systems, including:

• How each data exchange is triggered

• Whether each data exchange is one or two-way

• The frequency of each data exchange

A summary of the Data Exchange Between QNXT™ and Other Key Production Systems

Dynamo1 EMS2 AboveHealth® QNXT™ Automated Automated Automated

QNXT™ ►Dynamo QNXT™ ►EMS QNXT™ ►AboveHealth® Daily Weekly Daily

- Member - Provider

- Claims - Provider (PRN)

- Authorizations - Claims - Enrollment - Member - Provider - EPSDT Status - Remittance Advices

AboveHealth® ► QNXT™ Twice Daily - Authorizations

1Aetna Better Health’s web-based care management business application 2Encounter Management System

The following network diagram illustrates the manner in which Aetna Better Health’s systems are organized and interact with one another, DHH and our respective trading partners for the purposes of exchanging Information and automating and/or facilitating specific functions associated with the Louisiana Medicaid Coordinated Care Network (CCN) Program. This diagram shows all systems that interact with QNXT™, including minor systems that provide editing and other features that fail to meet the overall qualification to be included in this response.


35

122 R.5



R.5 Describe your ability to provide and store encounter data in accordance with the requirements in this RFP. In your response:

● Explain whether and how your systems meet (or exceed) each of these requirements.

● Cite at least three currently-live instances where you are successfully providing encounter data in accordance with DHH coding, data exchange format and transmission standards and specifications or similar standards and specifications, with at least two of these instances involving the provision of encounter information from providers with whom you have capitation arrangements. In elaborating on these instances, address all of the requirements in Section 17. Also, explain how that experience will apply to the Louisiana Medicaid CCN Program.

● If you are not able at present to meet a particular requirement contained in the aforementioned section, identify the applicable requirement and discuss the effort and time you will need to meet said requirement.

● Identify challenges and “lessons learned” from your implementation and operations experience in other states and describe how you will apply these lessons to this contract.

Provide and Storage of Encounter Data Aetna Better Health’s expert team of claims system developers and encounter system design specialists have reviewed DHH’s system guide and compared it to similar guides from other Medicaid agencies. Based on this review and our recent experience implementing three new encounter systems for Medicaid managed care programs in Florida, Pennsylvania and Illinois we will meet DHH’s encounter system requirements, specifications and program elements. We also recently expanded our Missouri Medicaid managed care program into two large regions and successfully transitioned providers (PCP, hospital, ancillary, specialist and others) from fee-for-service to managed care. We have the knowledge, experience and skill to support providers during this transition. We have successfully converted providers from submitting paper claims to electronic claims in each of these instances. Our relational database design is an efficient and optimal method to store claims and encounter data. Each claim and corresponding encounter has a unique number that supports seamless extraction of data to support claim and encounter adjustments, voiding, or modification. We have sufficient storage capacity to support the Louisiana Coordinated Care Network (CCN) Program during the term of this contract. Our storage capacity can be easily expanded to meet the needs of this program.

Capacity of our Encounter System to Meet DHH’s Requirements – Applying our Experience

In the table below we have specifically addressed each of the encounter specifications and requirements in RFP sections 17.5.4.1 to 17.5.4.17. We have selected three example states (Delaware, Florida, and Maryland) in accordance with the instructions of this question. These states were selected because they are representative of the range of encounter requirements from the other seven states. We are aware that encounters are important to DHH for several reasons. We also value claim and encounter data because these data provide the source of information to understand our members, providers and the communities we serve. We constantly use claim and


36



encounter data in performing critical activities related to predictive modeling, improving health outcomes, increasing the quality of life, determine compliance with HEDIS®3 measures and measure our performance.

Please see a detailed flow chart at the end on this section for a description of the encounter process.

3 HEDIS® is a registered trademark of the National Committee for Quality Assurance.


37

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

Me

ets/E

xcee

ds R

equi

rem

ent

17

.5.4.1

The

CCN

’s sy

stem

shall

be ab

le to

trans

mit to

an

d rec

eive e

ncou

nter d

ata fr

om th

e DHH

FI’s

syste

m as

re

quire

d for

the a

ppro

priat

e sub

miss

ion of

enco

unter

da

ta.

Meets

Me

ets

Meets

In

Delaw

are,

Florid

a and

Mar

yland

we m

eet e

ach

Medic

aid ag

encie

s enc

ounte

r data

subm

ission

re

quire

ments

. We a

lso re

ceive

enco

unter

data

resp

onse

s fro

m ea

ch M

edica

id ag

ency

in ac

cord

ance

with

the

proto

cols

of tha

t Med

icaid

agen

cy.

Aetna

Bett

er H

ealth

’s pr

oprie

tary E

ncou

nter M

anag

emen

t Sy

stem

(EMS

) pro

vides

for t

he ac

cura

te, tim

ely an

d co

mplet

e sub

miss

ion of

enco

unter

data

–inclu

ding a

ll bil

led an

d paid

units

and c

harg

es4 ,

as w

ell as

the N

ation

al Pr

ovide

r Ide

ntifie

r (NP

I) – i

n HIP

AA co

mplia

nt 83

7(I/P

) for

mat. D

evelo

ped w

ith th

e fun

ction

ality

to ma

nage

en

coun

ter da

ta ac

ross

the e

ncou

nter s

ubmi

ssion

co

ntinu

um –

includ

ing pr

epar

ation

, rev

iew, v

erific

ation

, ce

rtifica

tion,

subm

ission

, and

repo

rting –

the s

ystem

co

nsoli

dates

requ

ired c

laims

data

from

multip

le so

urce

s (e

.g. Q

NXT™

and c

ontra

cted s

ervic

e pro

vider

s) for

all

servi

ces e

ligibl

e for

proc

essin

g.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

W

e hav

e dev

elope

d enc

ounte

r imple

menta

tion s

trateg

ies an

d app

roac

hes t

hat fa

cilita

te the

timely

, ac

cura

te an

d com

plete

enco

unter

s. T

hese

stra

tegies

and a

ppro

ache

s sup

port

the ef

ficien

t and

eff

ectiv

e ide

ntific

ation

, cate

goriz

ation

and a

ccou

nting

for e

ncou

nter s

pecif

icatio

ns to

desig

n, tes

t and

im

pleme

nt the

enco

unter

man

agem

ent s

ystem

. In e

ach o

f thes

e sam

ple in

stanc

es (D

elawa

re,

Florid

a and

Mar

yland

) and

in ou

r othe

r sev

en (7

) Med

icaid

mana

ged c

are w

e met

the cr

iteria

for

subm

itting

enco

unter

s to t

he st

ate or

its ag

ent.

In fac

t we h

ave r

ecen

tly im

pleme

nted t

hree

new

enco

unter

syste

ms fo

r Med

icaid

mana

ged c

are p

rogr

ams (

Florid

a, Pe

nnsy

lvania

and I

llinois

) and

met

each

of th

ese s

tates

requ

ireme

nts an

d spe

cifica

tions

for t

he de

velop

ment

and s

ubmi

ssion

of

enco

unter

s. W

e hav

e exp

erien

ce su

ppor

ting p

rovid

ers t

rans

itionin

g fro

m fee

-for-s

ervic

e to M

edica

id ma

nage

d car

e and

in sh

ifting

prov

iders

from

subm

itting

pape

r clai

ms to

elec

tronic

claim

s. W

e will

apply

this

expe

rienc

e to t

he Lo

uisian

a CCN

prog

ram.

We e

xpec

t that

initia

lly w

e may

expe

rienc

e a

4 W

e ar

e no

t req

uire

d to

sub

mit

deni

ed e

ncou

nter

s fo

r th

ese

Med

icai

d pr

ogra

ms.

How

ever

, we

do s

ubm

it a

dmin

istr

ativ

e de

nial

to th

e P

enns

ylva

nia

Med

icai

d ag

ency

. W

e al

so s

ubm

it d

enia

ls to

the

Med

icai

d co

unty

reg

ulat

ory

orga

niza

tion

in C

alif

orni

a, b

ut th

is is

a d

iffe

rent

pro

cess

than

in P

enns

ylva

nia.


38

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

high v

olume

of pa

per c

laim

subm

ission

, but

we w

ill sy

stema

ticall

y tar

get a

nd re

duce

this

prac

tice.

Ou

r exp

ert te

am of

claim

s sys

tem de

velop

ers a

nd en

coun

ter sy

stem

desig

n spe

cialis

ts ha

ve al

read

y re

viewe

d DHH

’s sy

stem

guide

and c

ompa

red i

t to si

milar

guide

s fro

m oth

er M

edica

id ag

encie

s.

17.5.

4.2 W

ithin

sixty

(60)

days

of op

erati

on in

the

appli

cable

geog

raph

ic se

rvice

area

, the C

CN’s

syste

m sh

all be

read

y to s

ubmi

t enc

ounte

r data

to th

e FI in

a pr

ovide

r-to-

paye

r-to-

paye

r COB

form

at.

The C

CN m

ust in

cur a

ll cos

ts as

socia

ted w

ith ce

rtifyin

g HI

PAA

trans

actio

ns re

adine

ss th

roug

h a th

ird-p

arty,

ED

IFEC

S, pr

ior to

subm

itting

enco

unter

data

to the

FI.

Data

eleme

nts an

d rep

ortin

g req

uirem

ents

are p

rovid

ed

in the

CCN

-P S

ystem

s Com

panio

n Guid

e. ●

Al

l enc

ounte

rs sh

all be

subm

itted

electr

onica

lly in

the s

tanda

rd H

IPAA

tra

nsac

tion f

orma

ts, sp

ecific

ally t

he A

NSI

X12N

837 p

rovid

er-to

-pay

er-to

-pay

er C

OB

Tran

sacti

on fo

rmats

(P -

Profe

ssion

al, an

d I

- Ins

titutio

nal).

Comp

lianc

e with

all

appli

cable

HIP

AA, fe

dera

l and

state

ma

ndate

s, bo

th cu

rrent

and f

uture

is

requ

ired.

Meets

Me

ets

Meets

In

each

of th

e Stat

es w

e are

using

as an

exam

ple w

e met

the re

quire

d enc

ounte

r sub

miss

ion in

acco

rdan

ce w

ith th

e Me

dicaid

agen

cies r

equir

emen

ts. W

e suc

cess

fully

met th

e re

quire

ments

in ea

ch S

tate a

nd ha

ve th

e exp

erien

ce,

capa

bility

, and

tech

nical

expe

rtise t

o mee

t the

expe

ctatio

ns in

Louis

iana.

We w

ill inc

ur al

l cos

ts as

socia

ted w

ith th

is ac

tivity

. We

have

met

the te

sting

proto

cols

for ea

ch of

our t

en st

ates;

includ

ing th

e mos

t rec

ent im

pleme

ntatio

ns of

Illino

is,

Penn

sylva

nia an

d Flor

ida.

We h

ave r

eview

ed th

e data

elem

ents

and r

epor

ting

requ

ireme

nts in

the C

CN-P

Sys

tems C

ompa

nion G

uide

and w

ill me

et all

spec

ificati

ons a

nd re

quire

ments

, inclu

ding

but n

ot lim

ited t

o: 1.

Subm

itting

enco

unter

s elec

tronic

ally i

n the

stan

dard

HI

PAA

trans

actio

n for

mats,

spec

ificall

y ANS

I X12

N 83

7. 2.

We w

ill co

mply

with

all H

IPAA

, fede

ral a

nd st

ate

mand

ates –

curre

nt an

d futu

re –

as su

ch

requ

ireme

nts/sp

ecific

ation

s are

imple

mente

d; pr

ovide

d tha

t ther

e is a

dequ

ate tim

e to t

est tr

ansm

ission

proto

cols

with

DHH

and i

ts FI

.


39

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

W

e hav

e dev

elope

d enc

ounte

r imple

menta

tion s

trateg

ies an

d app

roac

hes t

hat fa

cilita

te the

timely

, ac

cura

te an

d com

plete

enco

unter

s. T

hese

stra

tegies

and a

ppro

ache

s sup

port

the ef

ficien

t and

eff

ectiv

e ide

ntific

ation

, cate

goriz

ation

and a

ccou

nting

for e

ncou

nter s

pecif

icatio

ns to

desig

n, tes

t and

im

pleme

nt the

enco

unter

man

agem

ent s

ystem

. In e

ach o

f thes

e sam

ple in

stanc

es (D

elawa

re,

Florid

a and

Mar

yland

) and

in ou

r othe

r sev

en (7

) Med

icaid

mana

ged c

are w

e met

the cr

iteria

for

subm

itting

enco

unter

s to t

he st

ate or

its ag

ent.

In fac

t we h

ave r

ecen

tly im

pleme

nted t

hree

new

enco

unter

syste

ms fo

r Med

icaid

mana

ged c

are p

rogr

ams (

Florid

a, Pe

nnsy

lvania

and I

llinois

) and

met

each

of th

ese s

tates

requ

ireme

nts an

d spe

cifica

tions

for t

he de

velop

ment

and s

ubmi

ssion

of

enco

unter

s. O

ne of

our e

ncou

nter s

ystem

imple

menta

tion b

est p

racti

ces i

s the

early

, freq

uent

and

cons

isten

t mee

tings

with

the s

tate’s

enco

unter

man

agem

ent a

gent

to es

tablis

h a so

und w

orkin

g re

lation

ship.

This

soun

d wor

king r

elatio

nship

is a

metho

d to a

void

unne

cess

ary a

nd co

stly e

rrors

often

caus

ed by

misu

nder

stand

ings o

r misc

ommu

nicati

on.

17.5.

4.3 T

he C

CN sh

all pr

ovide

the F

I with

comp

lete a

nd

accu

rate

enco

unter

data

for al

l leve

ls of

healt

hcar

e se

rvice

s pro

vided

.

Meets

Me

ets

Meets

W

e mee

t this

requ

ireme

nt in

each

of th

ese s

tates

. We

have

the e

xper

ience

, exp

ertis

e and

syste

m ca

pabil

ities t

o su

bmit t

imely

, acc

urate

and c

omple

te en

coun

ters f

or al

l lev

els of

servi

ces.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

To

day w

e mee

t this

requ

ireme

nt in

the th

ree e

xamp

le sta

tes an

d in o

ur ot

her s

even

Med

icaid

mana

ged c

are s

tates

. We h

ave e

ncou

nter s

ystem

imple

menta

tion a

nd su

bmiss

ion be

st pr

actic

es to

va

lidate

data

valid

ity fo

r all l

evels

of he

althc

are s

ervic

es pr

ovide

d (an

cillar

y, ac

ute, a

nd in

stitut

ional

servi

ces)

prior

to su

bmitti

ng en

coun

ter da

ta to

DHH:

1.

The Q

NXT™

syste

m ve

rifies

that

all ne

cess

ary c

laims

fields

are p

opula

ted w

ith va

lues o

f the

appr

opria

te ra

nge a

nd ty

pe pr

ior to

the e

ncou

nter in

forma

tion b

eing l

oade

d onto

the E

MS.

2 .En

coun

ter da

ta file

s fro

m ve

ndor

sour

ces g

o thr

ough

a sta

ging p

roce

ss. T

he st

aging

proc

ess

cons

ists o

f auto

mated

and m

anua

l ver

ificati

on, to

valid

ate th

at file

s hav

e the

prop

er la

yout

and t

he

appr

opria

te fie

lds po

pulat

ed. In

this

stagin

g pro

cess

, cor

rect

files a

re al

lowed

to pa

ss; p

ende

d file

s ar

e cor

recte

d if th

ere a

re co

rrecta

ble er

rors,

or ar

e reje

cted i

f the e

rrors

cann

ot be

corre

cted.

This

stagin

g pro

cess

resu

lts in

only

the cl

eane

st file

s bein

g imp

orted

into

the E

MS.

3. Af

ter da

ta fro

m QN

XT™

and v

endo

r sou

rces a

re lo

aded

into

the E

MS, th

ey m

ust p

ass t

he E

MS

Scru

b Edit

s, wh

ich ar

e cus

tomize

d bas

ed on

DHH

’s re

quire

ments

for c

lean e

ncou

nters.

File

s tha

t are

un

likely

to pa

ss th

e DHH

’s ed

its ar

e not

subm

itted u

ntil th

ey ar

e cor

recte

d. En

coun

ter U

nit an

alysts

tak

e res

pons

ibility

for t

he co

rrecti

on. T

his pr

oacti

ve ap

proa

ch to

iden

tifying

and c

orre

cting

erro

rs


40

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

prior

to th

e sub

miss

ion of

data

to the

Com

monw

ealth

expe

dites

revie

w an

d adju

dicati

on.

17.5.

4.4 T

he C

CN sh

all ha

ve th

e abil

ity to

upda

te CP

T/HC

PCS,

ICD-

9-CM

, and

othe

r cod

es ba

sed o

n HI

PAA

stand

ards

and m

ove t

o futu

re ve

rsion

s as

requ

ired.

Meets

Me

ets

Meets

W

e hav

e in e

ach o

f thes

e stat

es up

dated

CPT

/HCP

CS,

ICD-

9-CM

and o

ther c

odes

in ac

cord

ance

with

HIP

AA

stand

ards

and t

he M

edica

id ag

encie

s’ re

quire

ments

and

spec

ificati

ons.

In ad

dition

, we c

ontin

ually

mee

t the

requ

ireme

nts of

thes

e Med

icaid

agen

cies’

to up

date

fee

sche

dules

and o

ther s

ystem

mod

ificati

ons.

We h

ave

desig

ned o

ur co

ntrols

, pro

cess

es an

d stan

dard

s to m

odify

CP

T/HC

PCS,

ICD-

9-CM

, inclu

de pr

otoco

ls to

thoro

ughly

tes

t thes

e mod

ificati

ons t

o con

firm tr

ansit

ional

accu

racy

. Ho

w we

will

apply

this

expe

rienc

e to t

he Lo

uisian

a CCN

pr

ogra

m?

Each

of th

e stat

es A

etna B

etter

Hea

lth pr

ovide

s Med

icaid

mana

ged c

are h

ave d

iffere

nt nu

isanc

es in

the

captu

re an

d rep

ortin

g of e

ncou

nter d

ata. W

e hav

e unif

orm

writte

n poli

cies a

nd pr

oced

ures

and

syste

m pr

otoco

ls tha

t we a

pply

to ma

intain

comp

lianc

e with

, but

sepa

ratio

n on a

state

-by-s

tate b

asis,

the

se en

coun

ter re

portin

g req

uirem

ents.

Aetn

a Bett

er H

ealth

main

tains

stric

t com

plian

ce w

ith

upda

tes re

gard

ing C

urre

nt P

roce

dura

l Ter

min

olog

y (C

PT),

the H

ealth

care

Pro

cedu

ral C

odin

g Sy

stem

(H

CPCS

) (CP

T/HC

PCS)

, and

ICD-

9-CM

and o

ther c

odes

in ac

cord

ance

with

HIP

AA st

anda

rds s

o tha

t clai

ms an

d res

ulting

enco

unter

s are

proc

esse

d in a

n ord

erly

and c

onsis

tent m

anne

r. CP

T pr

oced

ural

code

s are

publi

shed

by th

e Ame

rican

Med

ical A

ssoc

iation

(AMA

). Up

dated

annu

ally o

n Ja

nuar

y 1, C

PT is

a pr

oprie

tary t

ermi

nolog

y cre

ated a

nd m

aintai

ned b

y the

AMA

. Its p

urpo

se is

to

prov

ide a

unifo

rm la

ngua

ge fo

r des

cribin

g and

repo

rting t

he pr

ofess

ional

servi

ces p

rovid

ed by

ph

ysici

ans.

HC

PCS

is ma

intain

ed by

the C

enter

s for

Med

icare

and M

edica

id Se

rvice

s (CM

S). It

s pur

pose

is to

pr

ovide

a sy

stem

for re

portin

g the

med

ical s

ervic

es pr

ovide

d to M

edica

id/Me

dicar

e mem

bers.

HC

PCS

is ma

de up

of tw

o par

ts: Le

vel I

is co

mpos

ed en

tirely

of the

curre

nt ve

rsion

of C

PT; H

CPCS

Le

vel II

prov

ides c

odes

to re

pres

ent m

edica

l ser

vices

that

are n

ot co

vere

d by t

he C

PT sy

stem,

for

exam

ple, m

edica

l sup

plies

and s

ervic

es pe

rform

ed by

healt

hcar

e pro

fessio

nals

who a

re no

t ph

ysici

ans

The

CPT

is a

unifo

rm co

ding s

ystem

cons

isting

of de

scrip

tive t

erms

and i

denti

fying

co

des t

hat a

re us

ed pr

imar

ily to

iden

tify m

edica

l ser

vices

and p

roce

dure

s fur

nishe

d by p

hysic

ians

and o

ther h

ealth

care

profe

ssion

als. H

ealth

care

profe

ssion

als us

e the

CPT

to id

entify

servi

ces a

nd

proc

edur

es th

ey bi

ll to A

etna B

etter

Hea

lth fo

r cov

ered

and m

edica

lly ne

cess

ary s

ervic

es. W

e un

derst

and t

hat d

ecisi

ons r

egar

ding t

he ad

dition

, dele

tion,

or re

vision

of C

PT co

des a

re m

ade b

y the


41

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

AMA.

The

CPT

code

s are

repu

blish

ed an

d upd

ated a

nnua

lly by

the A

MA. L

evel

I of th

e HCP

CS, th

e CP

T co

des,

does

not in

clude

code

s nee

ded t

o sep

arate

ly re

port

medic

al ite

ms or

servi

ces t

hat a

re

regu

larly

billed

by su

pplie

rs oth

er th

an ph

ysici

ans.

We a

re aw

are t

hat H

CPCS

Leve

l II is

a sta

ndar

dized

codin

g sys

tem to

iden

tify pr

oduc

ts, su

pplie

s, an

d ser

vices

not in

clude

d in t

he C

PT

code

s, su

ch as

ambu

lance

servi

ces a

nd du

rable

med

ical e

quipm

ent, p

rosth

etics

, orth

otics

, and

su

pplie

s (DM

E) w

hen u

sed o

utside

a ph

ysici

an's

office

. Bec

ause

mos

t Med

icaid

agen

cies,

includ

ing

DHH,

requ

ire m

anda

tory c

over

age o

f a va

riety

of se

rvice

s, su

pplie

s, an

d equ

ipmen

t that

are n

ot ide

ntifie

d by C

PT co

des,

the le

vel II

HCP

CS co

des w

ere e

stabli

shed

by C

MS fo

r sub

mittin

g clai

ms fo

r the

se ite

ms. C

urre

ntly,

there

are n

ation

al HC

PCS

code

s rep

rese

nting

over

4,00

0 sep

arate

ca

tegor

ies of

like i

tems o

r ser

vices

that

enco

mpas

s milli

ons o

f pro

ducts

from

diffe

rent

manu

factur

ers.

Whe

n sub

mittin

g clai

ms, w

e req

uire o

ur pr

ovide

r to u

se on

e of th

ese c

odes

to id

entify

the i

tems t

hey

are b

illing

. The

desc

riptor

that

is as

signe

d to a

code

repr

esen

ts the

defin

ition o

f the i

tems a

nd

servi

ces t

hat c

an be

bille

d usin

g tha

t cod

e. F

or th

ese r

easo

ns an

d to p

rovid

e tim

ely, a

ccur

ate an

d co

mplet

e enc

ounte

rs to

the M

edica

id ag

encie

s we p

rovid

e man

aged

care

servi

ce to

, we c

losely

mo

nitor

and m

aintai

n com

plian

ce w

ith th

e mos

t cur

rent

CPT/

HCPC

S co

ding r

equir

emen

ts an

d sti

pulat

ions.

We a

lso ha

ve w

ritten

polic

ies an

d pro

cedu

res t

hat r

equir

e info

rming

our p

rovid

er

netw

ork o

f CPT

/HCP

CS co

ding m

odific

ation

s tha

t are

effec

tive a

s of a

date-

of-se

rvice

to av

oid

unne

cess

ary d

elays

, con

fusion

or pr

oblem

s in s

ubmi

tting c

omple

te, ac

cura

te an

d tim

ely en

coun

ters

to DH

H an

d othe

r Med

icaid

agen

cies.

In ad

dition

to th

e abo

ve w

e also

clos

ely m

onito

r and

rema

in co

mplia

nt wi

th the

follo

wing

re

quire

ments

:

• Pe

rman

ent N

ation

al Co

des -

Nati

onal

perm

anen

t HCP

CS le

vel II

code

s are

main

taine

d by t

he

CMS

HCPC

S W

orkg

roup

•

Misc

ellan

eous

Cod

es -

Natio

nal c

odes

also

inclu

de "m

iscell

aneo

us/no

t othe

rwise

clas

sified

" co

des.

Thes

e cod

es ar

e use

d whe

n a su

pplie

r is su

bmitti

ng a

bill fo

r an i

tem or

servi

ce an

d the

re

is no

exist

ing na

tiona

l cod

e tha

t ade

quate

ly de

scrib

es th

e item

or se

rvice

being

bille

d. •

Temp

orar

y Nati

onal

Code

s - T

empo

rary

code

s are

for t

he pu

rpos

e of m

eetin

g, wi

thin a

shor

t time

fra

me, th

e nati

onal

prog

ram

oper

ation

al ne

eds t

hat a

re no

t add

ress

ed by

an al

read

y exis

ting

natio

nal c

ode.

We a

re aw

are t

hat a

nd m

onito

r the

CMS

HCP

CS W

orkg

roup

has s

et as

ide ce

rtain

secti

ons o

f the H

CPCS

code

set to

allow

the W

orkg

roup

to de

velop

temp

orar

y cod

es.


42

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

• Ty

pes o

f temp

orar

y HCP

CS co

des:

o

The C

code

s wer

e esta

blish

ed to

perm

it imp

lemen

tation

of se

ction

201 o

f the B

alanc

ed

Budg

et Re

finem

ent A

ct of

1999

. o

Th

e Q co

des a

re us

ed to

iden

tify se

rvice

s tha

t wou

ld no

t be g

iven a

CPT

-4 co

de, s

uch a

s dr

ugs,

biolog

icals,

and o

ther t

ypes

of m

edica

l equ

ipmen

t or s

ervic

es, a

nd w

hich a

re no

t ide

ntifie

d by n

ation

al lev

el II c

odes

but fo

r whic

h cod

es ar

e nee

ded f

or cl

aims p

roce

ssing

pu

rpos

es.

o

The G

code

s are

used

to id

entify

profe

ssion

al he

althc

are p

roce

dure

s and

servi

ces t

hat w

ould

other

wise

be co

ded i

n CPT

-4 bu

t for w

hich t

here

are n

o CPT

-4 co

des.

o

Th

e K co

des w

ere e

stabli

shed

for u

se by

the D

ME M

ACs w

hen t

he cu

rrentl

y exis

ting

perm

anen

t nati

onal

code

s do n

ot inc

lude t

he co

des n

eede

d to i

mplem

ent a

DME

MAC

me

dical

revie

w po

licy.

o

Th

e S co

des a

re us

ed by

priva

te ins

urer

s to r

epor

t dru

gs, s

ervic

es, a

nd su

pplie

s for

whic

h the

re ar

e no n

ation

al co

des b

ut for

whic

h cod

es ar

e nee

ded b

y the

priva

te se

ctor t

o imp

lemen

t po

licies

, pro

gram

s, or

claim

s pro

cess

ing.

o

Certa

in H

code

s are

used

by th

ose S

tate M

edica

id ag

encie

s tha

t are

man

dated

by S

tate l

aw

to es

tablis

h sep

arate

code

s for

iden

tifying

men

tal he

alth s

ervic

es su

ch as

alco

hol a

nd dr

ug

treatm

ent s

ervic

es.

o

The T

code

s are

desig

nated

for u

se by

Med

icaid

State

agen

cies t

o esta

blish

code

s for

items

for

whic

h the

re ar

e no p

erma

nent

natio

nal c

odes

and f

or w

hich c

odes

are n

eces

sary

to me

et a

natio

nal M

edica

id pr

ogra

m op

erati

ng ne

ed.

• Co

de M

odifie

rs - I

n som

e ins

tance

s, Me

dicaid

agen

cies i

nstru

ct Ae

tna B

etter

Hea

lth to

requ

ire its

pr

ovide

rs to

requ

ire a

code

mod

ifier

to a

HCPC

S co

de to

prov

ide ad

dition

al inf

orma

tion r

egar

ding

the se

rvice

or ite

m ide

ntifie

d by t

he H

CPCS

code

. Mod

ifiers

are u

sed w

hen t

he in

forma

tion

prov

ided b

y a H

CPCS

code

desc

riptor

need

s to b

e sup

pleme

nted t

o ide

ntify

spec

ific

circu

mstan

ces t

hat m

ay ap

ply to

an ite

m or

servi

ce. F

or ex

ample

, a U

E mo

difier

is of

ten us

ed

when

the i

tem id

entifi

ed by

a HC

PCS

code

is "u

sed e

quipm

ent,"

a NU

mod

ifier is

used

for "

new

equip

ment.

" The

leve

l II H

CPCS

mod

ifiers

are e

ither

alph

a-nu

meric

or tw

o lett

ers.

• HC

PCS

Upda

tes to

Per

mane

nt Na

tiona

l Cod

es –

We a

re aw

are t

hat th

e nati

onal

code

s are

up

dated

annu

ally

CPT

Categ

ory I

I Cod

es -

We a

re aw

are t

hat C

PT C

atego

ry II c

odes

are s

upple

menta

l trac

king c

odes

us

ed fo

r per

forma

nce m

easu

reme

nt. T

hese

trac

king c

odes

for p

erfor

manc

e mea

sure

ment

decre

ase

the ne

ed fo

r rec

ord a

bstra

ction

and c

hart

revie

w, an

d the

reby

mini

mize

admi

nistra

tive b

urde

ns on


43

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

phys

ician

s and

othe

r hea

lthca

re pr

ofess

ionals

. The

se co

des a

re in

tende

d to f

acilit

ate da

ta co

llecti

on

abou

t qua

lity of

care

by co

ding c

ertai

n ser

vices

and/o

r tes

t res

ults t

hat s

uppo

rt pe

rform

ance

me

asur

es an

d tha

t hav

e bee

n agr

eed u

pon a

s con

tributi

ng to

good

patie

nt ca

re. C

PT II

code

s are

ma

intain

ed an

d upd

ated b

y the

Per

forma

nce M

easu

res A

dviso

ry Gr

oup (

PMAG

), an

advis

ory b

ody t

o the

CPT

Edit

orial

Pan

el. T

he P

MAG

comp

rises

perfo

rman

ce m

easu

reme

nt ex

perts

repr

esen

ting t

he

Agen

cy of

Hea

lthca

re R

esea

rch an

d Qua

lity (A

HRQ)

, the A

meric

an M

edica

l Ass

ociat

ion (A

MA),

the

Cente

rs for

Med

icare

and M

edica

id Se

rvice

s (CM

S), th

e Join

t Com

miss

ion on

Acc

redit

ation

of

Healt

hcar

e Org

aniza

tions

(JCA

HO),

the N

ation

al Co

mmitte

e for

Qua

lity A

ssur

ance

(NCQ

A) an

d the

Ph

ysici

an C

onso

rtium

for P

erfor

manc

e Imp

rove

ment.

Th

e Int

erna

tiona

l Cla

ssifi

catio

n of

Dis

ease

s, C

linic

al M

odifi

catio

n, cu

rrentl

y in i

ts nin

th re

vision

(ICD

-9-

CM),

is us

ed to

desc

ribe a

nd re

port

the ill

ness

es, c

ondit

ions,

and i

njurie

s of p

atien

ts wh

o req

uire

medic

al se

rvice

s. IC

D-9-

CM is

mad

e up o

f a se

ries o

f num

erica

l and

alph

anum

erica

l cod

es an

d cod

e de

scrip

tions

that

repr

esen

t ver

y spe

cific

illnes

ses a

nd in

juries

. Sim

ilarly

, the s

ervic

es pr

ovide

d by

phys

ician

s and

othe

r hea

lthca

re pr

ofess

ionals

are d

escri

bed a

nd re

porte

d by u

sing t

ermi

nolog

ies an

d cla

ssific

ation

syste

ms. T

he In

tern

atio

nal C

lass

ifica

tion

of D

isea

ses,

Clin

ical

Mod

ifica

tion,

prov

ides a

sy

stem

for co

ding m

edica

l pro

cedu

res p

erfor

med i

n the

inpa

tient

depa

rtmen

ts of

hosp

itals,

but tw

o oth

er sy

stems

apply

to th

e ser

vices

prov

ided b

y phy

sician

s and

othe

r med

ical p

rovid

ers i

n hos

pital-

base

d outp

atien

t dep

artm

ents,

phys

ician

s’ off

ices,

and o

ther a

mbula

tory s

etting

s: the

Cur

rent

Pr

oced

ural

Ter

min

olog

y an

d the

Hea

lthca

re C

omm

on P

roce

dure

Cod

ing

Syst

em.

17.5.

4.5 In

addit

ion to

CPT

, ICD-

9-CM

and o

ther n

ation

al co

ding s

tanda

rds,

the us

e of a

pplic

able

HCPC

S Le

vel II

an

d Cate

gory

II CPT

code

s are

man

dator

y, aid

ing bo

th the

CCN

and D

HH to

evalu

ate pe

rform

ance

mea

sure

s.

Meets

Me

ets

Meets

W

e use

HCP

CS Le

vel II

and C

atego

ry II C

PT co

des i

n ea

ch of

the e

xamp

le sta

tes. O

ur en

coun

ter sy

stem

is ful

ly ca

pable

of su

ppor

ting t

hese

and o

ther n

ation

al co

ding

stand

ards

to m

eet D

HH’s

requ

ireme

nts.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ea

ch of

the s

tates

Aetn

a Bett

er H

ealth

prov

ides M

edica

id ma

nage

d car

e hav

e diffe

rent

nuisa

nces

in

the ca

pture

and r

epor

ting o

f enc

ounte

r data

. We h

ave u

nifor

m wr

itten p

olicie

s and

proc

edur

es an

d sy

stem

proto

cols

that w

e app

ly to

maint

ain co

mplia

nce w

ith, b

ut se

para

tion o

n a st

ate-b

y-stat

e bas

is,

these

enco

unter

repo

rting r

equir

emen

ts. A

etna B

etter

Hea

lth m

aintai

ns st

rict c

ompli

ance

with

up

dates

rega

rding

Cur

rent

Pro

cedu

ral T

erm

inol

ogy

(CPT

), the

Hea

lthca

re P

roce

dura

l Cod

ing

Syst

em

(HCP

CS) (

CPT/

HCPC

S), a

nd IC

D-9-

CM an

d othe

r cod

es in

acco

rdan

ce w

ith H

IPAA

stan

dard

s so

that c

laims

and r

esult

ing en

coun

ters a

re pr

oces

sed i

n an o

rder

ly an

d con

sisten

t man

ner.

CPT

proc

edur

al co

des a

re pu

blish

ed by

the A

meric

an M

edica

l Ass

ociat

ion (A

MA).

Upda

ted an

nuall

y on


44

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

Janu

ary 1

, CPT

is a

prop

rietar

y ter

mino

logy c

reate

d and

main

taine

d by t

he A

MA. It

s pur

pose

is to

pr

ovide

a un

iform

lang

uage

for d

escri

bing a

nd re

portin

g the

profe

ssion

al se

rvice

s pro

vided

by

phys

ician

s. HC

PCS

is ma

intain

ed by

the C

enter

s for

Med

icare

and M

edica

id Se

rvice

s (CM

S). It

s pu

rpos

e is t

o pro

vide a

syste

m for

repo

rting t

he m

edica

l ser

vices

prov

ided t

o Med

icaid/

Medic

are

memb

ers.

HCPC

S is

made

up of

two p

arts:

Leve

l I is

comp

osed

entire

ly of

the cu

rrent

versi

on of

CP

T; H

CPCS

Leve

l II pr

ovide

s cod

es to

repr

esen

t med

ical s

ervic

es th

at ar

e not

cove

red b

y the

CPT

sy

stem,

for e

xamp

le, m

edica

l sup

plies

and s

ervic

es pe

rform

ed by

healt

hcar

e pro

fessio

nals

who a

re

not p

hysic

ians

The

CPT

is a

unifo

rm co

ding s

ystem

cons

isting

of de

scrip

tive t

erms

and i

denti

fying

co

des t

hat a

re us

ed pr

imar

ily to

iden

tify m

edica

l ser

vices

and p

roce

dure

s fur

nishe

d by p

hysic

ians

and o

ther h

ealth

care

profe

ssion

als. H

ealth

care

profe

ssion

als us

e the

CPT

to id

entify

servi

ces a

nd

proc

edur

es th

ey bi

ll to A

etna B

etter

Hea

lth fo

r cov

ered

and m

edica

lly ne

cess

ary s

ervic

es. W

e un

derst

and t

hat d

ecisi

ons r

egar

ding t

he ad

dition

, dele

tion,

or re

vision

of C

PT co

des a

re m

ade b

y the

AM

A. T

he C

PT co

des a

re re

publi

shed

and u

pdate

d ann

ually

by th

e AMA

. Lev

el I o

f the H

CPCS

, the

CPT

code

s, do

es no

t inclu

de co

des n

eede

d to s

epar

ately

repo

rt me

dical

items

or se

rvice

s tha

t are

re

gular

ly bil

led by

supp

liers

other

than

phys

ician

s. W

e are

awar

e tha

t HCP

CS Le

vel II

is a

stand

ardiz

ed co

ding s

ystem

to id

entify

prod

ucts,

supp

lies,

and s

ervic

es no

t inclu

ded i

n the

CPT

co

des,

such

as am

bulan

ce se

rvice

s and

dura

ble m

edica

l equ

ipmen

t, pro

stheti

cs, o

rthoti

cs, a

nd

supp

lies (

DME)

whe

n use

d outs

ide a

phys

ician

's off

ice. B

ecau

se m

ost M

edica

id ag

encie

s, inc

luding

DH

H, re

quire

man

dator

y cov

erag

e of a

varie

ty of

servi

ces,

supp

lies,

and e

quipm

ent th

at ar

e not

identi

fied b

y CPT

code

s, the

leve

l II H

CPCS

code

s wer

e esta

blish

ed by

CMS

for s

ubmi

tting c

laims

for

these

items

. Cur

rentl

y, the

re ar

e nati

onal

HCPC

S co

des r

epre

senti

ng ov

er 4,

000 s

epar

ate

categ

ories

of lik

e item

s or s

ervic

es th

at en

comp

ass m

illion

s of p

rodu

cts fr

om di

ffere

nt ma

nufac

turer

s. W

hen s

ubmi

tting c

laims

, we r

equir

e our

prov

ider t

o use

one o

f thes

e cod

es to

iden

tify th

e item

s the

y ar

e billi

ng. T

he de

scrip

tor th

at is

assig

ned t

o a co

de re

pres

ents

the de

finitio

n of th

e item

s and

se

rvice

s tha

t can

be bi

lled u

sing t

hat c

ode.

For

thes

e rea

sons

and t

o pro

vide t

imely

, acc

urate

and

comp

lete e

ncou

nters

to the

Med

icaid

agen

cies w

e pro

vide m

anag

ed ca

re se

rvice

to, w

e clos

ely

monit

or an

d main

tain c

ompli

ance

with

the m

ost c

urre

nt CP

T/HC

PCS

codin

g req

uirem

ents

and

stipu

lation

s. W

e also

have

writt

en po

licies

and p

roce

dure

s tha

t req

uire i

nform

ing ou

r pro

vider

ne

twor

k of C

PT/H

CPCS

codin

g mod

ificati

ons t

hat a

re ef

fectiv

e as o

f a da

te-of-

servi

ce to

avoid

un

nece

ssar

y dela

ys, c

onfus

ion or

prob

lems i

n sub

mittin

g com

plete,

accu

rate

and t

imely

enco

unter

s to

DHH

and o

ther M

edica

id ag

encie

s. In

addit

ion to

the a

bove

we a

lso cl

osely

mon

itor a

nd re

main

comp

liant

with

the fo

llowi

ng

requ

ireme

nts:


45

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

• Pe

rman

ent N

ation

al Co

des -

Nati

onal

perm

anen

t HCP

CS le

vel II

code

s are

main

taine

d by t

he

CMS

HCPC

S W

orkg

roup

•

Misc

ellan

eous

Cod

es -

Natio

nal c

odes

also

inclu

de "m

iscell

aneo

us/no

t othe

rwise

clas

sified

" co

des.

Thes

e cod

es ar

e use

d whe

n a su

pplie

r is su

bmitti

ng a

bill fo

r an i

tem or

servi

ce an

d the

re

is no

exist

ing na

tiona

l cod

e tha

t ade

quate

ly de

scrib

es th

e item

or se

rvice

being

bille

d. •

Temp

orar

y Nati

onal

Code

s - T

empo

rary

code

s are

for t

he pu

rpos

e of m

eetin

g, wi

thin a

shor

t time

fra

me, th

e nati

onal

prog

ram

oper

ation

al ne

eds t

hat a

re no

t add

ress

ed by

an al

read

y exis

ting

natio

nal c

ode.

We a

re aw

are t

hat a

nd m

onito

r the

CMS

HCP

CS W

orkg

roup

has s

et as

ide ce

rtain

secti

ons o

f the H

CPCS

code

set to

allow

the W

orkg

roup

to de

velop

temp

orar

y cod

es.

• Ty

pes o

f temp

orar

y HCP

CS co

des:

o Th

e C co

des w

ere e

stabli

shed

to pe

rmit i

mplem

entat

ion of

secti

on 20

1 of th

e Bala

nced

Bud

get

Refin

emen

t Act

of 19

99.

o Th

e Q co

des a

re us

ed to

iden

tify se

rvice

s tha

t wou

ld no

t be g

iven a

CPT

-4 co

de, s

uch a

s dru

gs,

biolog

icals,

and o

ther t

ypes

of m

edica

l equ

ipmen

t or s

ervic

es, a

nd w

hich a

re no

t iden

tified

by

natio

nal le

vel II

code

s but

for w

hich c

odes

are n

eede

d for

claim

s pro

cess

ing pu

rpos

es.

o Th

e G co

des a

re us

ed to

iden

tify pr

ofess

ional

healt

hcar

e pro

cedu

res a

nd se

rvice

s tha

t wou

ld oth

erwi

se be

code

d in C

PT-4

but fo

r whic

h the

re ar

e no C

PT-4

code

s.

o Th

e K co

des w

ere e

stabli

shed

for u

se by

the D

ME M

ACs w

hen t

he cu

rrentl

y exis

ting p

erma

nent

natio

nal c

odes

do no

t inclu

de th

e cod

es ne

eded

to im

pleme

nt a D

ME M

AC m

edica

l revie

w po

licy.

o

The S

code

s are

used

by pr

ivate

insur

ers t

o rep

ort d

rugs

, ser

vices

, and

supp

lies f

or w

hich t

here

ar

e no n

ation

al co

des b

ut for

whic

h cod

es ar

e nee

ded b

y the

priva

te se

ctor t

o imp

lemen

t po

licies

, pro

gram

s, or

claim

s pro

cess

ing.

o Ce

rtain

H co

des a

re us

ed by

thos

e Stat

e Med

icaid

agen

cies t

hat a

re m

anda

ted by

Stat

e law

to

estab

lish s

epar

ate co

des f

or id

entify

ing m

ental

healt

h ser

vices

such

as al

coho

l and

drug

tre

atmen

t ser

vices

. o

The T

code

s are

desig

nated

for u

se by

Med

icaid

State

agen

cies t

o esta

blish

code

s for

items

for

which

ther

e are

no pe

rman

ent n

ation

al co

des a

nd fo

r whic

h cod

es ar

e nec

essa

ry to

meet

a na

tiona

l Med

icaid

prog

ram

oper

ating

need

. •

Code

Mod

ifiers

- In s

ome i

nstan

ces,

Medic

aid ag

encie

s ins

truct

Aetna

Bett

er H

ealth

to re

quire

its

prov

iders

to re

quire

a co

de m

odifi

er to

a HC

PCS

code

to pr

ovide

addit

ional

infor

matio

n reg

ardin

g the

servi

ce or

item

identi

fied b

y the

HCP

CS co

de. M

odifie

rs ar

e use

d whe

n the

infor

matio

n pr

ovide

d by a

HCP

CS co

de de

scrip

tor ne

eds t

o be s

upple

mente

d to i

denti

fy sp

ecific


46

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

circu

mstan

ces t

hat m

ay ap

ply to

an ite

m or

servi

ce. F

or ex

ample

, a U

E mo

difier

is of

ten us

ed

when

the i

tem id

entifi

ed by

a HC

PCS

code

is "u

sed e

quipm

ent,"

a NU

mod

ifier is

used

for "

new

equip

ment.

" The

leve

l II H

CPCS

mod

ifiers

are e

ither

alph

a-nu

meric

or tw

o lett

ers.

• HC

PCS

Upda

tes to

Per

mane

nt Na

tiona

l Cod

es –

We a

re aw

are t

hat th

e nati

onal

code

s are

up

dated

annu

ally

CPT

Categ

ory I

I Cod

es -

We a

re aw

are t

hat C

PT C

atego

ry II c

odes

are s

upple

menta

l trac

king c

odes

us

ed fo

r per

forma

nce m

easu

reme

nt. T

hese

trac

king c

odes

for p

erfor

manc

e mea

sure

ment

decre

ase

the ne

ed fo

r rec

ord a

bstra

ction

and c

hart

revie

w, an

d the

reby

mini

mize

admi

nistra

tive b

urde

ns on

ph

ysici

ans a

nd ot

her h

ealth

care

profe

ssion

als. T

hese

code

s are

inten

ded t

o fac

ilitate

data

colle

ction

ab

out q

uality

of ca

re by

codin

g cer

tain s

ervic

es an

d/or t

est r

esult

s tha

t sup

port

perfo

rman

ce

meas

ures

and t

hat h

ave b

een a

gree

d upo

n as c

ontrib

uting

to go

od pa

tient

care

. CPT

II co

des a

re

maint

ained

and u

pdate

d by t

he P

erfor

manc

e Mea

sure

s Adv

isory

Grou

p (PM

AG),

an ad

visor

y bod

y to

the C

PT E

ditor

ial P

anel.

The

PMA

G co

mpris

es pe

rform

ance

mea

sure

ment

expe

rts re

pres

entin

g the

Ag

ency

of H

ealth

care

Res

earch

and Q

uality

(AHR

Q), th

e Ame

rican

Med

ical A

ssoc

iation

(AMA

), the

Ce

nters

for M

edica

re an

d Med

icaid

Servi

ces (

CMS)

, the J

oint C

ommi

ssion

on A

ccre

ditati

on of

He

althc

are O

rgan

izatio

ns (J

CAHO

), the

Nati

onal

Comm

ittee f

or Q

uality

Ass

uran

ce (N

CQA)

and t

he

Phys

ician

Con

sortiu

m for

Per

forma

nce I

mpro

veme

nt.

The I

nter

natio

nal C

lass

ifica

tion

of D

isea

ses,

Clin

ical

Mod

ifica

tion,

curre

ntly i

n its

ninth

revis

ion (I

CD-

9-CM

), is

used

to de

scrib

e and

repo

rt the

illne

sses

, con

dition

s, an

d inju

ries o

f pati

ents

who r

equir

e me

dical

servi

ces.

ICD-

9-CM

is m

ade u

p of a

serie

s of n

umer

ical a

nd al

phan

umer

ical c

odes

and c

ode

desc

riptio

ns th

at re

pres

ent v

ery s

pecif

ic illn

esse

s and

injur

ies. S

imila

rly, th

e ser

vices

prov

ided b

y ph

ysici

ans a

nd ot

her h

ealth

care

profe

ssion

als ar

e des

cribe

d and

repo

rted b

y usin

g ter

mino

logies

and

class

ificati

on sy

stems

. The

Inte

rnat

iona

l Cla

ssifi

catio

n of

Dis

ease

s, C

linic

al M

odifi

catio

n, pr

ovide

s a

syste

m for

codin

g med

ical p

roce

dure

s per

forme

d in t

he in

patie

nt de

partm

ents

of ho

spita

ls, bu

t two

other

syste

ms ap

ply to

the s

ervic

es pr

ovide

d by p

hysic

ians a

nd ot

her m

edica

l pro

vider

s in h

ospit

al-ba

sed o

utpati

ent d

epar

tmen

ts, ph

ysici

ans’

office

s, an

d othe

r amb

ulator

y sett

ings:

the C

urre

nt

Proc

edur

al T

erm

inol

ogy

and t

he H

ealth

care

Com

mon

Pro

cedu

re C

odin

g Sy

stem

.

17.5.

4.6 T

he C

CN sh

all ha

ve th

e cap

abilit

y to c

onve

rt all

inf

orma

tion t

hat e

nters

its cl

aims s

ystem

via h

ard c

opy

pape

r clai

ms to

elec

tronic

enco

unter

data,

to be

su

bmitte

d in t

he ap

prop

riate

HIPA

A co

mplia

nt for

mats

to DH

H’s F

I.

Meets

Me

ets

Meets

In

each

of th

e thr

ee st

ates w

e sele

cted (

in fac

t in ea

ch of

ou

r stat

es) w

e hav

e the

capa

bility

and c

apac

ity to

conv

ert

all th

e clai

m inf

orma

tion r

eceiv

ed vi

a har

d cop

y “pa

per”

claim

s to e

lectro

nic cl

aims u

sing O

ptica

l Cha

racte

r Re

cogn

ition (

OCR)

tech

nolog

y. A

ll pap

er cl

aims a

re


47

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

conv

erted

to el

ectro

nic im

ages

by ou

r ven

dor (

EMDE

ON–

using

their

Alch

emy p

rogr

am).

If the

claim

cann

ot be

tra

nslat

ed in

to an

elec

tronic

data

reco

rd by

the O

CR

proc

ess,

then t

he pa

per c

laims

is se

nt dir

ectly

to ou

r cla

ims d

epar

tmen

t for d

ata en

try. E

ach c

laim

is as

signe

d a u

nique

claim

numb

er an

d an e

lectro

nic fil

e of th

e clai

m is

create

d. T

his fil

e is u

pload

ed in

to QN

XT™

to be

ac

cess

ed by

the c

laims

team

. The

pape

r clai

m is

in the

QN

XT™

syste

m wi

thin 1

to 3

busin

ess d

ays f

rom

its

rece

ipt. A

dditio

nally

, the s

cann

ed im

age o

f the p

aper

cla

im is

stor

ed in

an im

age r

epos

itory

and i

s view

able

to Ae

tna B

etter

Hea

lth pe

rsonn

el, as

need

ed.

In ad

dition

, Micr

osoft

BizT

alk w

ith H

IPAA

Acc

elera

tor™

pr

oces

ses H

IPAA

-comp

liant

trans

actio

ns ea

sily a

nd

effici

ently

, allo

wing

Aetn

a Bett

er H

ealth

to ac

cept

infor

matio

n elec

tronic

ally f

rom

almos

t any

HIP

AA-

comp

liant

contr

actor

or pr

ovide

r. M

icros

oft B

izTalk

with

HI

PAA

Acce

lerato

r™ is

a da

ta tra

nsfor

matio

n app

licati

on

that tr

ansla

tes da

ta to

and f

rom

the fu

ll spe

ctrum

of H

IPAA

Tr

ansa

ction

s sets

in a

highly

custo

miza

ble, fl

exibl

e, an

d ro

bust

serve

r-bas

ed en

viron

ment.

Mor

eove

r, Ac

celer

ator

has t

he W

ashin

gton P

ublis

hing C

ompa

ny (W

PC)

Imple

menta

tion G

uide s

chem

as fo

r eac

h HIP

AA A

NSI X

12

trans

actio

n emb

edde

d dire

ctly i

nto its

appli

catio

n eng

ine,

includ

ing a

facilit

y to u

pdate

thes

e sch

emas

autom

atica

lly

as th

e Tra

nsac

tions

sets

are u

pdate

d ove

r tim

e. Al

so, F

ores

ight H

IPAA

Vali

dator

™ In

Stre

am™

a ful

ly fun

ction

al HI

PAA

editin

g and

valid

ation

appli

catio

n. It

can

valid

ate H

IPAA

tran

sacti

ons t

hrou

gh al

l sev

en le

vels

of ed

its as

defin

ed by

the W

orkg

roup

for E

lectro

nic D

ata

Inter

chan

ge an

d Stra

tegic

Natio

nal Im

pleme

ntatio

n Pr

oces

s (W

EDI/S

NIP)

, has

all s

tanda

rd H

IPAA

code

sets

embe

dded

, and

can s

uppo

rt cu

stom,

trad

ing-p

artne

r-


48

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

spec

ific co

mpan

ion gu

ides a

nd va

lidati

on re

quire

ments

. In

addit

ion, it

supp

orts

valid

ation

at th

e ind

ividu

al ed

it lev

el,

allow

ing A

etna B

etter

Hea

lth to

acce

pt all

comp

liant

reco

rds t

hat p

ass a

t a lo

wer le

vel o

f edit

, rath

er th

an

requ

iring a

ll sev

en le

vels

of ed

its. T

he ap

plica

tion a

lso

prov

ides d

escri

ptive

erro

r rep

orts

to su

bmitte

rs to

facilit

ate

quick

erro

r res

olutio

n. Ho

w we

will

apply

this

expe

rienc

e to t

he Lo

uisian

a CCN

pr

ogra

m?

The p

roce

dure

s des

cribe

d abo

ve ar

e unif

orml

y and

cons

isten

tly ap

plied

in ou

r othe

r 10 M

edica

id ma

nage

d car

e ope

ratio

ns. T

hese

proc

esse

s will

be ap

plied

to th

e Lou

isian

a CCN

prog

ram.

We

have

expe

rienc

e sup

portin

g pro

vider

s tra

nsitio

ning f

rom

fee-fo

r-ser

vice t

o Med

icaid

mana

ged c

are

and i

n shif

ting p

rovid

ers f

rom

subm

itting

pape

r clai

ms to

elec

tronic

claim

s. W

e will

apply

this

expe

rienc

e to t

he Lo

uisian

a CCN

prog

ram.

We e

xpec

t that

initia

lly w

e may

expe

rienc

e a hi

gh vo

lume

of pa

per c

laim

subm

ission

, but

we w

ill sy

stema

ticall

y tar

get a

nd re

duce

this

prac

tice.

17.5.

4.7 T

he F

I enc

ounte

r pro

cess

shall

utiliz

e a D

HH-

appr

oved

versi

on of

the c

laims

proc

essin

g sys

tem (e

dits

and a

djudic

ation

) to i

denti

fy va

lid an

d inv

alid e

ncou

nter

reco

rds f

rom

a batc

h sub

miss

ion by

the C

CN.

Any s

ubmi

ssion

whic

h con

tains

fatal

erro

rs tha

t pre

vent

proc

essin

g, or

that

does

not s

atisfy

defin

ed th

resh

old

erro

r rate

s, wi

ll be r

ejecte

d and

retur

ned t

o the

CCN

for

imme

diate

corre

ction

.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee th

at the

FI e

ncou

nter p

roce

ss

will u

se a

DHH

appr

oved

versi

on of

syste

m ed

its to

iden

tify

valid

and i

nvali

d enc

ounte

r rec

ords

. Eve

ry sta

te Me

dicaid

ag

ency

, inclu

ding t

he th

ree s

electe

d as o

ur sa

mple,

has

simila

r req

uirem

ents.

Our

appr

oach

is to

get

docu

menta

tion f

rom

the F

I reg

ardin

g the

appr

oved

edits

an

d adju

dicati

on re

quire

ments

and s

pecif

ically

desig

n our

en

coun

ter su

bmiss

ion pr

oces

s to t

rans

mit ti

mely,

accu

rate

and c

omple

te en

coun

ters c

onsis

tent w

ith th

ese

requ

ireme

nts to

avoid

confu

sion a

nd un

nece

ssar

y cos

t. Ou

r bes

t pra

ctice

is to

mee

t freq

uentl

y with

the M

edica

id ag

ency

and t

he F

I to pr

ovide

full u

nder

stand

ing of

desig

n, int

ent a

nd ap

plica

tion o

f thes

e edit

s and

adjud

icatio

n pr

oces

s dur

ing th

e sys

tem de

sign a

nd te

sting

phas

e. W

e wi

ll vali

date

our c

ompli

ance

durin

g rea

dines

s rev

iew an

d sy

stem

testin

g acti

vities

. W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,


49

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

To

day w

e mee

t thes

e req

uirem

ents

in the

thre

e exa

mple

states

and i

n our

othe

r sev

en M

edica

id ma

nage

d car

e stat

es. W

e hav

e enc

ounte

r sys

tem im

pleme

ntatio

n and

subm

ission

best

prac

tices

to

valid

ate da

ta va

lidity

for a

ll lev

els of

healt

hcar

e ser

vices

prov

ided (

ancil

lary,

acute

, and

insti

tution

al se

rvice

s) pr

ior to

subm

itting

enco

unter

data

to DH

H:

1. Th

e QNX

T™ sy

stem

verifi

es th

at all

nece

ssar

y clai

ms fie

lds ar

e pop

ulated

with

value

s of th

e ap

prop

riate

rang

e and

type

prior

to th

e enc

ounte

r infor

matio

n bein

g loa

ded o

nto th

e Enc

ounte

r Ma

nage

ment

Syste

m.

2 .En

coun

ter da

ta file

s fro

m ve

ndor

sour

ces g

o thr

ough

a sta

ging p

roce

ss. T

he st

aging

proc

ess

cons

ists o

f auto

mated

and m

anua

l ver

ificati

on, to

valid

ate th

at file

s hav

e the

prop

er la

yout

and t

he

appr

opria

te fie

lds po

pulat

ed. In

this

stagin

g pro

cess

, cor

rect

files a

re al

lowed

to pa

ss; p

ende

d file

s ar

e cor

recte

d if th

ere a

re co

rrecta

ble er

rors,

or ar

e reje

cted i

f the e

rrors

cann

ot be

corre

cted.

This

stagin

g pro

cess

resu

lts in

only

the cl

eane

st file

s bein

g imp

orted

into

the E

MS.

3. Af

ter da

ta fro

m QN

XT™

and v

endo

r sou

rces a

re lo

aded

into

the E

MS, th

ey m

ust p

ass t

he E

MS

Scru

b Edit

s, wh

ich ar

e cus

tomize

d bas

ed on

DHH

’s re

quire

ments

for c

lean e

ncou

nters.

File

s tha

t are

un

likely

to pa

ss th

e DHH

’s ed

its ar

e not

subm

itted u

ntil th

ey ar

e cor

recte

d. En

coun

ter U

nit an

alysts

tak

e res

pons

ibility

for t

he co

rrecti

on. T

his pr

oacti

ve ap

proa

ch to

iden

tifying

and c

orre

cting

erro

rs pr

ior to

the s

ubmi

ssion

of da

ta to

the C

ommo

nwea

lth ex

pedit

es re

view

and a

djudic

ation

17

.5.4.8

DHH

and i

ts FI

shall

deter

mine

whic

h clai

ms

proc

essin

g edit

s are

appr

opria

te for

enco

unter

s and

shall

se

t enc

ounte

r edit

s to “

pay”

or “d

eny”.

En

coun

ter de

nial c

odes

shall

be de

emed

“rep

airab

le” or

“n

on-re

paira

ble”.

An ex

ample

of a

repa

irable

enco

unter

is

“pro

vider

inva

lid fo

r date

of se

rvice

”. An

exam

ple of

a no

n-re

paira

ble en

coun

ter is

“exa

ct du

plica

te”.

The C

CN is

requ

ired t

o be f

amilia

r with

the F

I exc

eptio

n

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee th

at the

FI s

hall d

eterm

ine th

e cla

ims/e

ncou

nter p

roce

ssing

edits

to be

appli

ed w

hen

acce

pting

enco

unter

s. E

very

state

Medic

aid ag

ency

, inc

luding

the t

hree

selec

ted as

our s

ample

, has

simi

lar

requ

ireme

nts. O

ur ap

proa

ch is

to ge

t doc

umen

tation

from

the

FI r

egar

ding t

he ap

prov

ed pr

oces

sing e

dits a

nd

spec

ificall

y des

ign ou

r enc

ounte

r sub

miss

ion pr

oces

s to

trans

mit ti

mely,

accu

rate

and c

omple

te en

coun

ters


50

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

code

s and

disp

ositio

ns fo

r the

purp

ose o

f rep

airing

de

nied e

ncou

nters.

co

nsist

ent w

ith th

ese r

equir

emen

ts to

avoid

confu

sion a

nd

unne

cess

ary c

ost.

Our b

est p

racti

ce is

to m

eet fr

eque

ntly

with

the M

edica

id ag

ency

and t

he F

I to pr

ovide

full

unde

rstan

ding o

f des

ign, in

tent a

nd ap

plica

tion o

f thes

e ed

its an

d adju

dicati

on pr

oces

s dur

ing th

e sys

tem de

sign

and t

estin

g pha

se. W

e will

valid

ate ou

r com

plian

ce du

ring

read

iness

revie

w an

d sys

tem te

sting

activ

ities.

We u

nder

stand

and a

gree

to th

is sti

pulat

ion. T

he st

ate

Medic

aid ag

encie

s reg

ulatin

g the

thre

e hea

lth pl

ans w

e se

lected

as an

exam

ple ha

ve si

milar

requ

ireme

nts; in

fact,

it i

s our

expe

rienc

e tha

t this

is a c

ommo

n stip

ulatio

n. W

e ha

ve pr

otoco

ls to

effec

tively

and e

fficien

tly re

spon

d to

these

featu

res.

We u

nder

stand

and a

gree

to th

is sti

pulat

ion. O

ur ex

pert

team

of en

coun

ter sp

ecial

ists h

ave a

lread

y rev

iewed

DH

H’s s

ystem

guide

and c

ompa

red i

t to si

milar

guide

s fro

m oth

er M

edica

id ag

encie

s. E

ach o

f the s

tates

selec

ted

to re

pres

ent o

ur un

iverse

of en

coun

ter sy

stems

have

sim

ilar r

equir

emen

ts.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

To

day w

e mee

t this

requ

ireme

nt in

the th

ree e

xamp

le sta

tes an

d in o

ur ot

her s

even

Med

icaid

mana

ged c

are s

tates

. We h

ave e

ncou

nter s

ystem

imple

menta

tion a

nd su

bmiss

ion be

st pr

actic

es to

va

lidate

data

valid

ity fo

r all l

evels

of he

althc

are s

ervic

es pr

ovide

d (an

cillar

y, ac

ute, a

nd in

stitut

ional

servi

ces)

prior

to su

bmitti

ng en

coun

ter da

ta to

DHH:

1.

The Q

NXT™

syste

m ve

rifies

that

all ne

cess

ary c

laims

fields

are p

opula

ted w

ith va

lues o

f the

appr

opria

te ra

nge a

nd ty

pe pr

ior to

the e

ncou

nter in

forma

tion b

eing l

oade

d onto

the E

MS.

2 .En

coun

ter da

ta file

s fro

m ve

ndor

sour

ces g

o thr

ough

a sta

ging p

roce

ss. T

he st

aging

proc

ess

cons

ists o

f auto

mated

and m

anua

l ver

ificati

on, to

valid

ate th

at file

s hav

e the

prop

er la

yout

and t

he

appr

opria

te fie

lds po

pulat

ed. In

this

stagin

g pro

cess

, cor

rect

files a

re al

lowed

to pa

ss; p

ende

d file

s ar

e cor

recte

d if th

ere a

re co

rrecta

ble er

rors,

or ar

e reje

cted i

f the e

rrors

cann

ot be

corre

cted.

This

stagin

g pro

cess

resu

lts in

only

the cl

eane

st file

s bein

g imp

orted

into

the E

MS.

3. Af

ter da

ta fro

m QN

XT™

and v

endo

r sou

rces a

re lo

aded

into

the E

MS, th

ey m

ust p

ass t

he E

MS


51

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

Scru

b Edit

s, wh

ich ar

e cus

tomize

d bas

ed on

DHH

’s re

quire

ments

for c

lean e

ncou

nters.

File

s tha

t are

un

likely

to pa

ss th

e DHH

’s ed

its ar

e not

subm

itted u

ntil th

ey ar

e cor

recte

d. En

coun

ter U

nit an

alysts

tak

e res

pons

ibility

for t

he co

rrecti

on. T

his pr

oacti

ve ap

proa

ch to

iden

tifying

and c

orre

cting

erro

rs pr

ior to

the s

ubmi

ssion

of da

ta to

the C

ommo

nwea

lth ex

pedit

es re

view

and a

djudic

ation

17.5.

4.9 A

s spe

cified

in th

e CCN

-P S

ystem

s Com

panio

n Gu

ide, d

enial

s for

the f

ollow

ing re

ason

s will

be of

pa

rticula

r inter

est to

DHH

: ●

De

nied f

or M

edica

l Nec

essit

y inc

luding

lack

of

docu

menta

tion t

o sup

port

nece

ssity

; ●

Me

mber

has o

ther in

sura

nce t

hat m

ust b

e bil

led fir

st;

●

Prior

autho

rizati

on no

t on f

ile;

●

Claim

subm

itted a

fter f

iling d

eadli

ne; a

nd

●

Servi

ce no

t cov

ered

by C

CN.

Meets

Me

ets

Meets

W

e sha

re D

HH’s

inter

est in

thes

e den

ial re

ason

s. E

ach o

f the

se de

nial re

ason

s ind

icates

an is

sue w

ith ou

r pro

vider

do

cume

ntatio

n, co

mmun

icatio

n and

train

ing pr

otoco

ls.

Espe

cially

if the

re ar

e par

ticipa

ting p

rovid

ers w

ith a

patte

rn

of the

se de

nials

and w

e fail

to ta

ke co

rrecti

ve ac

tion.

Ae

tna B

etter

Hea

lth us

es th

e res

ults o

f clai

ms ad

judica

tion

– esp

ecial

ly de

nial –

to as

sess

our p

erfor

manc

e and

re

spon

siven

ess t

o mini

mal p

rovid

er se

rvice

proto

cols.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

W

e mon

itor d

enial

reas

ons i

n our

thre

e exa

mple

states

in ou

r othe

r sev

en da

tes as

a too

l to

deter

mine

if ou

r tra

ining

, pro

cess

es, p

rotoc

ols or

oper

ation

s req

uire p

erfor

manc

e imp

rove

ment.

We

also m

onito

r den

ial re

ason

s to d

eterm

ine if

a pro

vider

may

need

with

assis

tance

with

filing

claim

s ap

prop

riatel

y or in

follo

wing

our e

stabli

shed

proto

cols.

We t

rain

and i

nform

prov

iders

of ou

r clai

ms

requ

ireme

nts an

d spe

cifica

tion i

n the

Pro

vider

Man

ual, P

rovid

er N

ewsle

tters

and i

nitial

/on-g

oing

prov

ider t

raini

ng ev

ents.

We u

se th

e PDS

A ap

proa

ch to

mon

itor a

nd ad

just o

ur pr

oces

ses a

nd

proc

edur

es. E

stabli

shing

a po

sitive

wor

king r

elatio

nship

with

partic

ipatin

g and

non-

partic

ipatin

g pr

ovide

rs is

a prio

rity. A

etna B

etter

Hea

lth ha

s nev

er, n

or w

ill we

ever

, use

delib

erate

claim

s mi

shan

dling

or cl

aim de

nials

as a

metho

d to d

elay o

r avo

id pa

ymen

t of c

laims

. 17

.5.4.1

0 The

CCN

shall

utiliz

e DHH

prov

ider b

illing

ma

nuals

and b

ecom

e fam

iliar w

ith th

e clai

ms da

ta ele

ments

that

must

be in

clude

d in e

ncou

nters.

Th

e CCN

shall

retai

n all r

equir

ed da

ta ele

ments

in cl

aims

histor

y for

the p

urpo

se of

crea

ting e

ncou

nters

that a

re

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. Our

expe

rt tea

m of

claim

s sys

tem de

velop

ers a

nd en

coun

ter sy

stem

desig

n spe

cialis

ts ha

ve al

read

y rev

iewed

DHH

’s sy

stem

guide

and c

ompa

red i

t to si

milar

guide

s fro

m oth

er

Medic

aid ag

encie

s. E

ach o

f the s

tates

selec

ted to

re

pres

ent o

ur un

iverse

of en

coun

ter sy

stems

have

simi

lar


52

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

comp

atible

with

DHH

and i

ts FI

’s bil

ling r

equir

emen

ts.

requ

ireme

nts.

We u

nder

stand

and a

gree

to th

is sti

pulat

ion. W

e hav

e sta

ndar

d ope

ratin

g pro

cedu

res r

elated

to th

e reta

ining

and

stora

ge of

claim

s and

enco

unter

histo

ry an

d data

. Our

ex

pert

team

of cla

ims s

ystem

deve

loper

s and

enco

unter

sy

stem

desig

n spe

cialis

ts ha

ve al

read

y rev

iewed

DHH

’s sy

stem

guide

and c

ompa

red i

t to si

milar

guide

s fro

m oth

er

Medic

aid ag

encie

s. .

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ae

tna B

etter

Hea

lth ap

plies

the s

tate M

edica

id ag

ency

’s bil

ling a

nd en

coun

ter sp

ecific

requ

ireme

nts

to ou

r inter

nal p

roce

sses

in th

e thr

ee ex

ample

state

s and

in ea

ch of

our o

ther s

tates

. We u

nder

stand

tha

t pro

cess

ing an

d data

erro

rs cre

ate un

nece

ssar

y and

admi

nistra

tive b

urde

nsom

e pro

blems

and

addit

ional

admi

nistra

tive c

osts

for bo

th DH

H an

d our

selve

s. T

here

fore,

we ad

here

to pe

rform

ance

sta

ndar

ds to

redu

ce (g

oal is

to el

imina

te) is

sues

relat

ed to

failin

g to a

dher

e to D

HH’s

stipu

lation

s and

re

quire

ments

. 17

.5.4.1

1 Due

to th

e nee

d for

timely

data

and t

o main

tain

integ

rity of

proc

essin

g seq

uenc

e, the

CCN

shall

addr

ess

any i

ssue

s tha

t pre

vent

proc

essin

g of a

n enc

ounte

r; ac

cepta

ble st

anda

rds s

hall b

e nine

ty pe

rcent

(90%

) of

repo

rted r

epair

able

erro

rs ar

e add

ress

ed w

ithin

thirty

(30)

ca

lenda

r day

s and

nine

ty-nin

e per

cent

(99%

) of r

epor

ted

repa

irable

erro

rs wi

thin s

ixty (

60) c

alend

ar da

ys or

with

in a n

egoti

ated t

imefr

ame a

ppro

ved b

y DHH

. Fail

ure t

o pr

omptl

y res

earch

and a

ddre

ss re

porte

d erro

rs, in

cludin

g su

bmiss

ion of

and c

ompli

ance

with

an ac

cepta

ble

corre

ctive

actio

n plan

may

resu

lt in m

oneta

ry pe

naltie

s.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

For t

he pe

riod e

nding

May

1, 20

11, o

ur en

coun

ter

acce

ptanc

e rate

s are

as fo

llows

: De

lawar

e: Pr

ofes

siona

l 98.1

3% -

Inst

itutio

nal 9

9.97

Florid

a: Pr

ofes

siona

l 99.0

0% -

Inst

itutio

nal 9

8.72 -

NCPD

P 98

.00%

Ma

rylan

d: Pr

ofes

siona

l 98.6

2% -

Inst

itutio

nal 9

8.72%

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ba

sed o

n the

perfo

rman

ce st

atisti

cs pr

ovide

d abo

ve it

is ap

pare

nt tha

t Aetn

a Bett

er H

ealth

mee

ts DH

H’s r

equir

emen

ts in

the th

ree e

xamp

le sta

tes an

d in e

ach o

f the o

ther s

even

state

s. W

e will

apply

the

man

agem

ent p

rincip

les an

d adm

inistr

ative

disc

ipline

that

supp

orts

our r

ecor

d of e

xcell

ence

in th

is ar

ea to

the L

ouisi

ana C

CN pr

ogra

m.


53

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

17.5.

4.12 F

or en

coun

ter da

ta su

bmiss

ions,

the C

CN

shall

subm

it nine

ty-fiv

e (95

%) o

f its e

ncou

nter d

ata at

lea

st mo

nthly

due n

o late

r tha

n the

twen

ty-fift

h (25

th)

calen

dar d

ay of

the m

onth

follow

ing th

e mon

th in

which

the

y wer

e pro

cess

ed an

d app

rove

d/paid

, inclu

ding

enco

unter

s refl

ectin

g a ze

ro do

llar a

moun

t ($0

.00) a

nd

enco

unter

s in w

hich t

he C

CN ha

s a ca

pitati

on

arra

ngem

ent w

ith a

prov

ider.

The C

CN C

EO or

CFO

sh

all at

test to

the t

ruthf

ulnes

s, ac

cura

cy, a

nd

comp

leten

ess o

f all e

ncou

nter d

ata su

bmitte

d.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

For t

he pe

riod e

nding

May

1, 20

11, o

ur en

coun

ter

acce

ptanc

e rate

s are

as fo

llows

: De

lawar

e: Pr

ofes

siona

l 98.1

3% -

Inst

itutio

nal 9

9.97

Florid

a: Pr

ofes

siona

l 99.0

0% -

Inst

itutio

nal 9

8.72 -

NCPD

P 98

.00%

Ma

rylan

d: Pr

ofes

siona

l 98.6

2% -

Inst

itutio

nal 9

8.72%

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ba

sed o

n the

perfo

rman

ce st

atisti

cs pr

ovide

d abo

ve it

is ap

pare

nt tha

t Aetn

a Bett

er H

ealth

mee

ts DH

H’s r

equir

emen

ts in

the th

ree e

xamp

le sta

tes an

d in e

ach o

f the o

ther s

even

state

s. W

e will

apply

the

man

agem

ent p

rincip

les an

d adm

inistr

ative

disc

ipline

that

supp

orts

our r

ecor

d of e

xcell

ence

in th

is ar

ea to

the L

ouisi

ana C

CN pr

ogra

m.

17.5.

4.13 T

he C

CN sh

all en

sure

that

all en

coun

ter da

ta fro

m a c

ontra

ctor is

inco

rpor

ated i

nto a

single

file f

rom

the C

CN. T

he C

CN sh

all no

t sub

mit s

epar

ate en

coun

ter

files f

rom

CCN

contr

actor

s.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

In

each

of ou

r exa

mple

states

and i

n our

seve

n othe

r stat

es w

e hav

e cap

itated

prov

iders

or w

e re

ceive

enco

unter

s fro

m a p

rovid

er w

e dele

gate

claim

s pro

cess

ing au

thority

and r

espo

nsibi

lity.

Gene

rally

(dep

endin

g on t

he st

ate’s

sche

dule

of ca

rved o

ut se

rvice

s and

/or sp

ecific

servi

ce

limita

tions

or be

nefit

restr

iction

s) we

limite

d cap

itatio

n to d

ental

and v

ision

prov

iders.

We a

lso m

ay

capit

ate a

trans

porta

tion v

endo

r with

an ou

tstan

ding r

ecor

d of m

eetin

g ser

vice s

tanda

rds a

nd

spec

ificati

ons.

We a

lso de

legate

clam

s adju

dicati

on au

thority

to ou

r pha

rmac

y ben

efit m

anag

er.

Howe

ver,

in the

Louis

iana C

CN in

stanc

e both

denta

l and

phar

macy

are c

arve

d out

servi

ces.

Re

gard

less,

our s

tanda

rd op

erati

ng pr

oced

ure i

s to r

equir

e any

prov

ider t

hat s

ubmi

ts en

coun

ters

must

meet

strict

testi

ng gu

idanc

e and

requ

ireme

nts. A

s par

t of o

ur te

sting

proto

cols

with

DHH

we w

ill ad

equa

tely t

est th

e vali

dity o

f our

visio

n pro

vider

’s en

coun

ter pr

oces

sing a

t the s

ame t

ime w

e tes

t our

ow

n com

plian

ce.


54

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

17.5.

4.14 T

he C

CN sh

all en

sure

that

files c

ontai

n sett

led

claim

s and

claim

adjus

tmen

ts or

voids

, inclu

ding b

ut no

t lim

ited t

o, ad

justm

ents

nece

ssita

ted by

paym

ent e

rrors,

pr

oces

sed d

uring

that

paym

ent c

ycle,

as w

ell as

en

coun

ters p

roce

ssed

durin

g tha

t pay

ment

cycle

from

pr

ovide

rs wi

th wh

om th

e CCN

has a

capit

ation

ar

rang

emen

t.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ae

tna B

etter

Hea

lth’s

stand

ard o

pera

ting p

roce

dure

is to

subm

it an a

djuste

d, in

acco

rdan

ce w

ith

DHH’

s req

uirem

ents,

enco

unter

in th

ese c

ircum

stanc

es. W

e will

adop

t, app

ly an

d adh

ere t

o DHH

’s ad

minis

trativ

e and

enco

unter

codin

g and

subm

ission

requ

ireme

nts re

lated

to th

is re

quire

ment.

Our

wr

itten p

olicy

and p

roce

dure

s and

oper

ating

man

uals

are s

pecif

ically

desig

ned t

o mee

t this

requ

ireme

nt. F

urthe

rmor

e, we

requ

ire ea

ch ca

pitate

d or d

elega

ted pr

ovide

r to m

eet th

ese

requ

ireme

nts an

d will

test c

ompli

ance

durin

g rea

dines

s rev

iew. W

e rec

omme

nd th

at DH

H de

velop

en

coun

ter te

sting

proto

cols

to inc

lude e

xamp

les of

thes

e req

uirem

ents

to as

sure

its se

lf tha

t Aetn

a Be

tter H

ealth

mee

ts thi

s stip

ulatio

n. 17

.5.4.1

5 The

CCN

shall

ensu

re th

e lev

el of

detai

l as

socia

ted w

ith en

coun

ters f

rom

prov

iders

with

whom

the

CCN

has a

capit

ation

arra

ngem

ent s

hall b

e eq

uivale

nt to

the le

vel o

f deta

il ass

ociat

ed w

ith

enco

unter

s for

whic

h the

CCN

rece

ived a

nd se

ttled a

fee

-for-s

ervic

e clai

m.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ae

tna B

etter

Hea

lth’s

stand

ard o

pera

ting p

roce

dure

is to

subm

it an a

djuste

d, in

acco

rdan

ce w

ith

DHH’

s req

uirem

ents,

enco

unter

in th

ese c

ircum

stanc

es. W

e will

adop

t, app

ly an

d adh

ere t

o DHH

’s ad

minis

trativ

e and

enco

unter

codin

g and

subm

ission

requ

ireme

nts re

lated

to th

is re

quire

ment.

Our

wr

itten p

olicy

and p

roce

dure

s and

oper

ating

man

uals

are s

pecif

ically

desig

ned t

o mee

t this

requ

ireme

nt. F

urthe

rmor

e, we

requ

ire ea

ch ca

pitate

d or d

elega

ted pr

ovide

r to m

eet th

ese

requ

ireme

nts an

d will

test c

ompli

ance

durin

g rea

dines

s rev

iew. W

e rec

omme

nd th

at DH

H de

velop

en

coun

ter te

sting

proto

cols

to inc

lude e

xamp

les of

thes

e req

uirem

ents

to as

sure

itself

that

Aetna

Be

tter H

ealth

mee

ts thi

s stip

ulatio

n.


55

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Delaw

are

Flor

ida

Mary

land

Expl

anat

ion

17.5.

4.16 T

he C

CN sh

all ad

here

to fe

dera

l and

/or

depa

rtmen

t pay

ment

rules

in th

e defi

nition

and t

reatm

ent

of ce

rtain

data

eleme

nts, s

uch a

s unit

s of s

ervic

e tha

t are

a s

tanda

rd fie

ld in

the en

coun

ter da

ta su

bmiss

ions a

nd

will b

e tre

ated s

imila

rly by

DHH

acro

ss al

l CCN

s.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ae

tna B

etter

Hea

lth m

eets

a sim

ilar r

equir

emen

t in ea

ch of

the t

hree

exam

ple st

ates.

The

pr

oced

ures

desc

ribed

abov

e are

unifo

rmly

and c

onsis

tently

appli

ed in

our o

ther 1

0 Med

icaid

mana

ged c

are o

pera

tions

. The

se pr

oces

ses w

ill be

appli

ed to

the L

ouisi

ana C

CN pr

ogra

m. W

e ha

ve ex

perie

nce s

uppo

rting p

rovid

ers t

rans

itionin

g fro

m fee

-for-s

ervic

e to M

edica

id ma

nage

d car

e an

d in s

hiftin

g pro

vider

s fro

m su

bmitti

ng pa

per c

laims

to el

ectro

nic cl

aims.

Our

expe

rt tea

m of

claim

s sy

stem

deve

loper

s and

enco

unter

syste

m de

sign s

pecia

lists

have

alre

ady r

eview

ed D

HH’s

syste

m gu

ide an

d com

pare

d it to

simi

lar gu

ides f

rom

other

Med

icaid

agen

cies

17.5.

4.17 E

ncou

nter r

ecor

ds sh

all be

subm

itted s

uch t

hat

paym

ent fo

r disc

rete

servi

ces w

hich m

ay ha

ve be

en

subm

itted i

n a si

ngle

claim

can b

e asc

ertai

ned i

n ac

cord

ance

with

the C

CNs a

pplic

able

reim

burse

ment

metho

dolog

y for

that

servi

ce.

Meets

Me

ets

Meets

W

e und

ersta

nd an

d agr

ee to

this

stipu

lation

. The

state

Me

dicaid

agen

cies r

egula

ting t

he th

ree h

ealth

plan

s we

selec

ted as

an ex

ample

have

simi

lar re

quire

ments

; in fa

ct,

it is o

ur ex

perie

nce t

hat th

is is

a com

mon s

tipula

tion.

How

we w

ill ap

ply th

is ex

perie

nce t

o the

Louis

iana C

CN

prog

ram?

Ae

tna B

etter

Hea

lth m

eets

a sim

ilar r

equir

emen

t in ea

ch of

the t

hree

exam

ple st

ates.

The

pr

oced

ures

desc

ribed

abov

e are

unifo

rmly

and c

onsis

tently

appli

ed in

our o

ther 1

0 Med

icaid

mana

ged c

are o

pera

tions

. The

se pr

oces

ses w

ill be

appli

ed to

the L

ouisi

ana C

CN pr

ogra

m. W

e ha

ve ex

perie

nce s

uppo

rting p

rovid

ers t

rans

itionin

g fro

m fee

-for-s

ervic

e to M

edica

id ma

nage

d car

e an

d in s

hiftin

g pro

vider

s fro

m su

bmitti

ng pa

per c

laims

to el

ectro

nic cl

aims.

Our

expe

rt tea

m of

claim

s sy

stem

deve

loper

s and

enco

unter

syste

m de

sign s

pecia

lists

have

alre

ady r

eview

ed D

HH’s

syste

m gu

ide an

d com

pare

d it to

simi

lar gu

ides f

rom

other

Med

icaid

agen

cies


56



Challenges and Lessons Learned Implementing a new encounter system, especially with a State Medicaid State Agency that is new to managed care, can be a challenge. There are three primary lessons we have learned as a result of the last three Medicaid managed care implementations. These are:

There must be open communication between DHH’s FI and Aetna Better Health on the implementation. The old cliché is “if you’ve seen one Medicaid program, you’ve seen one Medicaid program” also applies to Medicaid managed care health plans and their encounter systems. Aetna Better Health is fully committed to aligning its encounter program to meet the needs of DHH and its FI. However, due to the complexity of encounter systems we recommend there be frequent and meaningful communication regarding design, development, implementation, and testing. We have discovered that regularly scheduled meeting between with the Medicaid agency and their agent (FI) and the CCN is one of the most meaningful communication methods. This way both parties can ask questions, review incremental test results and provide insight and direction. To facilitate these meetings and support communication we further recommend that DHH’s FI assign a project manager or equivalent level professional to work with each CCN. This will help avoid unnecessary confusion or errors.

DHH and its FI should set realistic encounter system development and testing timeline and goals. These timelines and goals should be as stable as possible once the development and testing process begins.

DHH and its FI should, once the development and testing process begins, avoid adjusting encounter system requirements, program design elements, reports and coding specifications. Stability in the design environment is critical to remain on target for quality and timeliness of development and testing.

Aetna Better Health is aware that changes in the timeline, requirements, design, reporting and coding are inevitable in a project of this size and complexity. The impact on the quality, timeframe and cost can be mitigated by working together and through close communication. Our QNXT™ and Encounter Management System (EMS) are responsive and flexible to meet DHH’s needs and requirements. These systems provide a state-of-the-art platform that can keep pace with the multiple enhancements that are expected as healthcare reform is implemented.

Aetna Better Health will assign an encounter development team to the Louisiana CCN implementation. This development team will be led by a senior manager of our organization and include representatives of our key operational units responsible for encounter management. Included on this team will be veterans from our last three implementations that will offer insight, knowledge and experience to DHH and its FI. DHH and its FI will have a highly dedicated and responsible encounter development team to manage this encounter system implementation.


57

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s


58

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s


59




60




61

123 R.6



R.6 Describe your ability to receive, process, and update eligibility/enrollment, provider data, and encounter data to and from the Department and its agents. In your response:

● Explain whether and how your systems meet (or exceed) each of these requirements.

● Cite at least three currently-live instances where you are successfully receiving, processing and updating eligibility/enrollment data in accordance with DHH coding, data exchange format and transmission standards and specifications or similar standards and specifications. In elaborating on these instances, address all of the requirements in Section 16 and 17, and CCN-P systems companion guide. Also, explain how that experience will apply to the Louisiana Medicaid CCN Program.

● If you are not able at present to meet a particular requirement contained in the aforementioned sections, identify the applicable requirement and discuss the effort and time you will need to meet said requirement.

Identify challenges and “lessons learned” from implementation in other states and describe how you will apply these lessons to this contract.

Aetna Better Health, as described below, meets each of DHH’s requirements and has the ability and capacity to receive, process and update eligibility/enrollment, provider data, and encounter data from DHH and its agents. We have selected Delaware, Florida and Maryland as representative states. We discuss challenges and lessons learned following the tables.

Eligibility Data Functionality/Requirement Delaware Florida Maryland

Maintain “real time” data connectivity to data source

We maintain “real time” data connectivity to the data source for the purpose of receiving, processing, updating and exchanging data with the State.

We maintain “real time” data connectivity to the data source for the purpose of receiving, processing, updating and exchanging data with the State

We maintain “real time” data connectivity to the data source for the purpose of receiving, processing, updating and exchanging data with the State

Data Source(s) The source for eligibility data is the State.

The source for eligibility data is the State

The source for eligibility data is the State

Frequency of receipt Daily receipt of adds, deletes (terms) and changes. Month end reconciliation. --File Transfer: Aetna Better Health prefers to have the state push the files to us. Aetna Better Health can accommodate a "pull"

Daily receipt of adds, deletes (terms) and changes. Month end reconciliation. --File Transfer: Aetna Better Health prefers to have the state push the files to us. Aetna Better Health can accommodate a "pull"

Daily receipt of adds, deletes (terms) and changes. Month end reconciliation. --File Transfer: Aetna Better Health prefers to have the state push the files to us. Aetna Better Health can accommodate a "pull"


62




strategy in which we go out and retrieve the files. However, the preference is to have the files sent (aka - pushed) to us. We can also perform manual daily website retrievals (once again, not our preference). --Frequency: We prefer Mon - Fri daily add/change files. We can accommodate daily changes 7 days a week. We prefer to reconcile once a month, but we can accommodate a more frequent reconciliation. --Loading: We load eligibility files daily Mon - Fri. Usually, files received over the weekend are loaded on Monday. We load files in sequential order. If we received a file out of sequence, we will hold the file until the sequence issue is resolved. --Timing: Our preference for eligibility processing is between 5:30 - 8:00 am (AZ time). --Processing: We process adds, changes, and terminations on a daily basis.




63




Transmission method Electronic data

transmission from the State to a secure FTP site

Electronic data transmission from the State to a secure FTP site

Electronic data transmission from the State to a secure FTP site

Transmission standard* *Please see a detailed EDI eligibility flow chart at the end of this section.

Aetna Better Health meets this State’s transmission standards – both incoming and outgoing standards are met. Aetna Better Health can accommodate DHH’s transmission standards, file formats, compression techniques, data formats and transmission protocols. Aetna Better Health will work with DHH’s MMIS vendor during testing to meet transmission standards.

Aetna Better Health meets this State’s transmission standards – both incoming and outgoing standards are met. Aetna Better Health can accommodate DHH’s transmission standards, file formats, compression techniques, data formats and transmission protocols. Aetna Better Health will work with DHH’s MMIS vendor during testing to meet transmission standards

Aetna Better Health meets this State’s transmission standards – both incoming and outgoing standards are met. Aetna Better Health can accommodate DHH’s transmission standards, file formats, compression techniques, data formats and transmission protocols. Aetna Better Health will work with DHH’s MMIS vendor during testing to meet transmission standards

HIPPA standard code set (specify)

ASC X12N 834 Benefit Enrollment and Maintenance



Account for and track: ● Member ID

Number ● Mailing Address ● Telephone

number ● Head of

household ● Rate code ● Age (Date of

Birth) ● Sex ● PCP assignment ● Primary language

(if other than English)

● Yes ● Yes ● Yes ● Yes ● Yes ● Yes ● Yes ● Yes ● Yes

These data are identified, retained and tracked in the QNXT™ system. We maintain integrity of these data through data mapping procedures.






64




Update eligibility record in QNXT™ within 24 hours?

Yes

Yes Yes

Inform State/Agent of member changes (Addresses, Telephone Number, Household adjustment)

Yes Yes Yes

Identify possible duplicate eligibility records o Correct records if

required

A standard routine is applied to each eligibility file to determine if there are duplicate records. If we identify a potential duplicate record we reconcile the duplicate by validating 5 data points [1. Name; 2. ID Number; 3. Address; 4) Date of Birth; 5) Sex.]. If 3 or more of these data points match we will consider the eligibility a match.



Maintain spans of eligibility periods

The QNXT™ system maintains each member’s span of eligibility and updates the eligibility continuously. Breaks in eligibility periods are defined by date spans [begin and end dates]. Eligibility spans are system accessible for eligibility feeds to providers, prior authorization, and claims adjudication.



Maintain Audit trail of eligibility record changes

The QNXT™ system performs the following major functions: • Adds, updates,

closes and voids eligibility spans

• Produces an audit trail detailing all changes made to the database








65




• Produces member database update error report

• Produces possible duplicate member reports

• Monthly Reconciliation

Audit report exceptions are research to determine the cause and resolved in accordance with standard operating procedures. QNXT™ maintain a detailed record of all changes made to eligibility records for tracking, auditing and reconciliation.









Protect confidentiality of records

Aetna Better Health’s management information system currently supports DHH’s required technical interfaces and complies with all applicable requirements of the Health Insurance Portability and Accountability Act (HIPAA). We are, and will continue to be, responsive, within a reasonable timeframe, to any and all adjustments or modifications to future HIPAA procedures, policies, rules and statutes that may be required during the term of our contract. Our management information system configuration supports




66




migration from one HIPAA version to another in the following ways:

• Microsoft BizTalk with HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, enabling Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.

• Foresight HIPAA Validator™ InStream™ is a fully functional HIPAA editing and validation application. It validates HIPAA transactions through all seven levels of edits as defined by the Workgroup for Electronic Data Interchange and Strategic National

migration from one HIPAA version to another in the following ways: • Microsoft BizTalk with

HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, enabling Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.


migration from one HIPAA version to another in the following ways: • Microsoft BizTalk with

HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, enabling Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.



67




Implementation Process (WEDI/SNIP), has all standard HIPAA code sets embedded, and can support custom, trading-partner-specific companion guides and validation requirements. The application also provides descriptive error reports to submitters to facilitate quick error resolution.

Aetna Better Health follows the Strategic National Implementation Project (SNIP) recommendations for testing created by the Workgroup for Electronic Data Interchange (WEDI), further promoting system compliance with federal IT mandates.





Reconcile eligibility records each month - process

Meet Member eligibility is reconciled in two different ways on a monthly basis. The first is a comparison between the Monthly 834 file and the membership listed in QNXT™ to identify any exceptions. All exceptions are researched, validated, and appropriately updated in QNXT™. The second reconciliation is a comparison of the membership in QNXT™ to the Capitation File.




68




All exceptions are identified, researched, validated, and appropriately updated in QNXT™.

All exceptions are identified, researched, validated, and appropriately updated in QNXT™.

All exceptions are identified, researched, validated, and appropriately updated in QNXT™

Web based system to validate eligibility information for providers

Above Health is a secure HIPAA-compliant web portal for our members and providers. Designed to foster open communication and facilitate access to a variety of data in a multitude of ways, this secure, ASP-based application synchronizes data on a daily basis with QNXT™ through data extract and load processes, allowing members to check eligibility status, review benefits and prior authorization status, and send secure emails to our Member Services personnel. Providers are afforded additional functionalities, including:

• Member eligibility verification

• Panel roster review • Searchable provider

list • Claim status search • Remittance advice

search • Submit

authorizations • Search

authorizations We configure the portal to provide HEDIS® scorecard data, as well





search • Submit







search • Submit




69




as alerts indicating when a member is due or past due for a HEDIS®-related service (e.g., well-child check-up, need for asthma controller medication, immunizations). This information is integrated within the application’s provider panels/rosters. If a member is due or past due for a service, a “flag” appears next to the member’s name, which, when clicked, permits providers to view a description of the needed service(s).

as alerts indicating when a member is due or past due for a HEDIS®-related service (e.g., well-child check-up, need for asthma controller medication, immunizations). This information is integrated within the application’s provider panels/rosters. If a member is due or past due for a service, a “flag” appears next to the member’s name, which, when clicked, permits providers to view a description of the needed service(s)

as alerts indicating when a member is due or past due for a HEDIS®-related service (e.g., well-child check-up, need for asthma controller medication, immunizations). This information is integrated within the application’s provider panels/rosters. If a member is due or past due for a service, a “flag” appears next to the member’s name, which, when clicked, permits providers to view a description of the needed service(s)

Apply eligibility records during prior authorization decision making

Meet This is a standard operating and processing process for all States. Eligibility records are applied during prior authorization requests by a routine in QNXT™. This routine applies the member’s span of eligibility to the prior authorization request. If the member’s eligibility record does not support the eligibility request the requestor is notified and a notice of action is issued in accordance with the State’s specific guidance. Each State has different criteria and specifications (including time lines) for issuing a Notice of Action.




70




System edits to: a) Confirming eligibility on

each member as claims are submitted on the basis of the eligibility information provided by DHH and the Enrollment Broker that applies to the period during which the charges were incurred

b) Perform system edits for valid dates of service, and assure that dates of services are valid dates such as not in the future or outside of a member’s Medicaid eligibility span

QNXT™ Data Edits QNXT™ has over 400 business rules that Aetna Better Health configures to support enforcement of our claims Policies and Procedures (P&Ps). The application of specific conditions, restrictions, and validation criteria promote the accuracy of claim processing against DHH standards. The edits can result in claims pending or denying depending on the editing logic. For example, if the member is not eligible on the date of service, QNXT™will automatically deny the claim. In the event that the category of service of the provider of record does not match the procedure code billed the claim will pend for manual review to validate accuracy of provider set-up. Examples of data edits specific to QNXT™ include the following: Benefits Package

Variations QNXT™ automatically analyzes CPT, REV, and HCPC codes to determine whether specific services are covered under the contract or benefit rules. If services are not covered, the system will






71




automatically deny the respective claim line. The claim line will deny with the appropriate HIPAA remittance remark on the EOB. Data Accuracy QNXT™ is continually updated based on the most current code sets available (HCPCS, REV, CPT codes) by year. As new codes are added, terminated, or changed, we update the codes in QNXT™ so the system is always in compliance with HIPAA standards. If a network provider bills a code that has been terminated, QNXT™ will deny the claim line and advise the provider the code is invalid via remittance advice. Adherence to Prior Authorization Requirements

QNXT™ is configured to enforce the supporting documentation requirements of certain services. In addition, QNXT™ has the ability to configure Prior Authorization (PA) by code, provider type, and place of service. QNXT™ is configured to automatically identify certain types of authorizations for medical director review. Claim edit rules are set to validate the claim






72




against the network provider, member, dates of service, services rendered, and units authorized. Provider Qualifications QNXT™ provider files are configured by specialty and category of service. This allows for the enforcement of categories of service and provider type on claims validation. Certain procedures can only be performed by select network provider types. For example, QNXT™ will not permit the processing of a claim for in-office heart surgery by a podiatrist. iHealth lends additional support in this regard, reviewing any claim line set to “Pay” for billing appropriateness by specialty. QNXT™ checks other provider-specific items as well, verifying, for example, that each provider has obtained the requisite National Provider Identifier (NPI) or its equivalent and included the identifier on all claims submissions. Member Eligibility and

Enrollment QNXT™ validates the date of service against the member’s enrollment segment to determine if the member was eligible






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on the date of service. If the member was not eligible on the date of service, the system will automatically deny the claim using the appropriate HIPAA approved remittance comment. Duplicate Billing Logic QNXT™ uses a robust set of edits to determine duplication of services. Examples are same member, same date, same network provider, same service, or any combination of these criteria. In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against our paying for services rendered by the same physician or other physicians within the same provider group ClaimCheck® Edits ClaimCheck® is a comprehensive code auditing solution that supports QNXT™ by applying expert industry edits from a provider recognized knowledge base to analyze claims for accuracy and consistency with our P&Ps. ClaimCheck® clinical editing software identifies coding errors in the following categories:

• Procedure


• Procedure


• Procedure


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unbundling • Mutually exclusive

procedures • Incidental

procedures • Medical visits, same

date of service • Bilateral and

duplicate procedures

• Pre and Post-operative care

• Assistant Surgeon • Modifier Auditing • Medically Unlikely Aetna Better Health offers network providers access to Clear Claim Connection®, a provider reference tool that helps providers optimize their claims submission accuracy. Currently there are 2300 provider groups registered to use this web-based tool that providers can use to understand our clinical editing logic. This allows them to better understand the rules and clinical rationale affecting adjudication. Providers access Clear Claim Connection® through our web portal via secure login. Various coding combinations can then be entered to determine why, for example, a particular coding combination resulted in a denial. The provider may also review coding
















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combinations prior to claim submission, to determine if applicable auditing rules and clinical rationale will deny the claim before it is submitted. iHealth Edits iHealth clinically edits claims to assist in promoting the proper and fair payment of professional DME and outpatient claims. Coding Accuracy If the services are up-coded, or unbundled, iHealth will alert the Claims Department to deny the claim line along with the specific clinical editing policy justification for the denial. The claim line will deny with the appropriate HIPAA remittance remark on the Explanation of Benefits (EOB). Duplicate Billing Logic In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against Aetna Better Health paying for services rendered by the same physician or other physicians within the same provider group




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Durable Medical Equipment (DME) Editing iHealth Technologies’ (iHT) performs edits related to select DME payment policies that align with DHH covered service policies. These DME edits include but are not limited to; DME rentals, oxygen and oxygen systems, hospital beds and accessories, external infusion pumps and anatomic/functional modifiers required for DME services. Procedure Code Guidelines - iHealth Aetna Better Health follows the AMA CPT-4 Book and CMS HCPCS Book, which both provide instructions regarding code usage. iHT has developed these guidelines into edits. For example, if a vaccine administration code is billed without the correct vaccine/toxoid codes, Aetna Better Health would then deny the code as inappropriate coding based on industry standards. According to the AMA CPT Book, this vaccination must be reported in addition to the vaccine and toxoid code(s).




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Procedure Code Definition Policies - iHealth iHT supports correct coding based on the definition or nature of a procedure code or combination of procedure codes. These editing policies will either bundle or re-code procedures based on the appropriateness of the code selection. For example, if a provider attempts to unbundle procedures, iHT will apply editing logic that will bundle all of the procedures billed into the most appropriate code. For example, if a provider bills an office visit and also bills separately for heart monitoring with a stethoscope at the same visit, iHT will rebundle the service into the appropriate E&M or office code. Fraud & Abuse Aetna Better Health’s Fraud and Abuse Department utilizes claims payment tracking and trending reports, claims edits, audits and provider billing patterns as indicators of potential fraud and abuse. The Fraud and Abuse Department uses this information to detect aberrant provider billing behavior, prompting




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additional analysis and investigation. Our fraud and abuse personnel work in conjunction with Provider Services and Compliance Departments to address the questionable behavior(s) through provider education and outreach. If we discovers, or becomes aware, that an incident of potential/suspected fraud and abuse has occurred, internal P&Ps mandate that we report the incident to DHH in accordance with DHH’s requirements.



Identify members and children with special healthcare needs for assignment of a PCP (if the member does not choose) to meet the member’s/child’s needs.

Members with special needs are assigned, when and where available, to PCPs or specialists who have the capacity to provide and coordinate the necessary care and serve as the PCMH. Providers with this capability are identified in QNXT™ to facilitate member assignment. Identification in the system permits us to evaluate the availability of these providers in the network so we may conduct specific provider training or enhance recruitment activities as necessary.




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Identify providers with open access appointment system.

A system attribute identifies providers who have an open access or modified open access appointment system and increases member assignments if appropriate.

A system attribute identifies providers who have an open access or modified open access appointment system and increases member assignments if appropriate

A system attribute identifies providers who have an open access or modified open access appointment system and increases member assignments if appropriate

Identify members who have failed to adhere to EPSDT periodicity schedule, with a history of missed appointments (Provider Assistance Program) for special assistance when requesting PA or PCP change, or who have been hard to reach for Case Management follow-up.

If a member is considered non-compliant either with EPSDT periodicity schedule or has a history of missed appointments (Provider Assistance Program) a “flag” is entered into QNXT™ to alert Prior Authorization personnel, Member Services and Provider Services during administrative processes to either alert the provider of contact the member. Alerts are designed to notify the member’s PCP or attending physician specialist to encourage the member to complete EPSDT services or determine barriers to keeping appointments. Case managers (CM) document in QNXT™ when a member has been hard to reach (e.g., homelessness, etc) so that when the member contacts Aetna Better Health the Prior Authorization, Member Services, Grievance and Appeals or Quality Management personnel are aware of the




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situation and can attempt to obtain current contact information (cell phone number, address, e-mail address) and alert the case manager.



Provider Data Functionality/Requirement

Delaware Florida Maryland

Maintain, track and report provider types, specialty, and sub-specialty codes

Meet The specialty and sub-specialty are codes designated by the State. We design QNXT™ to meet the State’s coding structure. We load provider type as a attribute in QNXT™ to track.

Meet The specialty and sub-specialty are codes designated by the State. We design QNXT™ to meet the State’s coding structure. We load provider type as a attribute in QNXT™ to track

Meet The specialty and sub-specialty are codes designated by the State. We design QNXT™ to meet the State’s coding structure. We load provider type as a attribute in QNXT™ to track

Coordinate our provider enrollment records with the Medicaid agency’s by provider type, specialty and subspecialty codes as those used by the Medicaid agency and/or the Enrollment Broker

Meet The specialty and sub-specialty are codes designated by the State. We design QNXT™ to meet the State’s coding structure. We load provider type as a attribute in QNXT™ to track Provided by Medicaid agency, then mapped to the data field within QNXT™. Report that is written by IT – distinct reports.

Meet The specialty and sub-specialty are codes designated by the State. We design QNXT™ to meet the State’s coding structure. We load provider type as a attribute in QNXT™ to track Provided by Medicaid agency, then mapped to the data field within QNXT™. Report that is written by IT – distinct reports

Meet The specialty and sub-specialty are codes designated by the State. We design QNXT™ to meet the State’s coding structure. We load provider type as a attribute in QNXT™ to track Provided by Medicaid agency, then mapped to the data field within QNXT™. Report that is written by IT – distinct reports

Track, account for and report key provider record information, including but not limited to:

● Provider name, ● Address, ● licensing

Meet Tracking, accounting and reporting on provider record information is a standard process within




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information, ● Tax ID, ● National Provider

Identifier (NPI), ● Taxonomy and ● Payment

information

QNXT™. This is custom designed for each State based on State requirements and information to be included in the Provider Directory and provided to either the MMIS vendor, FI or enrollment broker.



Track, account for and report key provider functionality, including but not limited to:

● Audit trail and history of changes made to the provider file;

● Automated interfaces with all licensing and medical boards;

● Automated alerts when provider licenses are nearing expiration;

● Retention of NPI requirements;

● System generated letters to providers when their licenses are nearing expiration;

● Linkages of individual providers to groups;

● Credentialing information;

● Provider office hours;

● After hours/weekend

Meet There are two auditable trails for these functions. First, audit trail is through the Remedy Tracking System – System to account for all requests to add, change or modify a provider record. Second audit trail is tracked within QNXT™ itself. Historical record of all data changes are tracked by date, time and identification number of the individual making the addition, change or record modification. This is maintained in the provider management subsystem. Change request documentation is housed in the Provider Relations Department. Remedy also retains a copy of the change request for historical reference and auditing. Credentialing information is obtained from our affiliated NCQA® credentialing




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availability ● Provider

languages spoken

vendor. Credentialing information is maintained in QNXT™ and with the affiliated credentialing vendor. Provider Relations runs a monthly report to identify providers with expiring licenses and mails a letter to the provider. A copy of the letter is sent to our NCQA® vendor for appropriate action. The vendor checks with the appropriate State authority to determine if license is maintained and the QNXT™ file is adjusted as appropriate. The linkage (record of assignment) of members to a provider is using an affiliation (tying two records together) in the provider’s record. Housed in provider module. TTY and TTD will be built as needed for DHH. Languages spoken by provider office are maintained in the provider file and can be extracted for reporting purposes.



If a PCP, track member assignments (linkages)

Meet Aetna Better Health tracks and retains a history of member PCP assignments. Aetna Better Health can also track the members assigned to a PCP.

Meet Aetna Better Health does track and retain a history of member PCP assignments. Aetna Better Health can also track the members assigned to a PCP.

Meet Aetna Better Health does track and retain a history of member PCP assignments. Aetna Better Health can also track the members assigned to a PCP.


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Track if PCP is open or closed to new members

We capture this in QNXT™ and can report at any time and monitor on a monthly basis to see that there are enough providers for auto-assignment



Track member grievances and appeals

Meet Aetna Better Health maintains a database for tracking member grievances and appeals. This database is customizable to meet the specific requirements of each State. Maintained by Aetna Better Health’s Grievance and Appeals personnel, the data base can support reporting and tracking of individual grievance and appeal actions from initiation to final decision at the State authority.



Track quality of care investigations and reviews quality investigations

Meet Quality investigations are tracked in Aetna's Potential Quality of Care (PQoC) Database. The database is maintained by Aetna Better Health’s Information System (AIS) Department. Quality investigations for all Aetna Better Health organizations, Medicaid, Medicare, Behavioral Health, and Commercial are tracked in the same database. It provides a global review and access to all providers with a quality




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investigation as part of their history. The PQoC is a VB.net frontend w/SQL server backend.



Apply provider information when adjudicating claims

Meet This is a standard operating and processing process for all States. Provider records are applied during claims adjudication processing to match against procedure performed, demographics of the member and other common edit criteria. Claims from providers without the appropriate provider types, specialty, and sub-specialty codes are denied, specific denial reason recorded on the remittance advice and a notice of action letter is issues. Each State has different criteria and specifications (including time lines) for issuing a Notice of Action.



Update and maintain accurate provider information for Provider Directory

Meet The appropriate fields to initially establish, update and maintain a provider directory is housed in our QNXT™ system. Our Network Provider Directory will be available for distribution to members and One Page Brochure (and the complete Provider




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Directory) will be available for distribution and the Enrollment Broker in accordance with GSA A, B and C timelines. Provider Directory will be available:

• A hard copy directory for members and upon request, potential members;

• Web-based, searchable, online directory for members and the public; and

• Electronic file of the directory for the Enrollment Broker

• Hard copy, abbreviated version for the Enrollment Broker

Our Provider Directory will be available in paper form and through our website. The web version of the Provider Directory is updated weekly, prior to distribution to the Enrollment Broker and posting on our website.

Directory) will be available for distribution and the Enrollment Broker in accordance with GSA A, B and C timelines. Provider Directory will be available: • A hard copy directory

for members and upon request, potential members;





Directory) will be available for distribution and the Enrollment Broker in accordance with GSA A, B and C timelines. Provider Directory will be available: • A hard copy directory

for members and upon request, potential members;






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Encounter Data Functionality/Requirement


Identify all data elements as required by DHH for encounter data submission as stipulated in this Section of the RFP and the Systems Guide

Meet All data elements required by the Medicaid single-state agency for encounter data submission are tracked, reported and included on encounter transmissions to the Medicaid single-state agency, its MMIS vendor or its FI as appropriate



The CCN’s system shall be able to transmit to and receive encounter data from the DHH FI’s system as required for the appropriate submission of encounter data




17.5.4.3 The CCN shall provide the FI with complete and accurate encounter data for all levels of healthcare services provided.

We meet this requirement in the three example states and in our other seven Medicaid managed care states. We have encounter system implementation and submission best practices to validate data validity for all levels of healthcare services provided (ancillary, acute, and institutional services) prior to submitting encounter data to DHH: 1. The QNXT™ system verifies that all necessary claims fields




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are populated with values of the appropriate range and type prior to the encounter information being loaded onto the EMS. 2 .Encounter data files from vendor sources go through a staging process. The staging process consists of automated and manual verification, to validate that files have the proper layout and the appropriate fields populated. In this staging process, correct files are allowed to pass; pended files are corrected if there are correctable errors, or are rejected if the errors cannot be corrected. This staging process results in only the cleanest files being imported into the EMS. 3. After data from QNXT™ and vendor sources are loaded into the EMS, they must pass the EMS Scrub Edits, which are customized based on DHH’s requirements for clean encounters. Files that are unlikely to pass the DHH’s edits are not submitted until they are corrected. Encounter Unit analysts take responsibility for the correction. This proactive approach to identifying and




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correcting errors prior to the submission of data to the Commonwealth expedites review and adjudication.



17.5.4.4 The CCN shall have the ability to update CPT/HCPCS, ICD-9-CM, and other codes based on HIPAA standards and move to future versions as required.

Each of the states Aetna Better Health provides Medicaid managed care have different nuisances in the capture and reporting of encounter data. We have uniform written policies and procedures and system protocols that we apply to maintain compliance with, but separation on a state-by-state basis, these encounter reporting requirements. Aetna Better Health maintains strict compliance with updates regarding Current Procedural Terminology (CPT), the Healthcare Procedural Coding System (HCPCS) (CPT/HCPCS), and ICD-9-CM and other codes in accordance with HIPAA standards so that claims and resulting encounters are processed in an orderly and consistent manner. CPT procedural codes are published by the American Medical Association (AMA). Updated annually on January 1, CPT is a proprietary terminology created and maintained by the AMA. Its purpose is to provide a uniform language for describing




89





and reporting the professional services provided by physicians. HCPCS is maintained by the Centers for Medicare and Medicaid Services (CMS). Its purpose is to provide a system for reporting the medical services provided to Medicaid/Medicare members. HCPCS is made up of two parts: Level I is composed entirely of the current version of CPT; HCPCS Level II provides codes to represent medical services that are not covered by the CPT system, for example, medical supplies and services performed by healthcare professionals who are not physicians The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Healthcare professionals use the CPT to identify services and procedures they bill to Aetna Better Health for covered and medically necessary services. We understand that decisions regarding the addition, deletion, or




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revision of CPT codes are made by the AMA. The CPT codes are republished and updated annually by the AMA. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians. We are aware that HCPCS Level II is a standardized coding system to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DME) when used outside a physician's office. Because most Medicaid agencies, including DHH, require mandatory coverage of a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established by CMS for submitting claims for these items. Currently, there are national HCPCS codes representing over 4,000 separate categories of like items or services that encompass millions of products from different manufacturers.




91





When submitting claims, we require our provider to use one of these codes to identify the items they are billing. The descriptor that is assigned to a code represents the definition of the items and services that can be billed using that code. For these reasons and to provide timely, accurate and complete encounters to the Medicaid agencies we provide managed care service to, we closely monitor and maintain compliance with the most current CPT/HCPCS coding requirements and stipulations. We also have written policies and procedures that require informing our provider network of CPT/HCPCS coding modifications that are effective as of a date-of-service to avoid unnecessary delays, confusion or problems in submitting complete, accurate and timely encounters to DHH and other Medicaid agencies. In addition to the above we also closely monitor and remain compliant with the following requirements: • Permanent National

Codes - National


Codes - National


Codes - National


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permanent HCPCS level II codes are maintained by the CMS HCPCS Workgroup

• Miscellaneous Codes - National codes also include "miscellaneous/not otherwise classified" codes. These codes are used when a supplier is submitting a bill for an item or service and there is no existing national code that adequately describes the item or service being billed.

• Temporary National Codes - Temporary codes are for the purpose of meeting, within a short time frame, the national program operational needs that are not addressed by an already existing national code. We are aware that and monitor the CMS HCPCS Workgroup has set aside certain sections of the HCPCS code set to allow the Workgroup to develop temporary codes.

• Types of temporary HCPCS codes: o The C codes were

established to permit implementation of section 201 of the












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Balanced Budget Refinement Act of 1999.

o The Q codes are used to identify services that would not be given a CPT-4 code, such as drugs, biologicals, and other types of medical equipment or services, and which are not identified by national level II codes but for which codes are needed for claims processing purposes.

o The G codes are used to identify professional health care procedures and services that would otherwise be coded in CPT-4 but for which there are no CPT-4 codes.

o The K codes were established for use by the DME MACs when the currently existing permanent national codes do not include the codes needed to implement a DME MAC medical review policy.

o The S codes are





o The S codes are





o The S codes are


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used by private insurers to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the private sector to implement policies, programs, or claims processing.

o Certain H codes are used by those State Medicaid agencies that are mandated by State law to establish separate codes for identifying mental health services such as alcohol and drug treatment services.

o The T codes are designated for use by Medicaid State agencies to establish codes for items for which there are no permanent national codes and for which codes are necessary to meet a national Medicaid program operating need.








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• Code Modifiers - In some instances, Medicaid agencies instruct Aetna Better Health to require its providers to require a code modifier to a HCPCS code to provide additional information regarding the service or item identified by the HCPCS code. Modifiers are used when the information provided by a HCPCS code descriptor needs to be supplemented to identify specific circumstances that may apply to an item or service. For example, a UE modifier is often used when the item identified by a HCPCS code is "used equipment," a NU modifier is used for "new equipment." The level II HCPCS modifiers are either alpha-numeric or two letters.

• HCPCS Updates to Permanent National Codes – We are aware that the national codes are updated annually

CPT Category II Codes - We are aware that CPT Category II codes are supplemental tracking codes used for








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performance measurement. These tracking codes for performance measurement decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that support performance measures and that have been agreed upon as contributing to good patient care. CPT II codes are maintained and updated by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel. The PMAG comprises performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the




97





Physician Consortium for Performance Improvement. The International Classification of Diseases, Clinical Modification, currently in its ninth revision (ICD-9-CM), is used to describe and report the illnesses, conditions, and injuries of patients who require medical services. ICD-9-CM is made up of a series of numerical and alphanumerical codes and code descriptions that represent very specific illnesses and injuries. Similarly, the services provided by physicians and other healthcare professionals are described and reported by using terminologies and classification systems. The International Classification of Diseases, Clinical Modification, provides a system for coding medical procedures performed in the inpatient departments of hospitals, but two other systems apply to the services provided by physicians and other medical providers in hospital-based outpatient departments, physicians’ offices, and other ambulatory settings: the Current Procedural Terminology




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and the Healthcare Common Procedure Coding System.



17.5.4.5 In addition to CPT, ICD-9-CM and other national coding standards, the use of applicable HCPCS Level II and Category II CPT codes are mandatory, aiding both the CCN and DHH to evaluate performance measures.

Each of the states Aetna Better Health provides Medicaid managed care have different nuisances in the capture and reporting of encounter data. We have uniform written policies and procedures and system protocols that we apply to maintain compliance with, but separation on a state-by-state basis, these encounter reporting requirements. Aetna Better Health maintains strict compliance with updates regarding Current Procedural Terminology (CPT), the Healthcare Procedural Coding System (HCPCS) (CPT/HCPCS), and ICD-9-CM and other codes in accordance with HIPAA standards so that claims and resulting encounters are processed in an orderly and consistent manner. CPT procedural codes are published by the American Medical Association (AMA). Updated annually on January 1, CPT is a proprietary terminology created and maintained by the AMA. Its purpose is to provide a uniform language for describing and reporting the professional services




99





provided by physicians. HCPCS is maintained by the Centers for Medicare and Medicaid Services (CMS). Its purpose is to provide a system for reporting the medical services provided to Medicaid/Medicare members. HCPCS is made up of two parts: Level I is composed entirely of the current version of CPT; HCPCS Level II provides codes to represent medical services that are not covered by the CPT system, for example, medical supplies and services performed by healthcare professionals who are not physicians The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Health care professionals use the CPT to identify services and procedures they bill to Aetna Better Health for covered and medically necessary services. We understand that decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are

provided by physicians. HCPCS is maintained by the Centers for Medicare and Medicaid Services (CMS). Its purpose is to provide a system for reporting the medical services provided to Medicaid/Medicare members. HCPCS is made up of two parts: Level I is composed entirely of the current version of CPT; HCPCS Level II provides codes to represent medical services that are not covered by the CPT system, for example, medical supplies and services performed by healthcare professionals who are not physicians The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other healthcare professionals. Healthcare professionals use the CPT to identify services and procedures they bill to Aetna Better Health for covered and medically necessary services. We understand that decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are

provided by physicians. HCPCS is maintained by the Centers for Medicare and Medicaid Services (CMS). Its purpose is to provide a system for reporting the medical services provided to Medicaid/Medicare members. HCPCS is made up of two parts: Level I is composed entirely of the current version of CPT; HCPCS Level II provides codes to represent medical services that are not covered by the CPT system, for example, medical supplies and services performed by healthcare professionals who are not physicians The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals. Healthcare professionals use the CPT to identify services and procedures they bill to Aetna Better Health for covered and medically necessary services. We understand that decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are


100





republished and updated annually by the AMA. Level I of the HCPCS, the CPT codes, does not include codes needed to separately report medical items or services that are regularly billed by suppliers other than physicians. We are aware that HCPCS Level II is a standardized coding system to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DME) when used outside a physician's office. Because most Medicaid agencies, including DHH, require mandatory coverage of a variety of services, supplies, and equipment that are not identified by CPT codes, the level II HCPCS codes were established by CMS for submitting claims for these items. Currently, there are national HCPCS codes representing over 4,000 separate categories of like items or services that encompass millions of products from different manufacturers. When submitting claims, we require our provider to use one of these




101





codes to identify the items they are billing. The descriptor that is assigned to a code represents the definition of the items and services that can be billed using that code. For these reasons and to provide timely, accurate and complete encounters to the Medicaid agencies we provide managed care service to, we closely monitor and maintain compliance with the most current CPT/HCPCS coding requirements and stipulations. We also have written policies and procedures that require informing our provider network of CPT/HCPCS coding modifications that are effective as of a date-of-service to avoid unnecessary delays, confusion or problems in submitting complete, accurate and timely encounters to DHH and other Medicaid agencies. In addition to the above we also closely monitor and remain compliant with the following requirements: • Permanent National

Codes - National permanent HCPCS level II codes are maintained by the CMS HCPCS






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Workgroup • Miscellaneous Codes

- National codes also include "miscellaneous/not otherwise classified" codes. These codes are used when a supplier is submitting a bill for an item or service and there is no existing national code that adequately describes the item or service being billed.



established to permit implementation of section 201 of the Balanced Budget Refinement Act of 1999.

o The Q codes are






o The Q codes are






o The Q codes are


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used to identify services that would not be given a CPT-4 code, such as drugs, biologicals, and other types of medical equipment or services, and which are not identified by national level II codes but for which codes are needed for claims processing purposes.

o The G codes are used to identify professional healthcare procedures and services that would otherwise be coded in CPT-4 but for which there are no CPT-4 codes.


o The S codes are used by private insurers to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the




o The S codes are used by private insurers to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the private sector to




o The S codes are used by private insurers to report drugs, services, and supplies for which there are no national codes but for which codes are needed by the private sector to


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private sector to implement policies, programs, or claims processing.



• Code Modifiers - In some instances, Medicaid agencies instruct Aetna Better Health to require its providers to require a code modifier to a HCPCS code to provide additional information regarding the service or item identified by the HCPCS code. Modifiers are used when the information provided by a HCPCS

implement policies, programs, or claims processing.



• Code Modifiers - In some instances, Medicaid agencies instruct Aetna Better Health to require its providers to require a code modifier to a HCPCS code to provide additional information regarding the service or item identified by the HCPCS code. Modifiers are used when the information provided by a HCPCS code descriptor needs

implement policies, programs, or claims processing.



• Code Modifiers - In some instances, Medicaid agencies instruct Aetna Better Health to require its providers to require a code modifier to a HCPCS code to provide additional information regarding the service or item identified by the HCPCS code. Modifiers are used when the information provided by a HCPCS code descriptor needs


105





code descriptor needs to be supplemented to identify specific circumstances that may apply to an item or service. For example, a UE modifier is often used when the item identified by a HCPCS code is "used equipment," a NU modifier is used for "new equipment." The level II HCPCS modifiers are either alpha-numeric or two letters.


CPT Category II Codes - We are aware that CPT Category II codes are supplemental tracking codes used for performance measurement. These tracking codes for performance measurement decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other healthcare professionals. These codes are intended to facilitate data collection about quality of care by coding certain services

to be supplemented to identify specific circumstances that may apply to an item or service. For example, a UE modifier is often used when the item identified by a HCPCS code is "used equipment," a NU modifier is used for "new equipment." The level II HCPCS modifiers are either alpha-numeric or two letters.


CPT Category II Codes - We are aware that CPT Category II codes are supplemental tracking codes used for performance measurement. These tracking codes for performance measurement decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that

to be supplemented to identify specific circumstances that may apply to an item or service. For example, a UE modifier is often used when the item identified by a HCPCS code is "used equipment," a NU modifier is used for "new equipment." The level II HCPCS modifiers are either alpha-numeric or two letters.


CPT Category II Codes - We are aware that CPT Category II codes are supplemental tracking codes used for performance measurement. These tracking codes for performance measurement decrease the need for record abstraction and chart review, and thereby minimize administrative burdens on physicians and other health care professionals. These codes are intended to facilitate data collection about quality of care by coding certain services and/or test results that


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and/or test results that support performance measures and that have been agreed upon as contributing to good patient care. CPT II codes are maintained and updated by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel. The PMAG comprises performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement. The International Classification of Diseases, Clinical Modification, currently in its ninth revision (ICD-9-CM), is used to describe and report the illnesses, conditions, and injuries of patients who require medical services. ICD-9-CM is made up of a series of numerical and

support performance measures and that have been agreed upon as contributing to good patient care. CPT II codes are maintained and updated by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel. The PMAG comprises performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement. The International Classification of Diseases, Clinical Modification, currently in its ninth revision (ICD-9-CM), is used to describe and report the illnesses, conditions, and injuries of patients who require medical services. ICD-9-CM is made up of a series of numerical and alphanumerical codes

support performance measures and that have been agreed upon as contributing to good patient care. CPT II codes are maintained and updated by the Performance Measures Advisory Group (PMAG), an advisory body to the CPT Editorial Panel. The PMAG comprises performance measurement experts representing the Agency of Healthcare Research and Quality (AHRQ), the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Committee for Quality Assurance (NCQA) and the Physician Consortium for Performance Improvement. The International Classification of Diseases, Clinical Modification, currently in its ninth revision (ICD-9-CM), is used to describe and report the illnesses, conditions, and injuries of patients who require medical services. ICD-9-CM is made up of a series of numerical and alphanumerical codes


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alphanumerical codes and code descriptions that represent very specific illnesses and injuries. Similarly, the services provided by physicians and other healthcare professionals are described and reported by using terminologies and classification systems. The International Classification of Diseases, Clinical Modification, provides a system for coding medical procedures performed in the inpatient departments of hospitals, but two other systems apply to the services provided by physicians and other medical providers in hospital-based outpatient departments, physicians’ offices, and other ambulatory settings: the Current Procedural Terminology and the Healthcare Common Procedure Coding System.

and code descriptions that represent very specific illnesses and injuries. Similarly, the services provided by physicians and other healthcare professionals are described and reported by using terminologies and classification systems. The International Classification of Diseases, Clinical Modification, provides a system for coding medical procedures performed in the inpatient departments of hospitals, but two other systems apply to the services provided by physicians and other medical providers in hospital-based outpatient departments, physicians’ offices, and other ambulatory settings: the Current Procedural Terminology and the Healthcare Common Procedure Coding System.

and code descriptions that represent very specific illnesses and injuries. Similarly, the services provided by physicians and other healthcare professionals are described and reported by using terminologies and classification systems. The International Classification of Diseases, Clinical Modification, provides a system for coding medical procedures performed in the inpatient departments of hospitals, but two other systems apply to the services provided by physicians and other medical providers in hospital-based outpatient departments, physicians’ offices, and other ambulatory settings: the Current Procedural Terminology and the Healthcare Common Procedure Coding System.

17.5.4.6 The CCN shall have the capability to convert all information that enters its claims system via hard copy paper claims to electronic encounter data, to be submitted in the appropriate HIPAA compliant formats to DHH’s FI.

In each of the three states we selected (in fact in each of our states) we have the capability and capacity to convert all the claim information received via hard copy “paper” claims to electronic claims using Optical Character Recognition (OCR) technology. All paper




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claims are converted to electronic images by our vendor (EMDEON– using their Alchemy program). If the claim cannot be translated into an electronic data record by the OCR process, then the paper claims is sent directly to our claims department for data entry. Each claim is assigned a unique claim number and an electronic file of the claim is created. This file is uploaded into QNXT™ to be accessed by the claims team. The paper claim is in the QNXT™ system within 1 to 3 business days from its receipt. Additionally, the scanned image of the paper claim is stored in an image repository and is viewable to Aetna Better Health personnel, as needed. In addition, Microsoft BizTalk with HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, allowing Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Microsoft BizTalk with HIPAA Accelerator™ is a data transformation application that translates data to and




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from the full spectrum of HIPAA Transactions sets in a highly customizable, flexible, and robust server-based environment. Moreover, Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the Transactions sets are updated over time. Also, Foresight HIPAA Validator™ InStream™ a fully functional HIPAA editing and validation application. It can validate HIPAA transactions through all seven levels of edits as defined by the Workgroup for Electronic Data Interchange and Strategic National Implementation Process (WEDI/SNIP), has all standard HIPAA code sets embedded, and can support custom, trading-partner-specific companion guides and validation requirements. In addition, it supports validation at the individual edit level, allowing Aetna Better Health to accept all compliant records that pass at a lower level of




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edit, rather than requiring all seven levels of edits. The application also provides descriptive error reports to submitters to facilitate quick error resolution.



17.5.4.11 Due to the need for timely data and to maintain integrity of processing sequence, the CCN shall address any issues that prevent processing of an encounter; acceptable standards shall be ninety percent (90%) of reported repairable errors are addressed within thirty (30) calendar days and ninety-nine percent (99%) of reported repairable errors within sixty (60) calendar days or within a negotiated timeframe approved by DHH. Failure to promptly research and address reported errors, including submission of and compliance with an acceptable corrective action plan may result in monetary penalties.

We understand and agree to this stipulation. The state Medicaid agencies regulating the three health plans we selected as an example have similar requirements; in fact, it is our experience that this is a common stipulation. For the twelve months ending May 1, 2011, our encounter acceptance rates are as follows: Delaware: Professional 98.13% - Institutional 99.97 Florida: Professional 99.00% - Institutional 98.72 -NCPDP 98.00% Maryland: Professional 98.62% - Institutional 98.72%



17.5.4.12 For encounter data submissions, the CCN shall submit ninety-five (95%) of its encounter data at least monthly due no later than the twenty-fifth (25th) calendar day of the month following the month in which they were processed and approved/paid, including encounters reflecting a zero dollar amount ($0.00) and encounters in which the CCN

We understand and agree to this stipulation. The state Medicaid agencies regulating the three health plans we selected as an example have similar requirements; in fact, it is our experience that this is a common stipulation.




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has a capitation arrangement with a provider. The CCN CEO or CFO shall attest to the truthfulness, accuracy, and completeness of all encounter data submitted.

For the twelve months ending May 1, 2011, our encounter acceptance rates are as follows: Delaware: Professional 98.13% - Institutional 99.97 Florida: Professional 99.00% - Institutional 98.72 -NCPDP 98.00% Maryland: Professional 98.62% - Institutional 98.72%



17.5.4.13 The CCN shall ensure that all encounter data from a contractor is incorporated into a single file from the CCN. The CCN shall not submit separate encounter files from CCN contractors.




17.5.4.14 The CCN shall ensure that files contain settled claims and claim adjustments or voids, including but not limited to, adjustments necessitated by payment errors, processed during that payment cycle, as well as encounters processed during that payment cycle from providers with whom the CCN has a capitation arrangement.





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Connectivity Functionality/Requirement


16.3.1. DHH is requiring that the CCN interface with DHH, the Medicaid Fiscal Intermediary (FI), the Enrollment Broker (EB) and its trading partners. The CCN must have capacity for real time connectivity to all DHH approved systems.

16.3.2. The System shall conform and adhere to the data and document management standards of DHH and its FI, inclusive of standard transaction code sets. 16.3.3. The CCN’s Systems shall utilize mailing address standards in accordance with the United States Postal Service. 16.3.4. At such time that DHH requires, the CCN shall participate and cooperate with DHH to implement, within a reasonable timeframe, a secure, web-accessible health record for members, such as Personal Health Record (PHR) or Electronic Health Records (EHR).

16.3.5. At such time that DHH requires, the CCN shall participate in statewide efforts to incorporate all hospital, physician, and other provider information into a statewide health information exchange.

16.3.6. The CCN shall meet, as requested by DHH, with work groups or committees to coordinate activities and develop system strategies that actively reinforce the healthcare reform initiative.

Meet Aetna Better Health maintains interface with the Medicaid single-state agency, its MMIS vendor, FI and EB as required. This connectivity is real time and meets the specifications of the Medicaid single-state agency. Our QNXT™ system conforms to the data and document management standards of the Medicaid single-state agency, its MMIS vendor, FI and EB. Aetna Better Health fulfillment house uses U.S. Postal approved software for mailing address standardization in accordance with U.S. Postal regulations. Aetna Better Health understands, acknowledges and agrees to this requirement. We will participate and cooperate as required. We have experience in these areas and are interested in supporting DHH in its efforts. Aetna Better Health understands, acknowledges and agrees to this requirement. We will participate and cooperate as required.




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Connectivity Functionality/Requirement


16.3.7. All information, whether data or documentation and reports that contain or references to that information involving or arising out of the Contract is owned by DHH. The CCN is expressly prohibited from sharing or publishing DHH’s information and reports without the prior written consent of DHH. In the event of a dispute regarding the sharing or publishing of information and reports, DHH’s decision on this matter shall be final.

16.3.9. The CCN shall be responsible for all initial and recurring costs required for access to DHH system(s), as well as DHH access to the CCN’s system(s). These costs include, but are not limited to, hardware, software, licensing, and authority/permission to utilize any patents, annual maintenance, support, and connectivity with DHH, the Fiscal Intermediary (FI) and the Enrollment Broker.

16.3.10. The CCN shall complete an Information Systems Capabilities Assessment (ISCA), which will be provided by DHH. The ISCA shall be completed and returned to DHH no later than thirty (30) days from the date the CCN signs the Contract with DHH.

We have experience in these areas and are interested in supporting DHH in its efforts. Aetna Better Health understands, acknowledges and agrees to this requirement. We will participate and cooperate as required. We have experience in these areas and are interested in supporting DHH in its efforts. Aetna Better Health understands, acknowledges and agrees to this requirement. Aetna Better Health understands, acknowledges and agrees to this requirement. Aetna Better Health understands, acknowledges and agrees to this requirement.




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Challenges and Lessons Learned Implementing a new IT and data management system, including establishing connectivity for the exchange of information between a Medicaid single-state agency and its MMIS vendor, FI and EB especially with a Medicaid State Agency that is new to managed care, can be a challenge. There are three primary lessons we have learned ass a result of the last three Medicaid managed care implementations. These are:

1) There must be open communication between DHH’s FI and Aetna Better Health on the implementation. The old cliché is “if you’ve seen one Medicaid program, you’ve seen one Medicaid program” also applies to Medicaid managed care health plans and their encounter systems. Aetna Better Health is fully committed to aligning its IT and data management system, including establishing connectivity for the exchange of information to meet the needs of DHH, its FI and EB. However, due to the complexity of IT and data management system, including processes to establish connectivity for the exchange of information between systems we recommend there be frequent and meaningful communication regarding design, development, implementation, and testing. We have discovered that regularly scheduled meeting between with the Medicaid agency and their agent (FI) and the CCN is one of the most meaningful communication methods. This way both parties can ask questions, review incremental test results and provide insight and direction. To facilitate these meetings and support communication we further recommend that DHH’s FI assign a project manager or equivalent level professional to work with each CCN. This will help avoid unnecessary confusion or errors.

2) DHH and its FI should set realistic IT and data management system, including connectivity for the exchange of information system development and testing timeline and goals. These timelines and goals should be as stable as possible once the development and testing process begins.

3) DHH and its FI should, once the development and testing process begins, avoid adjusting IT and data management system, including data exchange connectivity requirements, program design elements, reports and coding specifications. Stability in the design environment is critical to remain on target for quality and timeliness of development and testing.

Aetna Better Health is aware that changes in the timeline, requirements, design, reporting and coding are inevitable in a project of this size and complexity. The impact on the quality, timeframe and cost can be mitigated by working together and through close communication. Our QNXT™ system is responsive and flexible to meet DHH’s needs and requirements. This system provides a state-of-the-art platform that can keep pace with the multiple enhancements that are expected as healthcare reform is implemented.

Aetna Better Health will assign an IT and data management system, including expertise to establish connectivity for the exchange of information development team to the Louisiana CCN implementation. This development team will be led by a senior manager of our organization and include representatives of our key operational units responsible for IT and data management system and connectivity for the exchange of information. Included on this team will be veterans from our last three implementations that will offer insight, knowledge and experience to DHH and its FI.


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124 R.7



R.7 Describe the ability within your systems to meet (or exceed) each of the requirements in Section §16. Address each requirement. If you are not able at present to meet a particular requirement contained in the aforementioned section, identify the applicable requirement and discuss the effort and time you will need to meet said requirement.

Aetna Better Health and its affiliates have been implementing Medicaid managed care information systems for over 25 years. Today, Aetna Better Health administers or manages Medicaid health plans providing coverage to over 1.3 million members in 10 states. Well aware of the role sound, reliable information plays in effective healthcare administration, Aetna Better Health maintains robust processes safeguarding the integrity, validity and completeness of the information we provide to DHH, its Fiscal Intermediary and Enrollment Broker.

Aetna Better Health meets the requirements as specified in § 16 and shall continue to meet these requirements.


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s

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irem

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Meet

s or

Exce

eds

Expl

anat

ion

16 S

yste

ms a

nd T

echn

ical R

equi

rem

ents

16

.1 Ge

nera

l Req

uire

men

ts

16.1.

1 The

CCN

shall

main

tain a

n auto

mated

Man

agem

ent In

forma

tion

Syste

m (M

IS),

here

after

refer

red t

o as S

ystem

, whic

h acc

epts

and

proc

esse

s pro

vider

claim

s, ve

rifies

eligi

bility

, coll

ects

and r

epor

ts en

coun

ter da

ta an

d vali

dates

prior

autho

rizati

on an

d pre

-certif

icatio

n tha

t co

mplie

s with

DHH

and f

eder

al re

portin

g req

uirem

ents.

The

CCN

shall

en

sure

that

its S

ystem

mee

ts the

requ

ireme

nts of

the C

ontra

ct, st

ate

issue

d Guid

es (S

ee C

CN-P

Sys

tems G

uide)

and a

ll app

licab

le sta

te an

d fed

eral

laws,

rules

and r

egula

tions

, inclu

ding M

edica

id co

nfide

ntiali

ty an

d HI

PAA

and A

meric

an R

ecov

ery a

nd R

einve

stmen

t Act

(ARR

A) pr

ivacy

an

d sec

urity

requ

ireme

nts.

Meets

16.1.

2 The

CCN

’s ap

plica

tion s

ystem

s fou

ndati

on sh

all em

ploy t

he

relat

ional

data

mode

l in its

datab

ase a

rchite

cture

, whic

h wou

ld en

tail th

e uti

lizati

on of

a re

lation

al da

tabas

e man

agem

ent s

ystem

(RDB

MS) s

uch

as O

racle

®, D

B2®,

or S

QL S

erve

r®. It

is im

porta

nt tha

t the C

CN’s

appli

catio

n sys

tems s

uppo

rt qu

ery a

cces

s usin

g Stru

cture

d Que

ry La

ngua

ge (S

QL).

Othe

r stan

dard

conn

ector

tech

nolog

ies, s

uch a

s Ope

n Da

tabas

e Con

necti

vity (

ODBC

) and

/or O

bject

Linkin

g and

Emb

eddin

g (O

LE),

are d

esira

ble.

Meets

16.1.

3 All t

he C

CN’s

appli

catio

ns, o

pera

ting s

oftwa

re, m

iddlew

are,

and

netw

orkin

g har

dwar

e and

softw

are s

hall b

e able

to in

terop

erate

as

need

ed w

ith D

HH’s

syste

ms an

d sha

ll con

form

to ap

plica

ble st

anda

rds

and s

pecif

icatio

ns se

t by D

HH.

Meets

The d

esign

goal

for A

etna B

etter

Hea

lth’s

infor

matio

n sys

tem is

to us

e po

werfu

l, reli

able,

and e

xpan

dable

data

proc

essin

g sys

tems.

The

fou

ndati

on of

this

platfo

rm is

a re

dund

ant, h

igh sp

eed L

ocal

Area

Ne

twor

k (LA

N) an

d Wide

Are

a Netw

ork (

WAN

) and

clus

tering

of

serve

rs to

build

-in re

dund

ancy

. This

appr

oach

prov

ides 1

00 pe

rcent

uptim

e for

all c

ore b

usine

ss sy

stems

in 20

10. A

etna B

etter

Hea

lth’s

netw

ork i

nfras

tructu

re co

nsist

s enti

rely

of Ci

sco r

outer

s, sw

itche

s, an

d fire

walls

. Cisc

o stan

dard

izatio

n pro

vides

max

imum

latitu

de in

eq

uipme

nt co

nfigu

ratio

ns. C

isco r

outer

s sup

port

our M

PLS

netw

ork,

exter

nal tr

affic

to the

Inter

net, a

nd co

nnec

tions

to ot

her p

rivate

ne

twor

ks. C

ore b

usine

ss ap

plica

tions

run o

n Hew

lett P

acka

rd B

L 460

se

rvers.

Eac

h ser

ver is

equip

ped w

ith a

minim

um of

two q

uad-

core

Int

el pr

oces

sors

and 8

GB of

RAM

. App

licati

ons l

oade

d on t

he se

rver

pools

acce

ss da

ta on

high

-end

datab

ase s

erve

rs ru

nning

on th

e He

wlett

Pac

kard

’s BL

685 p

latfor

m an

d are

confi

gure

d with

24 co

res

and 9

6 giga

bytes

of R

AM. T

hese

64-b

it data

base

serve

rs att

ach t

o Hi

tachi

stora

ge ar

rays

via B

roca

de sw

itche

s. Th

is se

rver c

onfig

urati

on

will p

rovid

e all n

eces

sary

comp

uting

powe

r, re

dund

ancy

, and

sc

alabil

ity to

mee

t both

enro

llmen

t gro

wth a

nd an

incre

ase i

n re

quire

ments

. Aetn

a Bett

er H

ealth

is ab

le to

add s

erve

rs to

the cl

uster

to

incre

ase p

erfor

manc

e ver

ticall

y, an

d ser

vers

can a

ccep

t incre

ases

in

RAM

and p

roce

ssing

powe

r to g

row

horiz

ontal

ly. T

his sc

alabil

ity

allow

s sys

tems t

o matc

h any

esca

lation

in de

mand

asso

ciated

with

DH

H’s/A

etna B

etter

Hea

lth’s

perfo

rman

ce re

quire

ments

, whil

e at th

e sa

me tim

e main

tainin

g sys

tem up

time a

nd pe

rform

ance

. Netw

ork

traffic

and u

sers

acce

sses

to th

e cor

e app

licati

on ar

e loa

d bala

nced


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Meet

s or

Exce

eds

Expl

anat

ion

16.1.

4 The

CCN

’s Sy

stem

shall

have

, and

main

tain,

capa

city s

uffici

ent to

ha

ndle

the w

orklo

ad pr

ojecte

d for

the b

egin

date

of op

erati

ons a

nd sh

all

be sc

alable

and f

lexibl

e so t

hat it

can b

e ada

pted a

s nee

ded,

withi

n ne

gotia

ted tim

efram

es, in

resp

onse

to ch

ange

s in t

he C

ontra

ct re

quire

ments

.

Meets

by

f5 G

lobal

Load

Bala

ncing

servi

ces.

Aetna

Bett

er H

ealth

’s me

mber

se

rvice

s call

cente

r run

s on a

n Aetn

a Med

icaid-

supp

lied A

vaya

S85

00

IP sw

itch,

which

main

tains

20 pe

rcent

extra

capa

city t

o cov

er an

y sp

ikes a

nd gr

owth

spur

ts.

Appli

catio

ns lo

aded

on th

e ser

ver p

ool a

cces

s data

from

high

-end

da

tabas

e ser

vers.

The

se 64

-bit,

Itaniu

m cla

ss da

tabas

e ser

vers

attac

h to E

MC an

d HP

stora

ge ar

rays

via B

roca

de sw

itche

s. Th

is se

rver c

onfig

urati

on w

ill pr

ovide

all n

eces

sary

comp

uting

powe

r, re

dund

ancy

, and

scala

bility

to m

eet b

oth en

rollm

ent g

rowt

h and

an

incre

ase i

n req

uirem

ents

Aetna

Bett

er H

ealth

is ab

le to

add s

erve

rs to

the cl

uster

to in

creas

e per

forma

nce v

ertic

ally,

and s

erve

rs ca

n acc

ept

incre

ases

in R

AM an

d pro

cess

ing po

wer t

o gro

w ho

rizon

tally.

This

sc

alabil

ity al

lows s

ystem

s to m

atch a

ny es

calat

ion in

dema

nd

asso

ciated

with

DHH

’/ Aetn

a Bett

er H

ealth

’s pe

rform

ance

re

quire

ments

, whil

e at th

e sam

e tim

e main

tainin

g sys

tem up

time a

nd

perfo

rman

ce. N

etwor

k tra

ffic an

d use

rs ac

cess

es to

the c

ore

appli

catio

n are

load

balan

ced b

y f5 G

lobal

Load

Bala

ncing

servi

ces.

Aetna

Bett

er H

ealth

’s Me

mber

Ser

vices

call c

enter

runs

on an

Aetn

a Me

dicaid

-supp

lied A

vaya

S85

00 IP

switc

h, wh

ich m

aintai

ns 20

pe

rcent

extra

capa

city t

o cov

er an

y spik

es an

d gro

wth s

purts

. Ae

tna M

edica

id’s m

anag

emen

t wor

ks w

ith A

etna B

etter

Hea

lth’s

Infor

matio

n Man

agem

ent a

nd S

ystem

s Dire

ctor t

o dev

elop a

nd

maint

ain w

ritten

polic

ies, p

roce

dure

s, an

d job

desc

riptio

ns ne

cess

ary

to “lo

ck in

” sys

tem an

d ope

ratio

nal im

prov

emen

ts. A

nnua

l revie

ws

then v

erify

polic

y and

proc

edur

es’ (P

&Ps)

conti

nued

agre

emen

t with

cu

rrent

prac

tices

. Ae

tna M

edica

id ha

s eng

aged

KPM

G sin

ce 20

00 to

perfo

rm S

AS 70

au

dits,

includ

ing O

pera

ting E

ffecti

vene

ss fo

r Clai

ms P

roce

ssing

Co

ntrols

and R

elated

Gen

eral

Comp

uter C

ontro

ls. A

ll aud

it rep

orts

have

refle

cted u

nbias

ed op

inion

s.


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s

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irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

Syste

m de

scrip

tion:

QNXT

™ -

At th

e cor

e of A

etna M

edica

id’s a

pplic

ation

arch

itectu

re is

QN

XT™

, a ru

les-b

ased

infor

matio

n pro

cess

ing sy

stem

comp

rising

28

integ

rated

mod

ules t

hat m

aintai

n the

follo

wing

:

• Cl

aims d

ata, in

cludin

g ass

ociat

ed ad

judica

tion,

COB

and T

PL

proc

esse

s •

Demo

grap

hic, e

ligibi

lity an

d enr

ollme

nt da

ta, in

cludin

g prio

r co

vera

ge

• Pr

ovide

r con

tract

confi

gura

tion,

includ

ing ne

twor

k and

servi

ces

• ED

I pro

cess

es

• QM

/UM

includ

ing, b

ut no

t limi

ted to

Prio

r Auth

oriza

tions

and

conc

urre

nt re

views

QN

XT™

leve

rage

s Micr

osoft

’s .N

ET ar

chite

cture

, pro

viding

for f

lexibl

e, sc

alable

, and

seam

less s

ystem

s inte

grati

on. In

addit

ion, th

e sys

tem’s

found

ation

al da

tabas

e is M

icros

oft’s

SQL S

erve

r, pe

rmitti

ng a

wide

va

riety

of ap

plica

tions

to an

alyze

the d

ata, d

isplay

resu

lts, a

nd pr

int

stand

ardiz

ed an

d cus

tomize

d rep

orts.

Th

e cor

nerst

one o

f Aetn

a Med

icaid’

s clai

ms ad

judica

tion p

roce

ss,

QNXT

™ ac

cepts

– via

the s

uppo

rting t

echn

ical in

terfac

es –

DHH’

Da

ily E

nroll

ment

and M

anua

l Pay

ment

Tran

sacti

on fil

es’, a

nd th

en

upda

tes ou

r mem

ber r

ecor

ds ac

cord

ingly.

Auto

mated

proc

esse

s re

conc

ile Q

NXT™

’s re

siden

t mem

ber f

iles w

ith D

HH’ m

onthl

y upd

ate

reco

rding

the r

esult

s for

DHH

’ revie

w sh

ould

it be n

eces

sary.

Aetn

a Be

tter H

ealth

’s en

rollm

ent te

am th

en va

lidate

s the

data

for ac

cura

cy,

audit

ing re

levan

t files

and r

eview

ing an

y res

ultan

t fallo

ut re

ports

. Sh

ould

the pr

oces

s brin

g any

erro

rs to

light,

enro

llmen

t per

sonn

el pr

omptl

y noti

fy DH

H’ In

forma

tion S

ervic

es D

ivisio

n and

wor

k the

issu

e to

reso

lution

. Enr

ollme

nt pe

rsonn

el the

n res

ume p

ostin

g of d

aily

upda

tes, b

eginn

ing w

ith th

e las

t two d

ays o

f the m

onth.


120

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

QNXT

™ us

es w

eekly

down

loads

of pr

ovide

r data

from

DHH

’s se

cure

FT

P se

rver t

o upd

ate A

etna B

etter

Hea

lth’s

prov

ider f

iles.

Enro

llmen

t pe

rsonn

el the

n use

unas

signe

d enr

ollme

nt re

ports

to ve

rify ea

ch

memb

er’s

assig

nmen

t to an

indiv

idual

PCP/

PCMH

, our

PCP

/PCM

H as

signm

ent fi

le is

as cu

rrent

and c

omple

te as

poss

ible.

Syste

m qu

eries

iden

tify ne

w en

rollm

ents

and g

ener

ate w

elcom

e lett

ers

acco

rding

ly. T

hese

are a

dded

to ne

w me

mber

welc

ome p

acke

ts,

which

are d

elive

red b

y mem

bers’

assig

ned C

ase M

anag

er (C

M).

Upda

ted da

te-se

nsitiv

e PCP

assig

nmen

t infor

matio

n is a

vaila

ble to

DH

H in

electr

onic

forma

t upo

n req

uest.

QNXT

™ su

ppor

ts au

tomati

on of

routi

ng pr

oces

ses,

thus i

ntrod

ucing

im

prov

ed ef

ficien

cies a

nd ac

cura

cy to

the a

djudic

ation

proc

ess.

For

exam

ple, th

ree-

tier lo

gic m

atche

s clai

ms an

d auth

oriza

tions

base

d on

criter

ia su

ch as

mem

ber,

prov

ider,

servi

ce co

de, a

nd da

tes of

servi

ce.

The s

ystem

autom

atica

lly de

ducts

claim

ed se

rvice

s fro

m au

thoriz

ed

units

, thus

redu

cing t

he ne

ed fo

r man

ual a

ffiliat

ion by

claim

s ana

lysts.

Seve

ral a

pplic

ation

s com

plime

nt QN

XT™

’s cla

ims p

roce

ssing

fun

ction

ality.

The

first,

iHea

lth, e

nforce

s sele

ct pa

ymen

t poli

cies f

rom

one o

f the i

ndus

try’s

most

comp

rehe

nsive

corre

ct co

ding a

nd m

edica

l po

licy c

onten

t libr

aries

. The

seco

nd, M

cKes

son’s

Clai

mCh

eck® ,

expa

nds u

pon t

hose

capa

bilitie

s by a

llowi

ng cl

aims l

eade

rship

to de

fine a

nd co

mbine

spec

ific cl

aims d

ata cr

iteria

, suc

h as p

rovid

er or

dia

gnos

is, to

set u

p uniq

ue ed

its th

at de

liver

enha

nced

audit

ing

powe

r. Fin

ally,

Medic

al Da

ta Ex

pres

s’ (M

DE) O

utpa

tient

Fac

ility

Serv

ices P

ricer

supp

orts

the pr

icing

and c

orre

ction

of ou

tpatie

nt ho

spita

l clai

ms.

As th

e sys

tem of

reco

rd fo

r our

mem

bers’

demo

grap

hic, c

apita

tion,

PCP/

PCMH

, and

eligi

bility

and e

nroll

ment

data,

QNX

T™ se

rves a

s the

pr

imar

y sou

rce of

data

for m

ultipl

e app

licati

ons,

includ

ing ou

r web

-ba

sed c

are m

anag

emen

t bus

iness

appli

catio

n (Dy

namo

™) o

ur


121

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

princ

ipal m

embe

r and

Med

ical M

anag

emen

t app

licati

on, V

ision

Pro

and E

MS. O

ur sy

stems

data

flow,

prov

ided a

t the e

nd of

this

secti

on,

illustr

ates h

ow th

e exc

hang

e of d

ata be

twee

n the

se sy

stems

, and

thr

ough

out o

ur or

ganiz

ation

, add

ress

es th

e nee

ds of

our D

HH

memb

ers.

16.2

HIPA

A St

anda

rds a

nd C

ode S

ets

16.2.

1 The

Sys

tem sh

all be

able

to tra

nsmi

t, rec

eive a

nd pr

oces

s data

in

curre

nt HI

PAA-

comp

liant

or D

HH sp

ecific

form

ats an

d/or m

ethod

s, inc

luding

, but

not li

mited

to, s

ecur

e File

Tra

nsfer

Pro

tocol

(FTP

) ove

r a

secu

re co

nnec

tion s

uch a

s a V

irtual

Priva

te Ne

twor

k (VP

N), th

at ar

e in

use a

t the s

tart o

f Sys

tems r

eadin

ess r

eview

activ

ities.

Data

eleme

nts

and f

ile fo

rmat

requ

ireme

nts m

ay be

foun

d in t

he C

CN-P

Sys

tems

Comp

anion

Guid

e.

Meets

16.2.

2 All H

IPAA

-confo

rming

exch

ange

s of d

ata be

twee

n DHH

and t

he

CCN

shall

be su

bjecte

d to t

he hi

ghes

t leve

l of c

ompli

ance

as m

easu

red

using

an in

dustr

y-stan

dard

HIP

AA co

mplia

nce c

heck

er. T

he H

IPAA

Bu

sines

s Ass

ociat

e Agr

eeme

nt (A

ppen

dix C

) sha

ll bec

ome a

part

of the

Co

ntrac

t.

Meets

16.2.

3 The

Sys

tem sh

all co

nform

to th

e foll

owing

HIP

AA-co

mplia

nt sta

ndar

ds fo

r infor

matio

n exc

hang

e. Ba

tch tr

ansa

ction

type

s inc

lude,

but

are n

ot lim

ited t

o, the

follo

wing

:

Meets

16.2.

3.1. A

SC X

12N

834 B

enefi

t Enr

ollme

nt an

d Main

tenan

ce

Meets

16

.2.3.2

. ASC

X12

N 83

5 Clai

ms P

ayme

nt Re

mitta

nce A

dvice

Tr

ansa

ction

Me

ets

16.2.

3.3. A

SC X

12N

837I

Institu

tiona

l Clai

m/En

coun

ter T

rans

actio

n Me

ets

Aetn

a Be

tter H

ealth

’s m

anag

emen

t info

rmat

ion sy

stem

curre

ntly

supp

orts

DHH’

s req

uired

tech

nical

inter

face

s and

com

plies

with

all

appli

cable

requ

irem

ents

of th

e Hea

lth In

sura

nce

Porta

bility

and

Ac

coun

tabil

ity A

ct (H

IPAA

). W

e ar

e, an

d wi

ll con

tinue

to b

e,

resp

onsiv

e, w

ithin

a rea

sona

ble tim

efra

me,

to a

ny a

nd a

ll ad

justm

ents

or m

odific

ation

s to f

utur

e HIP

AA pr

oced

ures

, poli

cies,

rules

and

stat

utes

that

may

be r

equir

ed d

uring

the t

erm

of o

ur

cont

ract.

Our

man

agem

ent in

form

ation

syste

m co

nfigu

ratio

n su

ppor

ts mi

grat

ion fr

om o

ne H

IPAA

vers

ion to

ano

ther

in th

e fol

lowing

way

s: •

Micr

osof

t BizT

alk w

ith H

IPAA

Acc

elera

tor™

proc

esse

s HIP

AA-

com

plian

t tra

nsac

tions

eas

ily an

d ef

ficien

tly, e

nabli

ng A

etna

Be

tter H

ealth

to a

ccep

t infor

matio

n ele

ctron

ically

from

alm

ost

any H

IPAA

-com

plian

t con

tracto

r or p

rovid

er.

Acce

lerat

or h

as

the

Was

hingt

on P

ublis

hing

Com

pany

(WPC

) Im

plem

enta

tion

Guide

sche

mas f

or e

ach H

IPAA

ANS

I X12

tran

sacti

on

embe

dded

dire

ctly i

nto i

ts ap

plica

tion

engin

e, in

cludin

g a f

acilit

y to

upda

te th

ese s

chem

as a

utom

atica

lly a

s the

tran

sacti

on se

ts ar

e up

date

d ov

er tim

e.

• Fo

resig

ht H

IPAA

Vali

dato

r™ In

Stre

am™

is a

fully

func

tiona

l HI

PAA

editin

g an

d va

lidat

ion a

pplic

ation

. It

valid

ates

HIP

AA

trans

actio

ns th

roug

h all

seve

n lev

els o

f edit

s as d

efine

d by

the


122

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.2.

3.4. A

SC X

12N

837P

Pro

fessio

nal C

laim/

Enco

unter

Tra

nsac

tion

Meets

16.2.

3.5. A

SC X

12N

270/2

71 E

ligibi

lity/B

enefi

t Inqu

iry/R

espo

nse;

Will

Meet

16.2.

3.6. A

SC X

12N

276 C

laims

Stat

us In

quiry

Me

ets

16.2.

3.7. A

SC X

12N

277 C

laims

Stat

us R

espo

nse

Meets

16

.2.3.8

. ASC

X12

N 27

8 Utili

zatio

n Rev

iew In

quiry

/Res

pons

e Me

ets

16.2.

3.9. A

SC X

12N

820 P

ayro

ll Ded

ucted

and O

ther G

roup

Pre

mium

Pa

ymen

t for I

nsur

ance

Pro

ducts

. Me

ets

16.2.

4 The

CCN

shall

not r

evise

or m

odify

the s

tanda

rdize

d for

ms or

for

mats.

Me

ets

16.2.

5 Tra

nsac

tion t

ypes

are s

ubjec

t to ch

ange

and t

he C

CN sh

all

comp

ly wi

th ap

plica

ble fe

dera

l and

HIP

AA st

anda

rds a

nd re

gulat

ions a

s the

y occ

ur.

Meets

16.2.

6 The

CCN

shall

adhe

re to

natio

nal s

tanda

rds a

nd st

anda

rdize

d ins

tructi

ons a

nd de

finitio

ns th

at ar

e con

sisten

t with

indu

stry n

orms

that

are d

evelo

ped j

ointly

with

DHH

. The

se sh

all in

clude

, but

not b

e lim

ited t

o, HI

PAA

base

d stan

dard

s, fed

eral

safeg

uard

requ

ireme

nts in

cludin

g sig

natur

e req

uirem

ents

desc

ribed

in th

e CMS

Stat

e Med

icaid

Manu

al.

Meets

Wor

kgro

up fo

r Elec

tronic

Dat

a Int

erch

ange

and

Stra

tegic

Na

tiona

l Imple

men

tation

Pro

cess

(WED

I/SNI

P), h

as al

l sta

ndar

d HI

PAA

code

sets

embe

dded

, and

can s

uppo

rt cu

stom,

tra

ding-

partn

er-s

pecif

ic co

mpa

nion

guide

s and

valid

ation

re

quire

men

ts. T

he a

pplic

ation

also

prov

ides d

escr

iptive

erro

r re

ports

to su

bmitte

rs to

facil

itate

quic

k erro

r res

olutio

n.

Aetn

a Be

tter H

ealth

follo

ws th

e St

rate

gic N

ation

al Im

plem

enta

tion

Proje

ct (S

NIP)

reco

mmen

datio

ns fo

r tes

ting

crea

ted

by th

e W

orkg

roup

for E

lectro

nic D

ata I

nter

chan

ge (W

EDI),

furth

er

prom

oting

syste

m co

mpli

ance

with

fede

ral IT

man

date

s. To

dat

e no

ne o

f our

Med

icaid

single

-sta

te a

genc

ies w

here

we

hold

cont

racts

has

requ

ired

ASC

X12N

270/2

71 E

ligibi

lity/B

enefi

t Inq

uiry/R

espo

nse s

o this

HIP

AA in

forma

tion e

xcha

nge p

roce

ss is

un

avail

able

until

the fo

urth

quar

ter of

2011

. Aetn

a Bett

er H

ealth

does

no

t exp

ect m

eetin

g this

requ

ireme

nt to

be a

signif

icant

effor

t and

will

be re

ady t

o tes

t tran

sacti

ons u

sing H

IPAA

proc

ess b

y or b

efore

sy

stem

read

iness

revie

w.

16.3

Conn

ectiv

ity

16.3.

1 DHH

is re

quirin

g tha

t the C

CN in

terfac

e with

DHH

, the M

edica

id Fis

cal In

terme

diary

(FI),

the E

nroll

ment

Brok

er (E

B) an

d its

tradin

g pa

rtner

s. Th

e CCN

mus

t hav

e cap

acity

for r

eal ti

me co

nnec

tivity

to al

l DH

H ap

prov

ed sy

stems

.

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

unde

rstan

ds th

ese

requ

ireme

nts. A

etna B

etter

Hea

lth w

ill me

et Ae

tna B

etter

Hea

lth’s

spec

ificati

ons a

nd co

mply

with

each

of th

e req

uirem

ents

in thi

s se

ction

.


123

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.3.

2 The

Sys

tem sh

all co

nform

and a

dher

e to t

he da

ta an

d doc

umen

t ma

nage

ment

stand

ards

of D

HH an

d its

FI, in

clusiv

e of s

tanda

rd

trans

actio

n cod

e sets

.

Meets

16.3.

3 The

CCN

’s Sy

stems

shall

utiliz

e mail

ing ad

dres

s stan

dard

s in

acco

rdan

ce w

ith th

e Unit

ed S

tates

Pos

tal S

ervic

e. Me

ets

16.3.

4 At s

uch t

ime t

hat D

HH re

quire

s, the

CCN

shall

partic

ipate

and

coop

erate

with

DHH

to im

pleme

nt, w

ithin

a rea

sona

ble tim

efram

e, a

secu

re, w

eb-a

cces

sible

healt

h rec

ord f

or m

embe

rs, su

ch as

Per

sona

l He

alth R

ecor

d (PH

R) or

Elec

tronic

Hea

lth R

ecor

ds (E

HR).

Meets

16.3.

5 At s

uch t

ime t

hat D

HH re

quire

s, the

CCN

shall

partic

ipate

in sta

tewide

effor

ts to

incor

pora

te all

hosp

ital, p

hysic

ian, a

nd ot

her p

rovid

er

infor

matio

n into

a sta

tewide

healt

h info

rmati

on ex

chan

ge.

Meets

16.3.

6 The

CCN

shall

mee

t, as r

eque

sted b

y DHH

, with

wor

k gro

ups o

r co

mmitte

es to

coor

dinate

activ

ities a

nd de

velop

syste

m str

ategie

s tha

t ac

tively

reinf

orce

the h

ealth

care

refor

m ini

tiativ

e.

Meets

16.3.

7 All i

nform

ation

, whe

ther d

ata or

docu

menta

tion a

nd re

ports

that

conta

in or

refer

ence

s to t

hat in

forma

tion i

nvolv

ing or

arisi

ng ou

t of th

e Co

ntrac

t is ow

ned b

y DHH

. The

CCN

is ex

pres

sly pr

ohibi

ted fr

om

shar

ing or

publi

shing

DHH

’s inf

orma

tion a

nd re

ports

with

out th

e prio

r wr

itten c

onse

nt of

DHH.

In th

e eve

nt of

a disp

ute re

gard

ing th

e sha

ring o

r pu

blish

ing of

infor

matio

n and

repo

rts, D

HH’s

decis

ion on

this

matte

r sha

ll be

final.

Meets

Aetna

Bett

er H

ealth

unde

rstan

ds th

at DH

H ha

s the

right

and

resp

onsib

ility t

o cha

nge M

MIS

vend

ors a

t any

time.

Aetna

Bett

er

Healt

h is e

xper

ience

d in w

orkin

g with

an M

edica

id sin

gle-st

ate

agen

cy du

ring a

chan

ge in

MMI

S ve

ndor

s. Ae

tna B

etter

Hea

lth ha

s ex

perie

nced

comm

unica

tion a

nd ot

her is

sues

durin

g the

se ch

ange

s an

d rec

omme

nds c

lose a

nd co

nsist

ent m

eetin

gs an

d exc

hang

e of

infor

matio

n to a

void

poten

tially

costl

y situ

ation

s. Ae

tna B

etter

Hea

lth un

derst

ands

this

requ

ireme

nt an

d sha

ll full

y co

mply.

Ae

tna B

etter

Hea

lth un

derst

ands

this

requ

ireme

nt an

d sha

ll full

y co

mply.


124

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.3.

8 The

Med

icaid

Mana

geme

nt Inf

orma

tion S

ystem

(MMI

S) pr

oces

ses

claim

s and

paym

ents

for co

vere

d Med

icaid

servi

ces.

DHH’

s cur

rent

MMIS

contr

act e

xpire

d Dec

embe

r 31,

2010

. DHH

exer

cised

its rig

ht to

exten

d all o

r par

t of a

five (

5) ye

ar ex

tensio

n to i

ts cu

rrent

FI. D

HH sh

all

requ

ire th

e CCN

to co

mply

with

trans

itiona

l requ

ireme

nts as

nece

ssar

y sh

ould

DHH

contr

act w

ith a

new

FI du

ring t

he C

ontra

ct at

no co

st to

DHH

or its

FI.

Meets

16.3.

9 The

CCN

shall

be re

spon

sible

for al

l initia

l and

recu

rring

costs

re

quire

d for

acce

ss to

DHH

syste

m(s),

as w

ell as

DHH

acce

ss to

the

CCN’

s sys

tem(s)

. The

se co

sts in

clude

, but

are n

ot lim

ited t

o, ha

rdwa

re,

softw

are,

licen

sing,

and a

uthor

ity/pe

rmiss

ion to

utiliz

e any

paten

ts,

annu

al ma

inten

ance

, sup

port,

and c

onne

ctivit

y with

DHH

, the F

iscal

Inter

media

ry (F

I) an

d the

Enr

ollme

nt Br

oker

.

Meet

16.3.

10 T

he C

CN sh

all co

mplet

e an I

nform

ation

Sys

tems C

apab

ilities

As

sess

ment

(ISCA

), wh

ich w

ill be

prov

ided b

y DHH

. The

ISCA

shall

be

comp

leted

and r

eturn

ed to

DHH

no la

ter th

an th

irty (3

0) da

ys fr

om th

e da

te the

CCN

sign

s the

Con

tract

with

DHH.

Meets

16.3.

11 H

ardw

are a

nd S

oftwa

re

The C

CN m

ust m

aintai

n har

dwar

e and

softw

are c

ompa

tible

with

curre

nt DH

H re

quire

ments

whic

h are

as fo

llows

:

Meets


125

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.3.

11.1

Desk

top W

orks

tation

Har

dwar

e: ●

IB

M-co

mpati

ble P

C us

ing at

leas

t a D

ual C

ore P

roce

ssor

(2

.66 G

Hz, 6

MB

cach

e, 13

33 M

Hz F

SB);

●

At le

ast 4

GB

(giga

bytes

) of R

AM;

●

At le

ast 2

50 G

B HD

D;

●

256 M

B dis

crete

video

mem

ory;

●

A co

lor m

onito

r or L

CD ca

pable

of at

leas

t 800

x 64

0 sc

reen

reso

lution

; ●

A

DVD

+/-R

W an

d CD-

ROM

drive

capa

ble of

read

ing an

d wr

iting t

o both

med

ia;

●

1 giga

byte

Ethe

rnet

card

; ●

En

ough

spar

e USB

ports

to ac

comm

odate

thum

b driv

es,

etc.; a

nd

●

Print

er co

mpati

ble w

ith ha

rdwa

re an

d soft

ware

requ

ired.

Meets

16.3.

11.2

Desk

top W

orks

tation

Soft

ware

: ●

Op

erati

ng sy

stem

shou

ld be

Micr

osoft

Wind

ows X

P SP

3 or

later

, ●

W

eb br

owse

r tha

t is eq

ual to

or su

rpas

ses M

icros

oft

Inter

net E

xplor

er v7

.0 an

d is c

apab

le of

reso

lving

Ja

vaSc

ript a

nd A

ctive

X sc

ripts;

●

An

e-ma

il app

licati

on th

at is

comp

atible

with

Micr

osoft

Ou

tlook

; ●

An

offic

e pro

ducti

vity s

uite s

uch a

s Micr

osoft

Offic

e tha

t is

comp

atible

with

Micr

osoft

Offic

e 200

7 or la

ter;

●

Each

wor

kstat

ion sh

ould

have

acce

ss to

high

spee

d

Meets


126

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

Inter

net;

●

Each

wor

kstat

ion co

nnec

ted to

the I

ntern

et sh

ould

have

an

ti-viru

s, an

ti-spa

m, an

d anti

-malw

are s

oftwa

re. R

egula

r an

d fre

quen

t upd

ates o

f the v

irus d

efinit

ions a

nd se

curity

pa

rame

ters o

f thes

e soft

ware

appli

catio

ns sh

ould

be

estab

lishe

d and

admi

nister

ed;

●

A de

sktop

comp

ress

ion/en

crypti

on ap

plica

tion t

hat is

co

mpati

ble w

ith W

inZIP

v11.0

; ●

Al

l wor

kstat

ions,

laptop

s and

porta

ble co

mmun

icatio

n de

vices

shall

be in

stalle

d with

full d

isk en

crypti

on so

ftwar

e; an

d ●

Co

mplia

nt wi

th ind

ustry

-stan

dard

phys

ical a

nd pr

oced

ural

safeg

uard

s for

confi

denti

al inf

orma

tion (

NIST

800-

53A,

ISO

1778

8, etc

.).

16.3.

11.3

Netw

ork a

nd B

ack-u

p Cap

abilit

ies

●

Estab

lish a

loca

l are

a netw

ork o

r netw

orks

as ne

eded

to

conn

ect a

ll app

ropr

iate w

orks

tation

perso

nal d

eskto

p co

mpute

rs (P

Cs);

●

Estab

lish a

ppro

priat

e har

dwar

e fire

walls

, rou

ters,

and o

ther

secu

rity m

easu

res s

o tha

t the C

CN's

comp

uter n

etwor

k is

not a

ble to

be br

each

ed by

an ex

terna

l enti

ty;

●

Estab

lish a

ppro

priat

e bac

k-up p

roce

sses

that

ensu

re th

e ba

ck-u

p, ar

chiva

l, and

read

y retr

ieval

of ne

twor

k ser

ver

data

and d

eskto

p wor

kstat

ion da

ta;

●

Ensu

re th

at ne

twor

k har

dwar

e is p

rotec

ted fr

om el

ectric

al su

rges

, pow

er flu

ctuati

ons,

and p

ower

outag

es by

using

the

appr

opria

te un

inter

rupti

ble po

wer s

ystem

(UPS

) and

surg

e pr

otecti

on de

vices

; and

Meets


127

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

●

The C

CN sh

all es

tablis

h ind

epen

dent

gene

rator

back

-up

powe

r cap

able

of su

pplyi

ng ne

cess

ary p

ower

for f

our (

4)

days

. 16

.4 Re

sour

ce A

vaila

bilit

y and

Sys

tem

s Cha

nges


128

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.4.

1 Res

ource

Ava

ilabil

ity

The C

CN sh

all pr

ovide

Sys

tems H

elp D

esk s

ervic

es to

DHH

, its F

I, and

En

rollm

ent B

roke

r per

sonn

el tha

t hav

e dire

ct ac

cess

to th

e data

in th

e CC

N’s S

ystem

s.

Meet

Aetna

Bett

er H

ealth

take

s the

secu

rity of

our m

embe

rs’ da

ta ve

ry se

rious

ly an

d so m

aintai

ns si

gnific

ant p

rotoc

ols an

d con

trols

with

rega

rd its

exter

nal u

se. P

er ou

r stan

dard

oper

ating

proc

edur

e re

gard

ing re

ques

ts for

syste

m ac

cess

by an

exter

nal a

genc

y, we

will

confi

gure

a DH

H-su

pplie

d PC

or la

ptop s

uch t

hat a

uthor

ized e

xtern

al us

ers h

ave a

cces

s – vi

a Citri

x – to

a se

cure

, inqu

iry-o

nly en

viron

ment

wher

ein th

ey m

ay cr

eate

and/o

r gen

erate

repo

rts on

an ad

-hoc

basis

. W

e will

reac

h mutu

al ag

reem

ent w

ith D

HH on

the n

umbe

r of

perso

nnel

memb

ers t

hat n

eed a

NID

numb

er gr

antin

g the

m ro

le-ba

sed a

cces

s as a

non-

Aetna

Bett

er H

ealth

user

. Auth

orize

d use

rs wi

ll hav

e acc

ess t

o SPO

C, A

etna’s

Sing

le Po

int of

Con

tact H

elp D

esk,

prov

iding

toll-f

ree s

ystem

and t

echn

ical s

uppo

rt 24

/7/36

5. SP

OC

perso

nnel

will a

nswe

r que

stion

s reg

ardin

g Aetn

a Bett

er H

ealth

’s Sy

stem

functi

ons a

nd ca

pabil

ities;

repo

rt re

curri

ng pr

ogra

mmati

c and

op

erati

on pr

oblem

s to a

ppro

priat

e per

sonn

el for

follo

w-up

; red

irect

prob

lems o

r que

ries t

hat a

re no

t sup

porte

d by t

he S

ystem

s Help

De

sk, a

s app

ropr

iate,

via a

telep

hone

tran

sfer o

r othe

r agr

eed u

pon

metho

dolog

y; an

d red

irect

prob

lems o

r que

ries s

pecif

ic to

data

acce

ss au

thoriz

ation

to th

e app

ropr

iate D

HH pe

rsonn

el. R

ecur

ring

prob

lems n

ot sp

ecific

to S

ystem

s una

vaila

bility

iden

tified

by th

e Sy

stems

Help

Des

k will

be do

cume

nted a

nd re

porte

d to A

etna B

etter

He

alth m

anag

emen

t with

in on

e (1)

busin

ess d

ay of

reco

gnitio

n so t

hat


129

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.4.

1.1 T

he S

ystem

s Help

Des

k sha

ll: ●

Be

avail

able

via lo

cal a

nd to

ll-fre

e tele

phon

e ser

vice,

and

via e-

mail f

rom

7a.m

. to 7p

.m., C

entra

l Tim

e, Mo

nday

thr

ough

Frid

ay, w

ith th

e exc

eptio

n of D

HH de

signa

ted

holid

ays.

Upon

requ

est b

y DHH

, the C

CN sh

all be

requ

ired

to sta

ff the

Sys

tems H

elp D

esk o

n a st

ate ho

liday

, Sa

turda

y, or

Sun

day;

●

Answ

er qu

estio

ns re

gard

ing th

e CCN

’s Sy

stem

functi

ons

and c

apab

ilities

; rep

ort r

ecur

ring p

rogr

amma

tic an

d op

erati

on pr

oblem

s to a

ppro

priat

e per

sonn

el for

follo

w-up

; re

direc

t pro

blems

or qu

eries

that

are n

ot su

ppor

ted by

the

Syste

ms H

elp D

esk,

as ap

prop

riate,

via a

telep

hone

tra

nsfer

or ot

her a

gree

d upo

n meth

odolo

gy; a

nd re

direc

t pr

oblem

s or q

uerie

s spe

cific

to da

ta ac

cess

autho

rizati

on to

the

appr

opria

te DH

H pe

rsonn

el;

●

Ensu

re in

dividu

als w

ho pl

ace c

alls a

fter h

ours

are h

ave t

he

optio

n to l

eave

a me

ssag

e. Th

e CCN

’s pe

rsonn

el sh

all

resp

ond t

o mes

sage

s left

betw

een t

he ho

urs o

f 7p.m

. and

7a

.m. b

y noo

n tha

t nex

t bus

iness

day;

●

Ensu

re re

curri

ng pr

oblem

s not

spec

ific to

Sys

tems

unav

ailab

ility i

denti

fied b

y the

Sys

tems H

elp D

esk s

hall b

e do

cume

nted a

nd re

porte

d to

CCN

mana

geme

nt wi

thin o

ne

(1) b

usine

ss da

y of r

ecog

nition

so th

at de

ficien

cies a

re

prom

ptly c

orre

cted;

and

●

Have

an IS

servi

ce m

anag

emen

t sys

tem th

at pr

ovide

s an

autom

ated m

ethod

to re

cord

, trac

k and

repo

rt all

ques

tions

an

d/or p

roble

ms re

porte

d to t

he S

ystem

s Help

Des

k.

Meet

defic

iencie

s can

be pr

omptl

y cor

recte

d. An

issu

e man

agem

ent

syste

m wi

ll ass

ist in

that

rega

rd, p

rovid

ing S

POC

perso

nnel

an

autom

ated m

eans

to re

cord

, trac

k and

repo

rt all

ques

tions

and/o

r pr

oblem

s rep

orted

to th

e Sys

tems H

elp D

esk.

16.4.

2 Inf

orm

atio

n Sy

stem

s Doc

umen

tatio

n Re

quire

men

ts


130

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.4.

2.1 T

he C

CN sh

all en

sure

that

writte

n Sys

tems p

roce

ss an

d pr

oced

ure m

anua

ls do

cume

nt an

d des

cribe

all m

anua

l and

autom

ated

syste

m pr

oced

ures

for it

s info

rmati

on m

anag

emen

t pro

cess

es an

d inf

orma

tion s

ystem

s.

Meets

16.4.

2.2 T

he C

CN sh

all de

velop

, pre

pare

, prin

t, main

tain,

prod

uce,

and

distrib

ute to

DHH

disti

nct S

ystem

s des

ign an

d man

agem

ent m

anua

ls,

user

man

uals

and q

uick r

efere

nce G

uides

, and

any u

pdate

s.

Meets

16.4.

2.3 T

he C

CN sh

all en

sure

the S

ystem

s use

r man

uals

conta

in inf

orma

tion a

bout,

and i

nstru

ction

for,

using

appli

cable

Sys

tems f

uncti

ons

and a

cces

sing a

pplic

able

syste

m da

ta.

Meets

16.4.

2.4 T

he C

CN sh

all en

sure

whe

n a S

ystem

chan

ge is

subje

ct to

DHH

prior

writt

en ap

prov

al, th

e CCN

will

subm

it rev

ision

to th

e app

ropr

iate

manu

als be

fore i

mplem

entin

g said

Sys

tems c

hang

es.

Meets

16.4.

2.5 T

he C

CN sh

all en

sure

all a

forem

entio

ned m

anua

ls an

d re

feren

ce G

uides

are a

vaila

ble in

print

ed fo

rm an

d on-

line;

and

Meet

16.4.

2.6 T

he C

CN sh

all up

date

the el

ectro

nic ve

rsion

of th

ese m

anua

ls im

media

tely,

and u

pdate

print

ed ve

rsion

s with

in ten

(10)

busin

ess d

ays

of the

upda

te tak

ing ef

fect.

Meets

16.4.

2.7 T

he C

CN sh

all pr

ovide

to D

HH do

cume

ntatio

n des

cribin

g its

Syste

ms Q

uality

Ass

uran

ce P

lan.

Meets

Aetna

Bett

er H

ealth

and A

etna M

edica

id ha

s sys

tem an

d use

r ma

nuals

that

docu

ment

its sy

stem

and a

pplic

ation

s. In

some

ins

tance

s we u

se sy

stem

and u

ser m

anua

ls pr

ovide

d by t

he sy

stem

owne

r [e.g

., QNX

T™], i

n the

se in

stanc

es th

ere m

ay be

certa

in re

strict

ions o

r limi

ts re

gard

ing ac

cess

to th

ese m

anua

ls as

requ

ired b

y the

syste

m ow

ner a

nd ou

r lice

nsing

agre

emen

t. Sys

tem de

sign,

mana

geme

nt ma

nuals

, use

r man

uals

and q

uick r

efere

nce g

uides

av

ailab

le to

Aetna

Med

icaid

or A

etna B

etter

Hea

lth sh

all al

so be

av

ailab

le to

DHH.

Ae

tna B

etter

Hea

lth w

ill su

bmit r

evisi

ons t

o app

ropr

iate m

anua

ls fol

lowing

syste

m ch

ange

s tha

t are

subje

ct to

DHH

prior

appr

oval.

Ae

tna B

etter

Hea

lth sy

stem

desig

n, ma

nage

ment

manu

als, u

ser

manu

als an

d quic

k refe

renc

e guid

es w

ill be

avail

able

to DH

H in

print

ed fo

rm an

d on-

line.

16.4.

3 Sys

tem

s Cha

nges

16

.4.3.1

The

CCN

’s Sy

stems

shall

confo

rm to

futur

e fed

eral

and/o

r DHH

sp

ecific

stan

dard

s for

enco

unter

data

exch

ange

with

in on

e hun

dred

tw

enty

(120

) cale

ndar

days

prior

to th

e stan

dard

’s eff

ectiv

e date

or

Meets

As

part

of ou

r cha

nge o

rder

man

agem

ent p

roce

ss, w

e defi

ne a

syste

m ch

ange

as an

y mod

ificati

on th

at im

pacts

the s

hare

d netw

ork,

comp

uting

envir

onme

nt, or

busin

ess a

pplic

ation

s by a

lterin

g its


131

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

earlie

r, as

dire

cted b

y CMS

or D

HH.

16.4.

3.2 If

a sys

tem up

date

and/o

r cha

nge a

re ne

cess

ary,

the C

CN sh

all

draft

appr

opria

te re

vision

s for

the d

ocum

entat

ion or

man

uals,

and

pres

ent to

DHH

thirty

(30)

days

prior

to im

pleme

ntatio

n, for

DHH

revie

w an

d app

rova

l. Doc

umen

tation

revis

ions s

hall b

e acc

ompli

shed

ele

ctron

ically

and s

hall b

e mad

e ava

ilable

for D

epar

tmen

t rev

iew in

an

easil

y acc

essib

le, ne

ar re

al-tim

e meth

od. P

rinted

man

ual re

vision

s sha

ll oc

cur w

ithin

ten (1

0) bu

sines

s day

s of th

e actu

al re

vision

.

Meets

16.4.

3.3 T

he C

CN sh

all no

tify D

HH pe

rsonn

el of

the fo

llowi

ng ch

ange

s to

its S

ystem

with

in its

span

of co

ntrol

at lea

st nin

ety (9

0) ca

lenda

r day

s pr

ior to

the p

rojec

ted da

te of

the ch

ange

:

Meets

16.4.

3.4 M

ajor c

hang

es, u

pgra

des,

modif

icatio

n or u

pdate

s to a

pplic

ation

or

oper

ating

softw

are a

ssoc

iated

with

the f

ollow

ing co

re pr

oduc

tion

Syste

m: ●

Cl

aims p

roce

ssing

; ●

El

igibil

ity an

d enr

ollme

nt pr

oces

sing;

●

Servi

ce au

thoriz

ation

man

agem

ent;

●

Prov

ider e

nroll

ment

and d

ata m

anag

emen

t; and

●

Co

nver

sions

of co

re tr

ansa

ction

man

agem

ent S

ystem

s.

Meets

exist

ing st

ate. T

his in

clude

s, bu

t is no

t limi

ted to

:

• Sy

stem

Hard

ware

: Ser

vers

or se

rver c

ompo

nents

, pow

er

cond

itione

rs, et

c. •

Syste

m So

ftwar

e: Op

erati

ng sy

stems

, anti

virus

, cor

e bus

iness

ap

plica

tions

, etc.

•

Datab

ases

: Micr

osoft

SQL

Ser

ver,

Micro

soft A

cces

s, etc

. •

Netw

ork H

ardw

are:

Route

rs, sw

itche

s, fire

walls

, VPN

, sec

urity

ap

plian

ces,

etc.

• De

sktop

Man

agem

ent: H

ardw

are,

oper

ating

syste

ms, C

itrix

clien

t, anti

virus

, etc.

W

e ass

ign sy

stem

chan

ges t

o one

of th

ree c

atego

ries:

(1) F

ull C

ycle:

by

defau

lt all c

hang

es fa

ll into

this

categ

ory.

Thes

e cha

nges

are

discu

ssed

and m

ay be

appr

oved

at th

e wee

kly IT

COP

mee

ting;

(2)

Expe

dited

: cha

nge n

eeds

to oc

cur p

rior t

o the

next

IT C

OP m

eetin

g. Th

ese c

hang

es re

quire

appr

oval

of Ae

tna B

etter

Hea

lth’s

COO

or

desig

nee a

nd a

Aetna

Med

icaid’

s IT

Dire

ctor;

and (

3) R

outin

e: a

mino

r cha

nge (

e.g. c

hang

ing a

web p

age d

ocum

ent)

using

an

acce

pted p

roce

ss.

We r

ecog

nize t

hat o

ther a

ctivit

ies, d

eeme

d to b

e com

para

tively

mino

r, low

-risk

task

s, ar

e rou

tinely

perfo

rmed

in th

e inte

rest

of sy

stem

secu

rity an

d stab

ility.

It is o

ur ex

perie

nce t

hat th

e like

lihoo

d of th

ese


132

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.4.

3.5 T

he C

CN sh

all re

spon

d to D

HH no

tifica

tion o

f Sys

tem pr

oblem

s no

t res

ulting

in S

ystem

unav

ailab

ility a

ccor

ding t

o the

follo

wing

tim

efram

es:

●

With

in fiv

e (5)

calen

dar d

ays o

f rec

eiving

notifi

catio

n fro

m DH

H, th

e CCN

shall

resp

ond i

n writi

ng to

notic

es of

syste

m pr

oblem

s. ●

W

ithin

fiftee

n (15

) cale

ndar

days

, the c

orre

ction

shall

be

made

or a

requ

ireme

nts an

alysis

and s

pecif

icatio

ns

docu

ment

will b

e due

. ●

Th

e CCN

shall

corre

ct the

defic

iency

by an

effec

tive d

ate to

be

deter

mine

d by D

HH.

●

The C

CN’s

Syste

ms sh

all ha

ve a

syste

m-inh

eren

t me

chan

ism fo

r rec

ordin

g any

chan

ge to

a so

ftwar

e mod

ule

or su

bsys

tem.

●

The C

CN sh

all pu

t in pl

ace p

roce

dure

s and

mea

sure

s for

sa

fegua

rding

again

st un

autho

rized

mod

ificati

on to

the

CCN’

s Sys

tems.

Meets

16.4.

3.6 U

nless

othe

rwise

agre

ed to

in ad

vanc

e by D

HH, th

e CCN

shall

no

t sch

edule

Sys

tems u

nava

ilabil

ity to

perfo

rm sy

stem

maint

enan

ce,

repa

ir and

/or up

grad

e acti

vities

to ta

ke pl

ace d

uring

hour

s tha

t can

co

mpro

mise

or pr

even

t criti

cal b

usine

ss op

erati

ons.

Meets

activ

ities h

aving

an im

pact

on sy

stem

stabil

ity is

extre

mely

rare

, as

they a

re no

t cha

nges

to a

proc

essin

g env

ironm

ent. T

here

fore,

our I

T ma

nage

ment

team

identi

fies,

track

s, ma

nage

s, an

d rep

orts

on th

ese

activ

ities.

Exam

ples o

f thes

e adm

inistr

ative

chan

ges i

nclud

e, bu

t are

no

t limi

ted to

the f

ollow

ing:

●

Acco

unt a

dmini

strati

on (i.

e., us

er pr

ofiles

, pas

swor

d re

sets,

user

desk

top ap

plica

tion s

etup)

●

Ad

ding s

hare

point

s ●

Re

storin

g file

s (ind

ividu

al PC

’s)

●

Chan

ging b

acku

p tap

es an

d job

sche

dules

●

Fil

e sys

tem ad

justm

ents

●

Wor

k man

agem

ent (

outpu

t que

ues)

●

Ma

nagin

g stor

age p

ools

We r

equir

e our

IT te

am to

mitig

ate th

e risk

asso

ciated

with

any

upgr

ade b

y: (1

) rele

asing

any u

pgra

de in

a se

cure

Aetn

a Med

icaid’

s “b

ack o

ffice”

envir

onme

nt to

test it

s imp

act p

rior t

o pro

motin

g it to

the

“pro

ducti

on” e

nviro

nmen

t; (2)

back

ing up

the e

ntire

syste

m pr

ior to

the

upgr

ade s

o Aetn

a Med

icaid

can r

ever

se th

e pro

cess

and r

eturn

the

syste

m to

its pr

e-up

grad

e stat

e if n

eces

sary;

(3) r

equir

ing th

e ha

rdwa

re/so

ftwar

e ven

dor t

o hav

e its

perso

nnel

on-si

te to

facilit

ate

and m

onito

r the

COP

; and

(4) t

raini

ng ou

r emp

loyee

s/end

user

s on

the co

nver

sion/u

pgra

de. S

tanda

rd op

erati

ng pr

oced

ure m

anda

tes th

at


133

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.4.

3.7 T

he C

CN sh

all w

ork w

ith D

HH pe

rtaini

ng to

any t

estin

g init

iative

as

requ

ired b

y DHH

and s

hall p

rovid

e suff

icien

t sys

tem ac

cess

to al

low

testin

g by D

HH an

d/or it

s FI o

f the C

CN’s

Syste

m.

Meets

we

prov

ide D

HH w

ith th

e foll

owing

infor

matio

n prio

r to a

ny sy

stem

conv

ersio

n or u

pgra

de:

• Sy

stem

(har

dwar

e/soft

ware

) to b

e upg

rade

d and

the n

ature

of

the up

grad

e •

Timefr

ame f

or th

e upg

rade

•

How

PHI w

ill be

secu

red a

nd pr

otecte

d dur

ing th

e upg

rade

•

How

the up

grad

e will

be te

sted p

rior t

o fina

l pro

motio

n •

A pla

n to r

ever

t to th

e orig

inal s

ystem

if the

re’s

a pro

blem

Aetna

Bett

er H

ealth

will

prov

ide sy

stem

acce

ss to

DHH

and/o

r FI fo

r sy

stem

testin

g pur

pose

s. Su

ch ac

cess

will

be as

agre

ed to

by A

etna

Bette

r Hea

lth an

d DHH

and l

imite

d to t

he pu

rpos

es in

clude

d in t

his

agre

emen

t.

16.5

Syst

ems R

efre

sh P

lan

16.5.

1 The

CCN

shall

prov

ide to

DHH

an an

nual

Syste

ms R

efres

h Plan

. Th

e plan

shall

outlin

e how

Sys

tems w

ithin

the C

CN’s

span

of co

ntrol

will

be sy

stema

ticall

y ass

esse

d to d

eterm

ine th

e nee

d to m

odify

, upg

rade

an

d/or r

eplac

e app

licati

on so

ftwar

e, op

erati

ng ha

rdwa

re an

d soft

ware

, tel

ecom

munic

ation

s cap

abilit

ies, in

forma

tion m

anag

emen

t poli

cies a

nd

proc

edur

es, a

nd/or

syste

ms m

anag

emen

t poli

cies a

nd pr

oced

ures

in

resp

onse

to ch

ange

s in b

usine

ss re

quire

ments

, tech

nolog

y ob

soles

cenc

e, pe

rsonn

el tur

nove

r and

othe

r rele

vant

factor

s.

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

unde

rstan

ds th

ese

requ

ireme

nts. A

etna B

etter

Hea

lth w

ill me

et Ae

tna B

etter

Hea

lth’s

spec

ificati

ons a

nd co

mply

with

each

of th

e req

uirem

ents

in thi

s se

ction

. Ae

tna B

etter

Hea

lth sh

all pr

ovide

DHH

a Sy

stem

Refre

sh P

lan th

at wi

ll mee

t the s

pecif

icatio

n as r

equir

ed he

rein.


134

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.5.

2 The

syste

ms re

fresh

plan

shall

also

indic

ate ho

w the

CCN

will

ensu

re th

at the

versi

on an

d/or r

eleas

e lev

el of

all of

its S

ystem

s co

mpon

ents

(app

licati

on so

ftwar

e, op

erati

ng ha

rdwa

re, o

pera

ting

softw

are)

are a

lway

s for

mally

supp

orted

by th

e orig

inal e

quipm

ent

manu

factur

er (O

EM),

softw

are d

evelo

pmen

t firm

(SDF

), or

a thi

rd pa

rty

autho

rized

by th

e OEM

and/o

r SDF

to su

ppor

t the S

ystem

s com

pone

nt.

Meets

16.6

Othe

r Elec

troni

c Dat

a Exc

hang

e

16

.6.1 T

he C

CN’s

syste

m sh

all ho

use i

ndex

ed el

ectro

nic im

ages

of

docu

ments

to be

used

by m

embe

rs an

d pro

vider

s to t

rans

act w

ith th

e CC

N an

d tha

t are

repo

sed i

n app

ropr

iate d

ataba

se(s)

and d

ocum

ent

mana

geme

nt sy

stems

(i.e.,

Mas

ter P

atien

t Inde

x) as

to m

aintai

n the

log

ical re

lation

ships

to ce

rtain

key d

ata su

ch as

mem

ber id

entifi

catio

n, pr

ovide

r iden

tifica

tion n

umbe

rs an

d clai

m ide

ntific

ation

numb

ers.

The

CCN

shall

ensu

re th

at re

cord

s ass

ociat

ed w

ith a

comm

on ev

ent,

trans

actio

n or c

ustom

er se

rvice

issu

e hav

e a co

mmon

inde

x tha

t will

facilit

ate se

arch

, retr

ieval

and a

nalys

is of

relat

ed ac

tivitie

s, su

ch as

int

erac

tions

with

a pa

rticula

r mem

ber a

bout

a rep

orted

prob

lem.

Meet

16.6.

2 The

CCN

shall

imple

ment

Optic

al Ch

arac

ter R

ecog

nition

(OCR

) tec

hnolo

gy th

at mi

nimize

s man

ual in

dexin

g and

autom

ates t

he re

trieva

l of

scan

ned d

ocum

ents.

Meet

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd un

derst

ands

thes

e re

quire

ments

. Aetn

a Bett

er H

ealth

will

meet

Aetna

Bett

er H

ealth

’s sp

ecific

ation

s and

comp

ly wi

th ea

ch of

the r

equir

emen

ts in

this

secti

on


135

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.7

Elec

troni

c Mes

sagi

ng

16.7.

1 The

CCN

shall

prov

ide a

conti

nuou

sly av

ailab

le ele

ctron

ic ma

il co

mmun

icatio

n link

(e-m

ail sy

stem)

to fa

cilita

te co

mmun

icatio

n with

DHH

. Th

is e-

mail s

ystem

shall

be ca

pable

of at

tachin

g and

send

ing do

cume

nts

create

d usin

g soft

ware

comp

atible

with

DHH

's ins

talled

versi

on of

Mi

croso

ft Offic

e (cu

rrentl

y 200

7) an

d any

subs

eque

nt up

grad

es as

ad

opted

.

Meets

16.7.

2 As n

eede

d, the

CCN

shall

be ab

le to

comm

unica

te wi

th DH

H ov

er

a sec

ure V

irtual

Priva

te Ne

twor

k (VP

N).

Meets

16.7.

3 The

CCN

shall

comp

ly wi

th na

tiona

l stan

dard

s for

subm

itting

pu

blic h

ealth

infor

matio

n (PH

I) ele

ctron

ically

and s

hall s

et up

a se

cure

em

ailing

syste

m wi

th tha

t is pa

sswo

rd pr

otecte

d for

both

send

ing an

d re

ceivi

ng an

y per

sona

l hea

lth in

forma

tion.

Meets

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd un

derst

ands

thes

e re

quire

ments

. Aetn

a Bett

er H

ealth

will

meet

Aetna

Bett

er H

ealth

’s sp

ecific

ation

s and

comp

ly wi

th ea

ch of

the r

equir

emen

ts in

this

secti

on.

16.8

Elig

ibilit

y and

Enr

ollm

ent D

ata E

xcha

nge

The C

CN sh

all:

16.8.

1 Rec

eive,

proc

ess a

nd up

date

enro

llmen

t files

sent

daily

by th

e En

rollm

ent B

roke

r; Me

ets

16.8.

2 Upd

ate its

eligi

bility

and e

nroll

ment

datab

ases

with

in tw

enty-

four

(24)

hour

s of r

eceip

t of s

aid fil

es;

Meets

16.8.

3 Tra

nsmi

t to D

HH, in

the f

orma

ts an

d meth

ods s

pecif

ied by

DHH

, me

mber

addr

ess c

hang

es an

d tele

phon

e num

ber c

hang

es;

Meets

16.8.

4 Be c

apab

le of

uniqu

ely id

entify

ing (i.

e., M

aster

Pati

ent In

dex)

a dis

tinct

Medic

aid m

embe

r acro

ss m

ultipl

e pop

ulatio

ns an

d Sys

tems

withi

n its

span

of co

ntrol;

and

Meet

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd un

derst

ands

thes

e re

quire

ments

. Aetn

a Bett

er H

ealth

will

meet

Aetna

Bett

er H

ealth

’s sp

ecific

ation

s and

comp

ly wi

th ea

ch of

the r

equir

emen

ts in

this

secti

on.

Aetna

Bett

er H

ealth

curre

ntly p

roce

sses

eligi

bility

and e

nroll

ment

data

in ten

(10)

state

s. In

each

of th

ese i

nstan

ces t

he M

edica

id sin

gle-st

ate

agen

cy an

d its

MMIS

vend

or an

d/or e

nroll

ment

brok

er ha

s uniq

ue

requ

ireme

nts an

d spe

cifica

tions

rega

rding

thes

e tra

nsac

tions

. Aetn

a Be

tter H

ealth

has s

tanda

rd op

erati

ng pr

oced

ures

to ap

ply el

igibil

ity

and e

nroll

ment

data

from

each

of th

ese s

tates

, trac

k spa

ns of

eli

gibilit

y, ac

coun

t for e

ligibi

lity ad

d, de

letes

and r

ate co

de ch

ange

s


136

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.8.

5 Be a

ble to

iden

tify po

tentia

l dup

licate

reco

rds f

or a

single

mem

ber

and,

upon

confi

rmati

on of

said

dupli

cate

reco

rd by

DHH

, res

olve t

he

dupli

catio

n suc

h tha

t the e

nroll

ment,

servi

ce ut

ilizati

on, a

nd cu

stome

r int

erac

tion h

istor

ies of

the d

uplic

ate re

cord

s are

linke

d or m

erge

d.

Meet

and t

o ide

ntify

dupli

cate

enro

llmen

t rec

ords

and “

near

dupli

cate”

en

rollm

ent r

ecor

ds. D

uplic

ate an

d nea

r dup

licate

enro

llmen

t rec

ords

ar

e res

earch

ed w

ith th

e Med

icaid

single

-state

agen

cy, o

r it M

MIS

vend

or, o

r its e

nroll

ment

brok

er, a

s app

licab

le. W

e hav

e nev

er be

en

sanc

tione

d nor

have

proc

essin

g erro

rs be

en de

tected

durin

g any

sta

te re

view

or au

dit of

our t

rans

actio

ns.

Sinc

e QNX

T™ is

the s

ingle

syste

m for

retai

ning e

ligibi

lity in

forma

tion

and i

s the

sour

ce of

mem

ber id

entifi

catio

n and

trac

king w

ithin

and

acro

ss th

e sys

tem w

e mee

t thes

e req

uirem

ents.

16.9

Prov

ider

Enr

ollm

ent

At th

e ons

et of

the C

CN C

ontra

ct an

d per

iodica

lly as

chan

ges a

re ne

cess

ary,

DHH

shall

publi

sh at

the u

rl: ww

w.lam

edica

id.co

m th

e list

of Lo

uisian

a Med

icaid

prov

ider t

ypes

, spe

cialty

, and

sub-

spec

ialty

code

s. In

orde

r to c

oord

inate

prov

ider e

nroll

ment

reco

rds,

the C

CN sh

all ut

ilize t

he pu

blish

ed lis

t of L

ouisi

ana

Medic

aid pr

ovide

r typ

es, s

pecia

lty, a

nd su

b-sp

ecial

ty co

des i

n all p

rovid

er da

ta co

mmun

icatio

ns w

ith D

HH an

d the

Enr

ollme

nt Br

oker

. The

CCN

shall

prov

ide

the fo

llowi

ng:

16.9.

1 Pro

vider

name

, add

ress

, lice

nsing

infor

matio

n, Ta

x ID,

Nati

onal

Prov

ider I

denti

fier (

NPI),

taxo

nomy

and p

ayme

nt inf

orma

tion;

Meets

16.9.

2 All r

eleva

nt pr

ovide

r own

ersh

ip inf

orma

tion a

s pre

scrib

ed by

DHH

, fed

eral

or st

ate la

ws; a

nd

Meets

16.9.

3 Per

forma

nce o

f all f

eder

al or

state

man

dated

exclu

sion

back

grou

nd ch

ecks

on al

l pro

vider

s (ow

ners

and m

anag

ers).

The

pr

ovide

rs sh

all pe

rform

the s

ame f

or al

l their

emplo

yees

at le

ast a

nnua

lly.

Meets

Prov

ider r

ecor

ds ar

e con

figur

ed to

mee

t the s

pecif

icatio

ns an

d re

quire

ments

of D

HH. P

rotoc

ols ex

ist fo

r the

deve

lopme

nt an

d qua

lity

revie

w of

docu

ments

used

to co

nver

t the p

rovid

er’s

contr

act fo

r loa

ding i

nto ou

r sys

tem. K

ey da

ta ele

ments

captu

red f

or m

embe

r inf

orma

tion a

nd en

rollm

ent p

eriod

are:

office

hour

s; sp

ecial

ty;

langu

ages

spok

en; h

andic

ap ac

cess

and i

f TTY

/TTD

or in

terpr

eter

servi

ces a

re av

ailab

le. T

hese

data

are p

art o

f the p

rovid

er’s

reco

rd

and a

vaila

ble fo

r rev

iew by

the m

embe

r ser

vice w

orke

r whe

n as

sistin

g a m

embe

r in se

lectin

g a P

CP/P

CMH,

inclu

ded i

n our


137

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.9.

4 Pro

vider

enro

llmen

t sys

tems s

hall i

nclud

e, at

minim

um, th

e fol

lowing

func

tiona

lity:

●

Audit

trail

and h

istor

y of c

hang

es m

ade t

o the

prov

ider f

ile;

●

Autom

ated i

nterfa

ces w

ith al

l lice

nsing

and m

edica

l boa

rds;

●

Autom

ated a

lerts

when

prov

ider li

cens

es ar

e nea

ring

expir

ation

; ●

Re

tentio

n of N

PI re

quire

ments

; ●

Sy

stem

gene

rated

lette

rs to

prov

iders

when

their

licen

ses

are n

earin

g exp

iratio

n; ●

Lin

kage

s of in

dividu

al pr

ovide

rs to

grou

ps;

●

Cred

entia

ling i

nform

ation

; ●

Pr

ovide

r offic

e hou

rs; an

d ●

Pr

ovide

r lang

uage

s spo

ken.

Meets

pr

ovide

r man

ual a

nd m

ade a

vaila

ble to

the e

nroll

ment

brok

er.

Aetna

Bett

er H

ealth

unde

rstan

ds an

d agg

ress

to th

e req

uirem

ents

rega

rding

prov

ider o

wner

ship

infor

matio

n, inc

luding

, but

not li

mited

to,

prov

ider o

wner

ship

of Ae

tna B

etter

Hea

lth. B

ut in

partic

ular t

o re

ferra

ls fro

m a p

rovid

er to

an en

tity th

at the

prov

ider h

as an

ow

nersh

ip int

eres

t. Ke

y com

pone

nts of

the i

nitial

cred

entia

ling p

roce

ss in

clude

:

• Su

bmitta

l of a

n init

ial ap

plica

tion a

nd at

testat

ion th

at is

signe

d an

d date

d by t

he pr

ovide

r •

Prim

ary s

ource

verifi

catio

n by A

etna B

etter

Hea

lth’s

contr

acted

Na

tiona

l Com

mitte

e for

Qua

lity A

ssur

ance

(NCQ

A)-a

ccre

dited

cre

denti

aling

verifi

catio

n org

aniza

tion (

CVO)

. The

CVO

verifi

es

with

indep

ende

nt so

urce

s: va

lid lic

ensu

re; v

alid D

EA or

CDS

ce

rtifica

te; ed

ucati

on an

d tra

ining

, inclu

ding b

oard

certif

icatio

n, if

appli

cable

; any

histo

ry of

profe

ssion

al lia

bility

settle

ments

or

judgm

ents;

and t

he ap

plica

nt’s w

ork h

istor

y.

• Ve

rifica

tion o

f san

ction

or lim

itatio

ns on

licen

sure

, or f

elony

co

nvict

ions,

utiliz

ing N

PDB,

healt

hcar

e inte

grity

prote

ction

data

bank

, stat

e age

ncies

etc.

• On

-site

visits

to ve

rify th

at PC

P an

d OB/

GYN

prov

iders

meet

our

office

and m

edica

l reco

rd ke

eping

stan

dard

s. (T

his pr

oces

s is

waive

d if th

e app

lican

t is jo

ining

a pr

ovide

r gro

up th

at is

alrea

dy a

part

of the

Aetn

a Bett

er H

ealth

prov

ider n

etwor

k).

The r

e-cre

denti

aling

proc

ess a

scer

tains

the c

ontin

ued q

ualifi

catio

ns of

the

healt

hcar

e pro

fessio

nal a

nd in

volve

s: 1)

attes

tation

and u

pdati

ng

of ini

tial a

pplic

ation

infor

matio

n by t

he pr

ovide

r; 2)

prim

ary s

ource

ve

rifica

tions

by th

e CVO

and 3

) a re

view

of the

prov

ider’s

pe

rform

ance

(e.g.

, mem

ber c

ompla

ints,

utiliz

ation

issu

es, r

esult

s of

ambu

lator

y med

ical re

cord

revie

ws, p

rovid

er pr

ofile

resu

lts an

d qua

lity

of ca

re co

ncer

ns).


138

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

Chan

ges t

o pro

vider

confi

gura

tion i

n the

syste

m of

reco

rd [Q

NXT™

] ar

e main

taine

d in t

he sy

stem.

The

state

s whe

re w

e cur

rentl

y hav

e Me

dicaid

man

aged

care

contr

acts

gene

rally

do no

t sup

port

autom

ated l

inkag

es to

their

prov

ider li

cens

ure d

ata ba

ses;

howe

ver,

we do

requ

ire re

-cred

entia

ling o

f pro

vider

s eve

ry 3 y

ears.

At th

is po

int

we va

lid al

l the i

nform

ation

in th

e cre

denti

aling

file.

We d

o hav

e ca

pabil

ities o

f res

earch

ing S

tate a

nd F

eder

al pr

ovide

r data

base

s on

a reg

ular a

nd ro

utine

basis

to va

lid cr

eden

tialin

g and

re-cr

eden

tialin

g re

quire

ments

. Cre

denti

aling

and r

e-cre

denti

aling

are p

erfor

med b

y an

NCQA

certif

ied af

filiate

d ven

dor.

16.10

Info

rmat

ion

Syst

ems A

vaila

bilit

y Th

e CCN

shall

:

16.10

.1 No

t be r

espo

nsibl

e for

the a

vaila

bility

and p

erfor

manc

e of

syste

ms an

d IT

infra

struc

ture t

echn

ologie

s outs

ide of

the C

CN’s

span

of

contr

ol;

Meets

16.10

.2 Al

low D

HH pe

rsonn

el, ag

ents

of the

Louis

iana A

ttorn

ey

Gene

ral’s

Offic

e or in

dividu

als au

thoriz

ed by

DHH

or th

e Lou

isian

a At

torne

y Gen

eral’

s Offic

e dire

ct ac

cess

to its

data

for th

e pur

pose

of da

ta mi

ning a

nd re

view;

Meets

16.10

.3 En

sure

that

critic

al me

mber

and p

rovid

er In

terne

t and

/or

telep

hone

-bas

ed IV

R fun

ction

s and

infor

matio

n fun

ction

s are

avail

able

to the

appli

cable

Sys

tem us

ers t

wenty

-four

(24)

hour

s a da

y, se

ven (

7) da

ys

a wee

k exc

ept d

uring

perio

ds of

sche

duled

Sys

tem un

avail

abilit

y agr

eed

upon

by D

HH an

d the

CCN

. Una

vaila

bility

caus

ed by

even

ts ou

tside

of

the C

CN’s

span

of co

ntrol

is ou

tside

of th

e sco

pe of

this

requ

ireme

nt;

Meets

Aetna

Bett

er H

ealth

take

s the

secu

rity of

our m

embe

rs’ da

ta ve

ry se

rious

ly an

d so m

aintai

ns si

gnific

ant p

rotoc

ols an

d con

trols

with

rega

rd its

exter

nal u

se. P

er ou

r stan

dard

oper

ating

proc

edur

e re

gard

ing re

ques

ts for

syste

m ac

cess

by an

exter

nal a

genc

y, we

will

confi

gure

a DH

H-su

pplie

d PC

or la

ptop s

uch t

hat a

uthor

ized e

xtern

al us

ers h

ave a

cces

s – vi

a Citri

x – to

a se

cure

, inqu

iry-o

nly en

viron

ment

wher

ein th

ey m

ay cr

eate

and/o

r gen

erate

repo

rts on

an ad

-hoc

basis

. W

e will

reac

h mutu

al ag

reem

ent w

ith D

HH on

the n

umbe

r of s

taff

memb

ers t

hat n

eed a

NID

numb

er gr

antin

g the

m ro

le-ba

sed a

cces

s as

a no

n-Ae

tna B

etter

Hea

lth us

er. A

uthor

ized u

sers

will h

ave a

cces

s to

SPOC

, Aetn

a’s S

ingle

Point

of C

ontac

t Help

Des

k, pr

ovidi

ng to

ll-fre

e sys

tem an

d tec

hnica

l sup

port

24/7/

365.

SPOC

perso

nnel

will

answ

er qu

estio

ns re

gard

ing A

etna B

etter

Hea

lth’s

Syste

m fun

ction

s an

d cap

abilit

ies; r

epor

t rec

urrin

g pro

gram

matic

and o

pera

tion


139

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.10

.4 En

sure

that

at a m

inimu

m all

othe

r Sys

tem fu

nctio

ns an

d inf

orma

tion a

re av

ailab

le to

the ap

plica

ble sy

stem

user

s betw

een t

he

hour

s of 7

a.m. a

nd 7p

.m., C

entra

l Tim

e, Mo

nday

thro

ugh F

riday

;

Meets

16.10

.5 En

sure

that

the sy

stems

and p

roce

sses

with

in its

span

of co

ntrol

asso

ciated

with

its da

ta ex

chan

ges w

ith D

HH’s

FI an

d/or E

nroll

ment

Brok

er an

d its

contr

actor

s are

avail

able

and o

pera

tiona

l;

Meets

16.10

.6 En

sure

that

in the

even

t of a

decla

red m

ajor f

ailur

e or d

isaste

r, the

CCN

’s co

re el

igibil

ity/en

rollm

ent a

nd cl

aims p

roce

ssing

syste

m sh

all

be ba

ck on

line w

ithin

seve

nty-tw

o (72

) hou

rs of

the fa

ilure

’s or

disa

ster’s

oc

curre

nce;

Meets

16.10

.7 No

tify de

signa

ted D

HH st

aff vi

a pho

ne, fa

x and

/or el

ectro

nic m

ail

withi

n sixt

y (60

) minu

tes up

on di

scov

ery o

f a pr

oblem

with

in or

outsi

de

the C

CN’s

span

of co

ntrol

that m

ay je

opar

dize o

r is je

opar

dizing

av

ailab

ility a

nd pe

rform

ance

of cr

itical

syste

ms fu

nctio

ns an

d the

av

ailab

ility o

f criti

cal in

forma

tion a

s defi

ned i

n this

Sec

tion,

includ

ing an

y pr

oblem

s imp

actin

g sch

edule

d exc

hang

es of

data

betw

een t

he C

CN an

d DH

H or

DHH

’s FI

. In its

notifi

catio

n, the

CCN

shall

expla

in in

detai

l the

impa

ct to

critic

al pa

th pr

oces

ses s

uch a

s enr

ollme

nt ma

nage

ment

and

enco

unter

subm

ission

proc

esse

s;

Meets

16.10

.8 No

tify de

signa

ted D

HH st

aff vi

a pho

ne, fa

x, an

d/or e

lectro

nic

mail w

ithin

fiftee

n (15

) minu

tes up

on di

scov

ery o

f a pr

oblem

that

resu

lts

in de

lays i

n rep

ort d

istrib

ution

or pr

oblem

s in o

n-lin

e acc

ess t

o criti

cal

syste

ms fu

nctio

ns an

d info

rmati

on du

ring a

busin

ess d

ay, in

orde

r for

the

appli

cable

wor

k acti

vities

to be

resc

hedu

led or

hand

led ba

sed o

n Sys

tem

unav

ailab

ility p

rotoc

ol;

Meets

16.10

.9 Pr

ovide

infor

matio

n on S

ystem

unav

ailab

ility e

vents

, as w

ell as

sta

tus up

dates

on pr

oblem

reso

lution

, to ap

prop

riate

DHH

staff.

At a

minim

um th

ese u

pdate

s sha

ll be p

rovid

ed on

an ho

urly

basis

and m

ade

avail

able

via ph

one a

nd/or

elec

tronic

mail

, and

;

Meets

prob

lems t

o app

ropr

iate p

erso

nnel

for fo

llow-

up; r

edire

ct pr

oblem

s or

quer

ies th

at ar

e not

supp

orted

by th

e Sys

tems H

elp D

esk,

as

appr

opria

te, vi

a a te

lepho

ne tr

ansfe

r or o

ther a

gree

d upo

n me

thodo

logy;

and r

edire

ct pr

oblem

s or q

uerie

s spe

cific

to da

ta ac

cess

autho

rizati

on to

the a

ppro

priat

e DHH

perso

nnel.

Rec

urrin

g pr

oblem

s not

spec

ific to

Sys

tems u

nava

ilabil

ity id

entifi

ed by

the

Syste

ms H

elp D

esk w

ill be

docu

mente

d and

repo

rted t

o Aetn

a Bett

er

Healt

h man

agem

ent w

ithin

one (

1) bu

sines

s day

of re

cogn

ition s

o tha

t de

ficien

cies c

an be

prom

ptly c

orre

cted.

An is

sue m

anag

emen

t sy

stem

will a

ssist

in th

at re

gard

, pro

viding

SPO

C pe

rsonn

el an

au

tomate

d mea

ns to

reco

rd, tr

ack a

nd re

port

all qu

estio

ns an

d/or

prob

lems r

epor

ted to

the S

ystem

s Help

Des

k. Ae

tna B

etter

Hea

lth ha

s stan

dard

oper

ating

proc

edur

es re

gard

ing

notifi

catio

n to o

ur M

edica

id sin

gle-st

ate ag

encie

s sho

uld ou

r sys

tem

or an

y com

pone

nt of

our s

ystem

fail.

Our

Infor

matio

n Man

agem

ent

and S

ystem

s Dire

ctor w

ill be

DHH

’s po

int of

conta

ct re

gard

ing th

is inf

orma

tion.

We w

ill de

velop

proto

cols

with

DHH

rega

rding

such

no

tifica

tion d

uring

read

iness

revie

w an

d ann

ually

ther

eafte

r.


140

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.10

.10 R

esolv

e and

imple

ment

syste

m re

stora

tion w

ithin

sixty

(60)

mi

nutes

of of

ficial

decla

ratio

n of u

nsch

edule

d Sys

tem un

avail

abilit

y of

critic

al fun

ction

s cau

sed b

y the

failu

re of

syste

m an

d tele

comm

unica

tions

tec

hnolo

gies w

ithin

the C

CN’s

span

of co

ntrol.

Uns

ched

uled S

ystem

un

avail

abilit

y to a

ll othe

r Sys

tem fu

nctio

ns ca

used

by sy

stem

and

telec

ommu

nicati

ons t

echn

ologie

s with

in the

CCN

’s sp

an of

contr

ol sh

all

be re

solve

d, an

d the

resto

ratio

n of s

ervic

es im

pleme

nted,

withi

n eigh

t (8)

ho

urs o

f the o

fficial

decla

ratio

n of S

ystem

unav

ailab

ility.

Meets

16.10

.10.1

Cumu

lative

Sys

tems u

nava

ilabil

ity ca

used

by sy

stems

and/o

r IS

infra

struc

ture t

echn

ologie

s with

in the

CCN

’s sp

an of

contr

ol sh

all no

t ex

ceed

twelv

e (12

) hou

rs du

ring a

ny co

ntinu

ous t

wenty

(20)

busin

ess

day p

eriod

; and

Meets

16.10

.11 W

ithin

five (

5) bu

sines

s day

s of th

e occ

urre

nce o

f a pr

oblem

wi

th sy

stem

avail

abilit

y, the

CCN

shall

prov

ide D

HH w

ith fu

ll writt

en

docu

menta

tion t

hat in

clude

s a co

rrecti

ve ac

tion p

lan de

scrib

ing ho

w the

CC

N wi

ll pre

vent

the pr

oblem

from

reoc

curri

ng.

Meets

16.11

Con

tinge

ncy P

lan

16.11

.1 Th

e CCN

, reg

ardle

ss of

the a

rchite

cture

of its

Sys

tems,

shall

de

velop

and b

e con

tinua

lly re

ady t

o inv

oke,

a con

tinge

ncy p

lan to

prote

ct the

avail

abilit

y, int

egrity

, and

secu

rity of

data

durin

g une

xpec

ted fa

ilure

s or

disa

sters,

(eith

er na

tural

or m

an-m

ade)

to co

ntinu

e ess

entia

l ap

plica

tion o

r sys

tem fu

nctio

ns du

ring o

r imme

diatel

y foll

owing

failu

res o

r dis

aster

s.

Meets

Di

sast

er R

ecov

ery a

nd B

usin

ess C

ontin

uity

Ae

tna B

etter

Hea

lth's

disas

ter ba

ckup

and r

ecov

ery s

trateg

y is t

o pr

ovide

and m

aintai

n an i

ntern

al dis

aster

reco

very

capa

bility

. This

str

ategy

leve

rage

s the

inter

nal c

ompu

ter pr

oces

sing c

apac

ity of

two

state

of the

art, h

arde

ned c

ompu

ter ce

nters

locate

d in b

oth


141

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.11

.2 Co

nting

ency

plan

s sha

ll inc

lude a

disa

ster r

ecov

ery p

lan (D

RP)

and a

busin

ess c

ontin

uity p

lan (B

CP).

A DR

P is

desig

ned t

o rec

over

sy

stems

, netw

orks

, wor

kstat

ions,

appli

catio

ns, e

tc. in

the e

vent

of a

disas

ter. A

BCP

shall

focu

s on r

estor

ing th

e ope

ratio

nal fu

nctio

n of th

e or

ganiz

ation

in th

e eve

nt of

a disa

ster a

nd in

clude

s item

s rela

ted to

IT, a

s we

ll as o

pera

tiona

l item

s suc

h as e

mploy

ee no

tifica

tion p

roce

sses

and

the pr

ocur

emen

t of o

ffice s

uppli

es ne

eded

to do

busin

ess i

n the

em

erge

ncy m

ode o

pera

tion e

nviro

nmen

t. The

prac

tice o

f inclu

ding b

oth

the D

RP an

d the

BCP

in th

e con

tinge

ncy p

lannin

g pro

cess

is a

best

prac

tice.

Meets

16.11

.3 Th

e CCN

shall

have

a Co

nting

ency

Plan

that

must

be su

bmitte

d to

DHH

for ap

prov

al no

later

than

thirty

(30)

days

from

the d

ate th

e Co

ntrac

t is si

gned

.

Meets

16.11

.4 At

a mi

nimum

, the C

ontin

genc

y Plan

shall

addr

ess t

he fo

llowi

ng

scen

arios

: Me

ets

16.11

.4.1

The c

entra

l com

puter

insta

llatio

n and

resid

ent s

oftwa

re ar

e de

stroy

ed or

dama

ged;

Meets

16.11

.4.2 T

he sy

stem

inter

rupti

on or

failu

re re

sultin

g fro

m ne

twor

k, op

erati

ng ha

rdwa

re, s

oftwa

re, o

r ope

ratio

ns er

rors

that c

ompr

omise

the

integ

rity of

tran

sacti

on th

at ar

e acti

ve in

a liv

e sys

tem at

the t

ime o

f the

outag

e;

Meets

16.11

.4.3 S

ystem

inter

rupti

on or

failu

re re

sultin

g fro

m ne

twor

k, op

erati

ng

hard

ware

, soft

ware

or op

erati

ons e

rrors

that c

ompr

omise

the i

ntegr

ity of

da

ta ma

intain

ed in

a liv

e or a

rchiva

l sys

tem;

Meets

Midd

letow

n and

Wind

sor,

Conn

ectic

ut. B

oth fa

cilitie

s hav

e exte

nsive

fire

supp

ress

ion sy

stems

, dua

l inco

ming

powe

r fee

ds, U

PS, a

nd

back

up di

esel

gene

rator

s sup

portin

g 24/7

/365 o

pera

tion.

Phys

ical

acce

ss is

stric

tly co

ntroll

ed an

d mon

itore

d, an

d acc

ess t

o vita

l are

as

is se

greg

ated b

y floo

r and

busin

ess f

uncti

on as

appr

opria

te. T

he tw

o da

ta ce

nters

hous

e Aetn

a Bett

er H

ealth

’s co

mpute

r pro

cess

ing

capa

bilitie

s on t

hree

majo

r plat

forms

, main

frame

(Z/O

S), m

id-ra

nge

(Var

ious U

NIX

versi

ons),

and L

AN (W

indow

s on X

86 pr

oces

sors)

. Th

e data

cente

rs ar

e loa

d bala

nced

and s

upple

mente

d by q

uick-s

hip

and c

apac

ity-o

n-de

mand

contr

acts,

perm

itting

each

cente

r to b

ack t

he

other

up in

the e

vent

of dis

aster

. We m

aintai

n con

tracts

with

natio

nal

vend

ors p

rovid

ing fo

r rep

lacem

ent e

quipm

ent a

nd su

pplem

ental

ca

pacit

y as n

eede

d, fur

ther p

romo

ting c

ompli

ance

with

reco

very

time

objec

tives

(RTO

). In

the ev

ent o

f a da

ta ce

nter d

isaste

r, the

RTO

to re

sume

mos

t pr

oduc

tion p

roce

ssing

is fo

ur da

ys fr

om di

saste

r dec

larati

on fo

r all

mainf

rame

and m

id-ra

nge s

ystem

s and

five d

ays f

or LA

N sy

stems

. Po

rtfoli

os of

high

ly av

ailab

le ap

plica

tions

, suc

h as w

eb an

d pha

rmac

y, ha

ve R

TO’s

of six

hour

s or le

ss. T

hese

appli

catio

ns ut

ilize m

irror

ing

and/o

r load

balan

cing t

echn

ologie

s betw

een t

he da

tacen

ters t

o mak

e ce

rtain

that th

e red

uced

RTO

’s ca

n be m

et. A

etna B

etter

Hea

lth’s

voice

and d

ata ne

twor

k bac

kbon

es ar

e full

y red

unda

nt us

ing S

ONET

rin

g tec

hnolo

gy an

d are

reco

vere

d with

in 1 h

our o

f a da

ta ce

nter

outag

e. In

shor

t, Aetn

a Bett

er H

ealth

’s da

ta ce

nter r

ecov

ery s

trateg

y an

d its

appli

catio

n RTO

’s ar

e con

sisten

t with

or be

tter t

han i

ndus

try


142

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.11

.4.4 S

ystem

inter

rupti

on or

failu

re re

sultin

g fro

m ne

twor

k, op

erati

ng

hard

ware

, soft

ware

or op

erati

onal

erro

rs tha

t doe

s not

comp

romi

se th

e int

egrity

of tr

ansa

ction

s or d

ata m

aintai

ned i

n a liv

e or a

rchiva

l sys

tem,

but d

oes p

reve

nt ac

cess

to th

e Sys

tem, s

uch a

s it c

ause

s uns

ched

uled

Syste

m un

avail

abilit

y; an

d

Meets

16.11

.4.5 T

he P

lan sh

all sp

ecify

proje

cted r

ecov

ery t

imes

and d

ata lo

ss

for m

ission

-critic

al Sy

stems

in th

e eve

nt of

a dec

lared

disa

ster.

Meets

16.11

.5 Th

e CCN

shall

annu

ally t

est it

s plan

thro

ugh s

imula

ted di

saste

rs an

d low

er le

vel fa

ilure

s in o

rder

to de

mons

trate

to DH

H tha

t it ca

n res

tore

Syste

ms fu

nctio

ns.

Meets

16.11

.6 In

the ev

ent th

e CCN

fails

to de

mons

trate

throu

gh th

ese t

ests

that it

can r

estor

e Sys

tems f

uncti

ons,

the C

CN sh

all be

requ

ired t

o su

bmit a

corre

ctive

actio

n plan

to D

HH de

scrib

ing ho

w the

failu

re sh

all be

re

solve

d with

in ten

(10)

busin

ess d

ays o

f the c

onclu

sion o

f the t

est.

Meets

16.12

Off

Site

Sto

rage

and

Rem

ote B

ack-

up

16

.12.1

The C

CN sh

all pr

ovide

for o

ff-sit

e stor

age a

nd a

remo

te ba

ck-u

p of

oper

ating

instr

uctio

ns, p

roce

dure

s, re

feren

ce fil

es, s

ystem

do

cume

ntatio

n, an

d ope

ratio

nal fi

les.

Meets

16.12

.2 Th

e data

back

-up p

olicy

and p

roce

dure

s sha

ll inc

lude,

but n

ot be

lim

ited t

o: Me

ets

16.12

.2.1

Desc

riptio

ns of

the c

ontro

ls for

back

-up p

roce

ssing

, inclu

ding

how

frequ

ently

back

-ups

occu

r; Me

ets

16.12

.2.2 D

ocum

ented

back

-up p

roce

dure

s; Me

ets

16.12

.2.3 T

he lo

catio

n of d

ata th

at ha

s bee

n bac

ked u

p (off

-site

and o

n-sit

e, as

appli

cable

); Me

ets

16.12

.2.4 I

denti

ficati

on an

d des

cripti

on of

wha

t is be

ing ba

cked

up as

pa

rt of

the ba

ck-u

p plan

; and

Me

ets

stand

ards

. Da

ta B

acku

p Inf

rastr

uctur

e and

appli

catio

n data

is se

cure

d and

stor

ed of

fsite

on a

daily

basis

. Bac

ked-

up da

ta is

cross

vault

ed be

twee

n the

two

comp

uter c

enter

s, wi

th ma

infra

me ba

ckup

s stor

ed pr

imar

ily on

disk

me

dia an

d mid-

rang

e/LAN

back

ups s

tored

prim

arily

on ta

pe.

Addit

ionall

y, all

main

frame

disk

data

is mi

rrore

d to t

he al

terna

te da

ta ce

nter p

rovid

ing a

simpli

fied a

nd tim

elier

reco

very

for th

at pie

ce of

the

envir

onme

nt. A

ny cu

stome

r data

lost

as a

resu

lt of a

data

cente

r ca

tastro

phe w

ill be

reco

vere

d thr

ough

re-su

bmitta

ls by

servi

ce

prov

iders

and/o

r rec

over

y rec

oncil

iation

team

s. Di

sast

er R

ecov

ery P

lans

The A

etna I

nform

ation

Ser

vices

(AIS

) Exe

cutiv

e IT

Disa

ster R

ecov

ery

Plan

is th

e high

leve

l plan

for r

ecov

ery o

f a da

ta ce

nter a

nd its

critic

al co

mpon

ents.

The

plan

is de

rived

from

over

50 de

tailed

IT

infra

struc

ture p

lans w

hich a

re m

aintai

ned b

y eac

h criti

cal s

uppo

rt ar

ea. T

he pl

ans c

ontai

n pro

cess

es an

d pro

cedu

res t

o rec

over

all

functi

ons,

servi

ces,

and e

quipm

ent w

hich a

re ne

eded

to re

cove

r eit

her d

ata ce

nter.

Thes

e plan

s are

centr

ally m

aintai

ned b

y our

dis

aster

reco

very

grou

p, ar

e stor

ed bo

th loc

ally a

nd of

fsite

and a

re

upda

ted se

mi-a

nnua

lly or

as ne

eded

by th

e res

pecti

ve in

frastr

uctur

e ar

ea.

Appli

catio

n rec

over

y (DB

AR) p

lans d

ocum

ent te

chnic

al an

d ma

nage

ment

conta

cts, a

pplic

ation

reco

very

spec

ifics,

appli

catio

n de

pend

encie

s, int

egra

ted sy

stem

sync

hron

izatio

n, an

d che

ckou

t pr

oced

ures

. The

plan

s are

main

taine

d rou

tinely

and u

tilize

autom

ated

reco

very

proc

esse

s to i

nsur

e app

ropr

iate d

ata re

silien

ce. T

hese

DB

AR pl

ans a

re va

lidate

d ann

ually

with

the a

pplic

ation

owne

rs an

d bu

sines

s use

rs wi

th pe

riodic

integ

rated

table

top si

mulat

ions.


143

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.12

.2.5 A

ny ch

ange

in ba

ck-u

p pro

cedu

res i

n rela

tion t

o the

CCN

’s tec

hnolo

gy ch

ange

s. Me

ets

16.12

.3 DH

H sh

all be

prov

ided w

ith a

list o

f all b

ack-u

p file

s to b

e stor

ed

at re

mote

locati

ons a

nd th

e fre

quen

cy w

ith w

hich t

hese

files

are u

pdate

d. Me

ets

Esca

lation

and n

otific

ation

proc

edur

es ar

e con

taine

d with

in dis

aster

re

cove

ry pla

ns to

verify

reco

very

team

memb

ers,

affec

ted pa

rtner

s an

d bus

iness

unit o

wner

s are

activ

ated i

n a tim

ely m

anne

r. Ou

r IT

depa

rtmen

t’s ro

le du

ring a

disa

ster is

to le

ad, m

anag

e, an

d staf

f the

vario

us re

cove

ry tea

ms, w

hich w

ill als

o be a

ugme

nted b

y add

itiona

l ve

ndor

spec

ialist

s und

er co

ntrac

t for c

ertai

n sup

pleme

ntal re

cove

ry tec

hnolo

gies,

which

our I

T de

partm

ent w

ill co

ordin

ate.

Disa

ster

Rec

over

y Tes

ting

Aetna

Bett

er H

ealth

imple

ments

and m

aintai

ns on

going

en

hanc

emen

ts to

disas

ter re

cove

ry pla

ns an

d pro

cedu

res.

Testi

ng is

pe

rform

ed ac

ross

a va

riety

of ap

plica

tions

and i

nfras

tructu

re

comp

onen

ts on

a re

gular

basis

to pr

omote

ongo

ing di

saste

r rec

over

y re

adine

ss. A

etna B

etter

Hea

lth ro

utine

ly tes

ts re

cove

ry ele

ments

of

third

party

relat

ionsh

ips in

cludin

g tec

hnolo

gy co

mpon

ents,

critic

al pr

oces

ses,

and a

cces

s poin

ts. T

hese

exer

cises

can b

e init

iated

by

eithe

r par

ty an

d Aetn

a Bett

er H

ealth

welc

omes

the o

ppor

tunity

to te

st the

se re

lation

ships

as tim

e and

reso

urce

s per

mit.

Busin

ess C

ontin

uity

Ae

tna B

etter

Hea

lth m

aintai

ns an

d imp

lemen

ts a d

etaile

d bus

iness

co

ntinu

ity pr

ogra

m, w

ith ov

er 30

0 plan

s to a

ddre

ss its

critic

al bu

sines

s wo

rk gr

oup o

pera

tions

. In th

e eve

nt of

an of

fice o

utage

, pro

cess

ing is

tra

nsfer

red t

o sur

viving

offic

es w

ithin

Aetna

Bett

er H

ealth

’s ne

twor

k wi

th litt

le or

no di

srupti

on to

servi

ce le

vels.

The

detai

led bu

sines

s co

ntinu

ity pl

ans a

re m

aintai

ned o

n a qu

arter

ly ba

sis an

d in-

depth

tes

ts ar

e con

ducte

d per

iodica

lly. B

usine

ss C

ontin

uity P

lans a

re al

so

desig

ned t

o mitig

ate th

e effe

cts of

an ex

tende

d sys

tem ou

tage a

nd

loss o

f third

party

busin

ess a

ssoc

iates

; they

also

addr

ess s

ever

e sta

ffing s

horta

ges.

Ae

tna B

etter

Hea

lth’s

Busin

ess C

ontin

uity P

lannin

g and

Rec

over

y Co

ordin

ator is

resp

onsib

le for

coor

dinati

on of

Aetn

a Bett

er H

ealth

’s loc

al DR

/BC

activ

ities a

nd w

orks

clos

ely w

ith A

etna M

edica

id to


144

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

supp

ort c

ontin

uity o

f bus

iness

oper

ation

s. Th

e Bus

iness

Con

tinuit

y Pl

annin

g and

Rec

over

y Coo

rdina

tor’s

conta

ct inf

orma

tion i

s also

on

file w

ith D

HH.

Aetna

Bett

er H

ealth

and A

etna M

edica

id ma

intain

a loc

al ve

rsion

of

the D

isaste

r Rec

over

y/Bus

iness

Con

tinuit

y Plan

spec

ific to

their

re

spec

tive o

pera

tions

and l

ocal

reso

urce

s. Th

e Plan

conta

ins a

listin

g of

key c

ustom

er pr

ioritie

s, ke

y fac

tors t

hat c

ould

caus

e disr

uptio

n, an

d the

timeli

nes w

ithin

which

each

antic

ipates

resu

mptio

n of c

ritica

l cu

stome

r ser

vices

(e.g.

prov

iders’

rece

ipt of

prior

autho

rizati

on

appr

ovals

and d

enial

s), in

cludin

g the

perce

ntage

of re

cove

ry at

certa

in ho

urs,

as w

ell as

key a

ctivit

ies re

quire

d to m

eet th

ose

timeli

nes.

Aetn

a Bett

er H

ealth

’s Bu

sines

s Con

tinuit

y Plan

ning

Coor

dinato

r wor

ks in

conc

ert w

ith ou

r Tra

ining

Dep

artm

ent to

see t

hat

both

the P

lan an

d our

emplo

yee t

raini

ng pr

ogra

m ad

dres

s the

spec

ific

scen

arios

desc

ribed

in th

e ACO

M (S

ectio

n 104

– Bu

sines

s Con

tinuit

y an

d Rec

over

y Plan

). Ae

tna B

etter

Hea

lth w

ill su

bmit a

summ

ary o

f ou

r Bus

iness

Con

tinuit

y and

Rec

over

y Plan

– in

acco

rdan

ce w

ith

ACOM

requ

ireme

nts –

to the

Divi

sion o

f Hea

lth C

are M

anag

emen

t 15

days

after

the s

tart o

f the c

ontra

ct ye

ar an

d ann

ually

ther

eafte

r.

16.13

Rec

ords

Ret

entio

n

16

.13.1

The C

CN sh

all ha

ve on

line r

etriev

al an

d acc

ess t

o doc

umen

ts an

d file

s for

six (

6) ye

ars i

n live

syste

ms fo

r aud

it and

repo

rting p

urpo

ses,

ten (1

0) ye

ars i

n arch

ival s

ystem

s. Se

rvice

s whic

h hav

e a on

ce in

a life

-tim

e ind

icator

(i.e.,

appe

ndix

remo

val, h

yster

ectom

y) ar

e den

oted o

n DH

H’s p

roce

dure

form

ulary

file an

d clai

ms sh

all re

main

in the

cu

rrent/

activ

e clai

ms hi

story

that is

used

in cl

aims e

diting

and a

re no

t to

be ar

chive

d or p

urge

d. On

line a

cces

s to c

laims

proc

essin

g data

shall

be

by th

e Med

icaid

recip

ient ID

, pro

vider

ID an

d/or I

CN (in

terna

l con

trol

numb

er) t

o inc

lude p

ertin

ent c

laims

data

and c

laims

statu

s. Th

e CCN

sh

all pr

ovide

forty

-eigh

t (48

) hou

r tur

naro

und o

r bett

er on

requ

ests

for

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

unde

rstan

ds th

ese

requ

ireme

nts. A

etna B

etter

Hea

lth w

ill me

et Ae

tna B

etter

Hea

lth’s

spec

ificati

ons a

nd co

mply

with

each

of th

e req

uirem

ents

in thi

s se

ction

.


145

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

acce

ss to

infor

matio

n tha

t is si

x (6)

year

s old,

and s

even

ty-tw

o (72

) hou

r tur

naro

und o

r bett

er on

requ

ests

for ac

cess

to in

forma

tion i

n mac

hine

read

able

form,

that

is be

twee

n six

(6) t

o ten

(10)

year

s old.

If an

audit

or

admi

nistra

tive,

civil o

r crim

inal in

vesti

gatio

n or p

rose

cutio

n is i

n pro

gres

s or

audit

findin

gs or

admi

nistra

tive,

civil o

r crim

inal in

vesti

gatio

ns or

pr

osec

ution

s are

unre

solve

d, inf

orma

tion s

hall b

e kep

t in el

ectro

nic fo

rm

until

all ta

sks o

r pro

ceed

ings a

re co

mplet

ed.

16.13

.2 Th

e hist

orica

l enc

ounte

r data

subm

ission

shall

be re

taine

d for

a pe

riod n

ot les

s tha

n six

(6) y

ears,

follo

wing

gene

rally

acce

pted r

etenti

on

guide

lines

.

Meets

16.13

.3 Au

dit T

rails

shall

be m

aintai

ned o

nline

for n

o les

s tha

n six

(6)

year

s; ad

dition

al his

tory s

hall b

e reta

ined f

or no

less

than

ten (

10) y

ears

and s

hall b

e pro

vide f

orty-

eight

(48)

hour

turn

arou

nd or

bette

r on r

eque

st for

acce

ss to

infor

matio

n in m

achin

e rea

dable

form

, that

is be

twee

n six

(6) t

o ten

(10)

year

s old.

Meets

16.14

Info

rmat

ion

Secu

rity a

nd A

cces

s Man

agem

ent

The C

CN’s

syst

em sh

all:

16.14

.1 Em

ploy a

n acc

ess m

anag

emen

t func

tion t

hat r

estric

ts ac

cess

to

varyi

ng hi

erar

chica

l leve

ls of

syste

m fun

ction

ality

and i

nform

ation

. The

ac

cess

man

agem

ent fu

nctio

n sha

ll:

Meets

16.14

.1.1 R

estric

t acc

ess t

o info

rmati

on on

a “le

ast p

rivile

ge” b

asis,

such

as

user

s per

mitte

d inq

uiry p

rivile

ges o

nly, w

ill no

t be p

ermi

tted t

o mod

ify

infor

matio

n;

Meets

16.14

.1.2 R

estric

t acc

ess t

o spe

cific

syste

m fun

ction

s and

infor

matio

n ba

sed o

n an i

ndivi

dual

user

profi

le, in

cludin

g inq

uiry o

nly ca

pabil

ities;

globa

l acc

ess t

o all f

uncti

ons s

hall b

e res

tricted

to sp

ecifie

d staf

f joint

ly ag

reed

to by

DHH

and t

he C

CN; a

nd

Meets

Our t

wo st

ate of

the a

rt, ha

rden

ed co

mpute

r cen

ters l

ocate

d in b

oth

Midd

letow

n and

Wind

sor,

Conn

ectic

ut. B

oth fa

cilitie

s hav

e exte

nsive

fire

supp

ress

ion sy

stems

, dua

l inco

ming

powe

r fee

ds, U

PS, a

nd

back

up di

esel

gene

rator

s sup

portin

g 24/7

/365 o

pera

tion.

Phys

ical

acce

ss is

stric

tly co

ntroll

ed an

d mon

itore

d, an

d acc

ess t

o vita

l are

as

is se

greg

ated b

y floo

r and

busin

ess f

uncti

on as

appr

opria

te Ae

tna B

etter

Hea

lth ha

s a m

ulti-la

yere

d and

comp

rehe

nsive

syste

m se

curity

proc

ess t

o safe

guar

d and

prote

ct da

ta in

our s

ystem

. For

ins

tance

, Aetn

a Bett

er H

ealth

’s inf

orma

tion s

ystem

curre

ntly s

uppo

rts

requ

ired t

echn

ical in

terfac

es an

d com

plies

with

all a

pplic

able

requ

ireme

nts of

the H

ealth

Insu

ranc

e Por

tabilit

y and

Acc

ounta

bility

Ac

t (HI

PAA)

as w

ell as

the p

roce

dure

s, po

licies

, rule

s and

statu

tes in


146

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.14

.1.3 R

estric

t uns

ucce

ssful

attem

pts to

acce

ss sy

stem

functi

ons t

o thr

ee (3

), wi

th a s

ystem

func

tion t

hat a

utoma

ticall

y pre

vents

furth

er

acce

ss at

tempts

and r

ecor

ds th

ese o

ccur

renc

es.

Meets

16.14

.2 Ma

ke S

ystem

infor

matio

n ava

ilable

to du

ly au

thoriz

ed

repr

esen

tative

s of D

HH an

d othe

r stat

e and

fede

ral a

genc

ies to

evalu

ate,

throu

gh in

spec

tions

or ot

her m

eans

, the q

uality

, app

ropr

iaten

ess a

nd

timeli

ness

of se

rvice

s per

forme

d.

Meets

16.14

.3 Co

ntain

contr

ols to

main

tain i

nform

ation

integ

rity. T

hese

contr

ols

shall

be in

plac

e at a

ll app

ropr

iate p

oints

of pr

oces

sing.

The c

ontro

ls sh

all

be te

sted i

n per

iodic

and s

pot a

udits

follo

wing

a me

thodo

logy t

o be

deve

loped

by th

e CCN

and D

HH.

Meets

16.14

.4 En

sure

that

audit

trail

s be i

ncor

pora

ted in

to all

Sys

tems t

o allo

w inf

orma

tion o

n sou

rce da

ta file

s and

docu

ments

to be

trac

ed th

roug

h the

pr

oces

sing s

tages

to th

e poin

t whe

re th

e info

rmati

on is

finall

y rec

orde

d. Th

e aud

it tra

ils sh

all:

Meets

16.14

.4.1 C

ontai

n a un

ique l

og-o

n or t

ermi

nal ID

, the d

ate, a

nd tim

e of

any c

reate

/mod

ify/de

lete a

ction

and,

if app

licab

le, th

e ID

of the

syste

m job

that

effec

ted th

e acti

on;

Meets

16.14

.4.2 H

ave t

he da

te an

d ide

ntific

ation

“stam

p” di

splay

ed on

any o

n-lin

e inq

uiry;

Meets

16.14

.4.3 H

ave t

he ab

ility t

o tra

ce da

ta fro

m the

final

place

of re

cord

ing

back

to its

sour

ce da

ta file

and/o

r doc

umen

t; Me

ets

16.14

.4.4 B

e sup

porte

d by l

isting

s, tra

nsac

tion r

epor

ts, up

date

repo

rts,

trans

actio

n log

s, or

erro

r logs

; and

Me

ets

16.14

.4.5 F

acilit

ate au

diting

of in

dividu

al re

cord

s as w

ell as

batch

audit

s. Me

ets

effec

t dur

ing th

e ter

m of

our c

ontra

ct. E

ach d

ata tr

ansm

ission

is

acco

mpan

ied by

an A

etna B

etter

Hea

lth as

signe

d sec

urity

code

, the

reby

enha

ncing

data

secu

rity, a

nd sy

stem

proc

esse

s pro

vide f

or

the im

media

te ide

ntific

ation

of an

y data

inco

nsist

encie

s, all

owing

for

their p

romp

t res

olutio

n. Ae

tna B

etter

Hea

lth re

cogn

izes t

hat o

ther a

ctivit

ies, d

eeme

d to b

e co

mpar

ative

ly mi

nor,

low-ri

sk ta

sks,

are r

outin

ely pe

rform

ed in

the

inter

est o

f sys

tem se

curity

and s

tabilit

y. It i

s our

expe

rienc

e tha

t the

likeli

hood

of th

ese a

ctivit

ies ha

ving a

n imp

act o

n sys

tem st

abilit

y is

extre

mely

rare

, as t

hey a

re no

t cha

nges

to a

proc

essin

g env

ironm

ent.

Ther

efore

, Aetn

a Bett

er H

ealth

leav

es it

to Ae

tna M

edica

id’s I

T ma

nage

ment

team

to ide

ntify,

trac

k, ma

nage

and r

epor

t on t

hese

ac

tivitie

s. Ex

ample

s of th

ese a

dmini

strati

ve ch

ange

s inc

lude,

but a

re

not li

mited

to th

e foll

owing

:

• Ac

coun

t adm

inistr

ation

(i.e.,

user

profi

les, p

assw

ord r

esets

, use

r de

sktop

appli

catio

n setu

p)

• Ad

ding s

hare

point

s •

Resto

ring f

iles (

indivi

dual

PC’s)

•

Chan

ging b

acku

p tap

es an

d job

sche

dules

•

File s

ystem

adjus

tmen

ts •

Wor

k man

agem

ent (

outpu

t que

ues)

•

Mana

ging s

torag

e poo

ls W

e wi

ll cre

ate

detai

led fil

e spe

cifica

tions

for a

ll dat

a ex

chan

ges

includ

ing; in

put/o

utpu

t (I/O

), pu

rpos

e, se

nder

, rec

eiver

, sec

ure

trans

miss

ion m

ethod

, upd

ate

or fu

ll file

cont

ent,

frequ

ency

, de

pend

encie

s, bu

sines

s rule

s, file

nami

ng, f

ile la

yout

s, an

d th

e ac

coun

ts an

d co

ntro

l sys

tem

that

will

serv

e to s

yste

mat

ically

certi

fy da

ta a

nd b

alanc

es. D

ata

exch

ange

spec

ificat

ions w

ill inc

lude f

ile

trans

miss

ion va

lidat

ion a

nd ve

rifica

tion

proc

edur

es.


147

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.14

.5 Ha

ve in

here

nt fun

ction

ality

that p

reve

nts th

e alte

ratio

n of

finali

zed r

ecor

ds;

Meets

16.14

.6 Pr

ovide

for t

he ph

ysica

l safe

guar

ding o

f its d

ata pr

oces

sing

facilit

ies an

d the

syste

ms an

d info

rmati

on ho

used

ther

ein. T

he C

CN sh

all

prov

ide D

HH w

ith ac

cess

to da

ta fac

ilities

upon

requ

est. T

he ph

ysica

l se

curity

prov

ision

s sha

ll be i

n effe

ct for

the l

ife of

the C

ontra

ct;

Meets

16.14

.7 Re

strict

perim

eter a

cces

s to e

quipm

ent s

ites,

proc

essin

g are

as,

and s

torag

e are

as th

roug

h a ca

rd ke

y or o

ther c

ompa

rable

syste

m, as

we

ll as p

rovid

e acc

ounta

bility

contr

ol to

reco

rd ac

cess

attem

pts, in

cludin

g att

empts

of un

autho

rized

acce

ss;

Meets

16.14

.8 Inc

lude p

hysic

al se

curity

featu

res d

esign

ed to

safeg

uard

pr

oces

sor s

ites t

hrou

gh re

quire

d pro

vision

of fir

e reta

rdan

t cap

abilit

ies,

as w

ell as

smok

e and

elec

trical

alarm

s, mo

nitor

ed by

secu

rity pe

rsonn

el;

Meets

16.14

.9 Pu

t in pl

ace p

roce

dure

s, me

asur

es an

d tec

hnica

l sec

urity

to

proh

ibit u

nauth

orize

d acc

ess t

o the

regio

ns of

the d

ata co

mmun

icatio

ns

netw

ork i

nside

of a

CCN’

s spa

n of c

ontro

l. This

inclu

des,

but is

not

limite

d to,

any p

rovid

er or

mem

ber s

ervic

e app

licati

ons t

hat a

re di

rectl

y ac

cess

ible o

ver t

he In

terne

t, sha

ll be a

ppro

priat

ely is

olated

to en

sure

ap

prop

riate

acce

ss;

Meets

16.14

.10 E

nsur

e tha

t rem

ote ac

cess

user

s of it

s Sys

tems c

an on

ly ac

cess

said

Syste

ms th

roug

h two

-facto

r use

r auth

entic

ation

and v

ia me

thods

such

as V

irtual

Priva

te Ne

twor

k (VP

N), w

hich m

ust b

e prio

r ap

prov

ed by

DHH

no la

ter th

an fif

teen (

15) c

alend

ar da

ys af

ter th

e Co

ntrac

t awa

rd; a

nd

Meets

Aetna

Bett

er H

ealth

’s an

d Aetn

a Med

icaid’

s phy

sical

plants

are

secu

red a

nd ac

cess

limite

d thr

ough

card

read

ers a

nd ac

cess

leve

ls de

termi

ned b

y an i

ndivi

dual’

s role

and r

espo

nsibi

lity. U

nifor

m gu

ards

ar

e ass

igned

to sp

ecific

stati

ons 2

4/7 to

mon

itor a

cces

s. En

try do

ors

to ou

r phy

sical

plants

and s

erve

r roo

ms ar

e arm

ed w

ith ba

dge

read

ers t

hat li

mit a

cces

s exc

ept a

s per

mitte

d by b

uildin

g sec

urity

and

proto

cols.

The

secu

rity sy

stem

reco

rds d

ate an

d tim

e of e

ach d

oor

entry

. Sen

sitive

area

s of o

ur fa

cility

are m

onito

red 2

4/7 by

a vid

eo

secu

rity sy

stem;

CD

back

-up r

ecor

ds ar

e main

taine

d for

revie

w.

Susp

iciou

s acti

vity i

n or n

ear s

ecur

e doo

rs mu

st be

repo

rted t

o int

erna

l sec

urity

. Our

data

syste

ms in

clude

state

-of-t

he-a

rt fire

and

smok

e dete

ction

syste

ms an

d fire

repr

essio

n sys

tems s

pecif

ically

de

signe

d for

data

proc

essin

g cen

ters.

Emplo

yees

rece

ive in

itial a

nd

regu

lar tr

aining

rega

rding

phys

ical s

ecur

ity an

d HIP

AA re

quire

ments

. Pe

r our

stan

dard

oper

ating

proc

edur

e reg

ardin

g req

uests

for s

ystem

ac

cess

by an

exter

nal a

genc

y, we

will

confi

gure

a DH

H-su

pplie

d PC

or la

ptop s

uch t

hat a

uthor

ized e

xtern

al us

ers h

ave a

cces

s – vi

a Citri

x – t

o a se

cure

, inqu

iry-o

nly en

viron

ment

wher

ein th

ey m

ay cr

eate

and/o

r gen

erate

repo

rts on

an ad

-hoc

basis

. Re

mote

user

s can

only

acce

ss ou

r sys

tems v

ia VP

N. U

sers

must

have

both

a vali

d ide

ntific

ation

numb

er an

d pas

swor

d to g

ain en

try to

the

syste

m.

Each

user

has a

uniqu

e use

r ID

numb

er. U

sers

must

have

an se

ven

(7) le

tter u

sed i

denti

ficati

on nu

mber

and a

n eigh

t digi

t/lette

r pas

swor

d tha

t mus

t inclu

de a

comb

inatio

n of le

tters,

numb

ers a

nd sy

mbols

. Th

e sys

tem re

quire

s tha

t a us

er’s

pass

word

by re

-set o

n a re

gular

ba

sis an

d for

bids a

user

repe

ating

pass

word

s. Af

ter th

ree f

ailed


148

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.14

.11 C

omply

with

reco

gnize

d ind

ustry

stan

dard

s gov

ernin

g sec

urity

of

state

and f

eder

al au

tomate

d data

proc

essin

g sys

tems a

nd in

forma

tion

proc

essin

g. As

a mi

nimum

, the C

CN sh

all co

nduc

t a se

curity

risk

asse

ssme

nt an

d com

munic

ate th

e res

ults i

n an i

nform

ation

secu

rity pl

an

prov

ided n

o late

r tha

n fifte

en (1

5) ca

lenda

r day

s afte

r the

Con

tract

awar

d. Th

e risk

asse

ssme

nt sh

all al

so be

mad

e ava

ilable

to ap

prop

riate

feder

al ag

encie

s.

Meets

att

empts

the s

ystem

bloc

ks en

try an

d the

user

can o

nly ga

in ac

cess

thr

ough

our S

ystem

Adm

inistr

ation

team

. Ae

tna B

etter

Hea

lth ha

s stan

dard

proto

cols

to en

crypt

PHI. T

hese

pr

otoco

ls inc

lude a

secu

rity fe

ature

that

encry

pts P

HI on

all e

-mail

an

d othe

r tra

nsac

tions

. We h

ave a

full s

uite o

f sec

urity

and

confi

denti

ality

polic

ies an

d pro

cedu

res.

All e

mploy

ees r

eceiv

e tra

ining

on

HIP

AA, s

ecur

ity an

d con

fiden

tiality

polic

ies an

d pro

cedu

res.

Ae

tna B

etter

Hea

lth w

ill pe

rform

a se

curity

risk a

sses

smen

t and

inf

orm

DHH

of the

resu

lts w

ithin

15 ca

lenda

r afte

r Con

tract

awar

d.

16.15

Aud

it Re

quire

men

ts

16.15

.1 Th

e CCN

shall

ensu

re th

at the

ir Sys

tems f

acilit

ate th

e aud

iting o

f ind

ividu

al cla

ims.

Adeq

uate

audit

trail

s sha

ll be p

rovid

ed th

roug

hout

the

Syste

ms. T

o fac

ilitate

claim

s aud

iting,

the C

CN sh

all en

sure

that

the

Syste

ms fo

llows

, at a

mini

mum,

the g

uideli

nes a

nd ob

jectiv

es of

the

Amer

ican I

nstitu

te of

Certif

ied P

ublic

Acc

ounta

nts (A

ICPA

) Aud

it and

Ac

coun

t Guid

e, Th

e Aud

itor’s

Stud

y and

Eva

luatio

n of In

terna

l Con

trol in

El

ectro

nic D

ata P

roce

ssing

(EDP

) Sys

tems.

Meets

16.15

.2 Th

e CCN

shall

main

tain a

nd ad

here

to an

inter

nal E

DP P

olicy

an

d Pro

cedu

res m

anua

l ava

ilable

for D

HH re

view

upon

requ

est, w

hich a

t a m

inimu

m sh

all co

ntain

and a

ssur

e all a

cces

sible

scre

ens u

sed

throu

ghou

t the s

ystem

adhe

re to

the s

ame G

raph

ical U

ser I

nterfa

ce

(GUI

) stan

dard

s, an

d tha

t all p

rogr

amme

rs sh

all ad

here

to th

e high

est

indus

try st

anda

rds f

or co

ding,

testin

g, ex

ecuti

ng an

d doc

umen

ting a

ll sy

stem

activ

ities.

The m

anua

l is su

bject

to ye

arly

audit

, by b

oth st

ate an

d ind

epen

dent

audit

ors.

Meets

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd un

derst

ands

thes

e re

quire

ments

. Aetn

a Bett

er H

ealth

will

meet

Aetna

Bett

er H

ealth

’s sp

ecific

ation

s and

comp

ly wi

th ea

ch of

the r

equir

emen

ts in

this

secti

on.


149

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.16

Sta

te A

udits

16

.16.1

The C

CN sh

all pr

ovide

to st

ate au

ditor

s (inc

luding

legis

lative

au

ditor

s), up

on w

ritten

requ

est, f

iles f

or an

y spe

cified

acco

untin

g per

iod

that a

valid

Con

tract

exist

s in a

file f

orma

t or a

udit d

efine

d med

ia,

magn

etic t

apes

, CD

or ot

her m

edia

comp

atible

with

DHH

and/o

r stat

e au

ditor

’s fac

ilities

. The

CCN

shall

prov

ide in

forma

tion n

eces

sary

to as

sist

the st

ate au

ditor

in pr

oces

sing o

r utili

zing t

he fil

es.

Meets

16.16

.2 If t

he au

ditor

’s fin

dings

point

to di

scre

panc

ies or

erro

rs, th

e CCN

sh

all pr

ovide

a wr

itten c

orre

ctive

actio

n plan

to D

HH w

ithin

ten (1

0)

busin

ess d

ays o

f rec

eipt o

f the a

udit r

epor

t.

Meets

16.16

.3 At

the c

onclu

sion o

f the a

udit,

an ex

it inte

rview

is co

nduc

ted an

d a y

early

writt

en re

port

of all

findin

gs an

d rec

omme

ndati

ons i

s pro

vided

by

the st

ate au

ditor

s. Th

ese f

inding

s sha

ll be r

eview

ed by

DHH

and

integ

rated

into

the C

CN’s

EDP

manu

al.

Meets

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd un

derst

ands

thes

e re

quire

ments

. Aetn

a Bett

er H

ealth

will

meet

Aetna

Bett

er H

ealth

’s sp

ecific

ation

s and

comp

ly wi

th ea

ch of

the r

equir

emen

ts in

this

secti

on.

16.17

Inde

pend

ent A

udit

16.17

.1 Th

e CCN

shall

be re

quire

d to c

ontra

ct wi

th an

inde

pend

ent fi

rm,

subje

ct to

the w

ritten

appr

oval

of DH

H, w

hich h

as ex

perie

nce i

n co

nduc

ting E

DP an

d com

plian

ce au

dits i

n acc

orda

nce w

ith ap

plica

ble

feder

al an

d stat

e aud

iting s

tanda

rds f

or ap

plica

tions

comp

arab

le wi

th the

sc

ope o

f the C

ontra

ct’s S

ystem

s app

licati

on. T

he in

depe

nden

t firm

shall

:

Meets

16.17

.1.1 P

erfor

m lim

ited s

cope

EDP

audit

s on a

n ong

oing a

nd an

nual

basis

for c

ontra

ct co

mplia

nce u

sing D

HH’s

audit

prog

ram

spec

ificati

ons

at the

conc

lusion

of th

e firs

t twelv

e (12

) mon

th op

erati

on pe

riod a

nd ea

ch

twelv

e (12

) mon

th pe

riod t

here

after

, whil

e the

Con

tract

is in

force

with

DH

H an

d at th

e con

clusio

n of th

e Con

tract;

and

Meets

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd un

derst

ands

thes

e re

quire

ments

. Aetn

a Bett

er H

ealth

will

meet

Aetna

Bett

er H

ealth

’s sp

ecific

ation

s and

comp

ly wi

th ea

ch of

the r

equir

emen

ts in

this

secti

on.


150

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

R:

Info

rmat

ion

Sys

tem

s

Requ

irem

ent

Meet

s or

Exce

eds

Expl

anat

ion

16.17

.1.2 P

erfor

m a c

ompr

ehen

sive a

udit o

n an a

nnua

l bas

is, fo

r co

ntrols

plac

ed in

oper

ation

and

oper

ation

effec

tiven

ess,

to de

termi

ne

the C

CN’s

comp

lianc

e with

the o

bliga

tions

spec

ified i

n the

Con

tract

and

the S

ystem

s Guid

e.

Meets

16.17

.2 Th

e aud

iting f

irm sh

all de

liver

to th

e CCN

and t

o DHH

a re

port

of fin

dings

and r

ecom

mend

ation

s with

in thi

rty (3

0) ca

lenda

r day

s of th

e clo

se of

each

audit

. The

repo

rt sh

all be

prep

ared

in ac

cord

ance

with

ge

nera

lly ac

cepte

d aud

iting s

tanda

rds f

or E

DP ap

plica

tion r

eview

s.

Meets

16.17

.3 DH

H sh

all us

e the

findin

gs an

d rec

omme

ndati

ons o

f eac

h rep

ort

as pa

rt of

its m

onito

ring p

roce

ss.

Meets

16.17

.4 Th

e CCN

shall

deliv

er to

DHH

a co

rrecti

ve ac

tion p

lan to

addr

ess

defic

iencie

s ide

ntifie

d dur

ing th

e aud

it with

in ten

(10)

busin

ess d

ays o

f re

ceipt

of th

e aud

it rep

ort. A

t the c

onclu

sion o

f the a

udit,

an ex

it inte

rview

is

cond

ucted

and a

year

ly wr

itten r

epor

t of a

ll find

ings a

nd

reco

mmen

datio

ns is

prov

ided b

y the

inde

pend

ent a

uditin

g firm

. The

se

findin

gs ar

e rev

iewed

by D

HH an

d sha

ll bec

ome a

part

of the

CCN

’s ED

P ma

nual.

Meets

16.17

.5 Au

dits s

hall i

nclud

e a sc

ope n

eces

sary

to ful

ly co

mply

with

AICP

A Pr

ofess

ional

Stan

dard

s for

Rep

ortin

g on t

he P

roce

ssing

of

Tran

sacti

ons b

y Ser

vice O

rgan

izatio

ns (S

AS-7

0 Rep

ort).

Meets


151

125 R.8



R.8 Describe your information systems change management and version control processes. In your description address your production control operations.

Aetna Better Health is aware that effective and efficient change order management of our hardware and software resources is a critical administrative process. Our Chief Operating Officer (COO) has authority and responsibility over our IT change order management. Aetna Better Health has a comprehensive IT program. Our IT organization is efficient and has effectively supported Medicaid managed care for over 25 years and today is the system managing the health information of 1.3 million Medicaid health plan members in 10 states. Aetna Medicaid’s IT organization is flexible and responsive, led by a Vice President of Technology Support with over 15 years’ related experience. Aetna Medicaid’s IT organization includes 71 experienced and trained Phoenix-based FTEs responsible for the hardware and software change order processes. Aetna Better Health’s COO manages the business continuity process and holds Aetna Medicaid accountable for the Change Order Process (COP). Aetna Medicaid’s COP emphasizes detailed communication of business and associated technical requirements. It includes comprehensive planning and coordinating of project tasks, scheduling for minimum disruption, and change management quality control. Aetna Medicaid’s process protects Aetna Better Health’s core business applications and the systems from changes that may be disruptive or have an unacceptable level of risk. Our COP manages hardware/software changes through an approach based on technical and business evaluation, prioritization, coordination, and optimum use of resources. Aetna Medicaid uses Remedy Change Management system version 7.5 PS4 from BMC Software to manage system change requests.

As part of Aetna Better Health’s change order management process, we define a system change as any modification that impacts the shared network, computing environment, or business application by altering its existing state. This includes, but is not limited to:

• System Hardware: Servers or server components, power conditioners, etc.

• System Software: Operating systems, antivirus, core business applications, etc.

• Databases: Microsoft SQL Server, Microsoft Access, etc.

• Network Hardware: Routers, switches, firewalls, VPN, security appliances, etc.

• Desktop Management: Hardware, operating systems, Citrix client, antivirus, etc.

Aetna Better Health assigns system changes to one of three categories:

1) Full Cycle: by default all changes fall into this category. These changes are discussed and may be approved at the weekly IT COP meeting

2) Expedited: change needs to occur prior to the next IT COP meeting. These changes require approval of Aetna Better Health’s COO or designee and Aetna Medicaid’s IT Director; and

3) Routine: a minor change (e.g. changing a web page document) using an accepted process

Aetna Better Health maintains strict policies and procedures safeguarding against unauthorized modifications to our systems. When an IT Change Control request is submitted, a new request is created in Remedy. Requests need to be approved by both the support group and the committee


152



members. If an IT Work Request or an IT Change Control is not approved, or requires prior approval, it is sent back to the requestor with reasons for the denial. A system change may be minor (changes to access for an employee) or major (system migration or changes that impact operations). Minor system changes are processed, sent through the committee for approval, then confirmation of the change is provided to the employee’s manager. A major change is sent to Department of Health and Hospitals (DHH) for approval before receiving authorization from the Change Control Committee. With approval, development and testing complete, the change moves to production.

Aetna Better Health recognizes that other activities, deemed to be comparatively minor, low-risk tasks, are routinely performed in the interest of system security and stability. It is our experience that the likelihood of these activities having an impact on system stability is extremely rare, as they are not changes to a processing environment. Therefore, Aetna Better Health leaves it to Aetna Medicaid’s IT management team to identify, track, manage and report on these activities. Examples of these administrative changes include, but are not limited to the following:

• Account administration (i.e., user profiles, password resets, user desktop application setup)

• Adding share points

• Restoring files (individual PC’s)

• Changing backup tapes and job schedules

• File system adjustments

• Work management (output queues)

• Managing storage pools

Aetna Better Health mitigates the risk associated with any upgrade by: (1) releasing any upgrade in a secure “back office” environment to test its impact prior to promoting it to the “production” environment; (2) backing up the entire system prior to the upgrade so we can reverse the process and return the system to its pre-upgrade state if necessary; (3) requiring the hardware/software vendor to have its staff on-site to facilitate and monitor the COP; and (4) training Aetna Better Health employees/end users on the conversion/upgrade. Standard operating procedure mandates that Aetna Better Health provides DHH with the following information prior to any system conversion or upgrade:

• System (hardware/software) to be upgraded and the nature of the upgrade

• Timeframe for the upgrade

• How PHI will be secured and protected during the upgrade

• How the upgrade will be tested prior to final promotion

• A plan to revert to the original system if there’s a problem

Although there is a standard Aetna Better Health committee that reviews conversion/upgrade requests; it is the standard operating procedure that Aetna Better Health forms a COP team to manage a major conversion/upgrade. This team is led by Aetna Better Health’s COO or designee. Aetna Better Health upgraded QNXT™ to version 3.4 in July 2010. By adhering to our COP tools, this upgrade was executed without a disruption to system availability and zero deficits. The Aetna Better Health team responsible for this successful upgrade fully documented


153



the process. This documentation is a valuable resource for future system conversion/upgrades and will be a yardstick to guide future system conversion/upgrade activities.

Aetna Better Health’s change management process provides a structured, fully recoverable framework in which to implement system changes in accordance and on schedule with federal, state and contract-specific requirements. Our implementation schedule for Louisiana will provide for full conformance with future federal and/or DHH specific standards for encounter data exchange in accordance with the readiness review schedule. The COO will notify DHH personnel of major changes, upgrades, modifications or updates to the following core production systems or associated operating software within our span of control at least ninety (90) calendar days prior to the projected effective date of the change:

• Claims processing

• Eligibility and enrollment processing

• Service authorization management

• Provider enrollment and data management

• Conversions of core transaction management Systems

Associated documentation and/or manuals will be revised accordingly, and electronic versions of the drafts presented to DHH for review and approval no less than thirty (30) days prior to implementation in an easily accessible, near real-time format. Revisions to printed manuals will occur within ten (10) business days of DHH’s approval of the electronic draft.

Standard policy will prohibit the scheduling of systems unavailability attributable to maintenance, repair and/or upgrade activities during hours that might compromise or prevent critical business operations without DHH’s prior approval.

Additional policies will provide for the response to DHH notification of system problems not resulting in unavailability according to the following timeline:

• Within five (5) calendar days of receiving notification from DHH, Aetna Better Health will respond in writing to notices of system problems.

• Within fifteen (15) calendar days, the correction shall be made or a requirements analysis and specifications document will be due.

• Aetna Better Health will correct the deficiency by an effective date to be determined by DHH.

Please refer to the next page for a flowchart illustrating the IT Change Control Process that Aetna Better Health will use during this contract period.


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126 R.9



R.9 Describe your approach to demonstrating the readiness of your information

systems to DHH prior to the start date of operations. At a minimum your description must address:

● provider contract loads and associated business rules;

● eligibility/enrollment data loads and associated business rules;

● claims processing and adjudication logic; and

● encounter generation and validation prior to submission to DHH.

Aetna Better Health and its affiliates have been implementing Medicaid managed care information systems for over 25 years. We recently implemented three new encounter systems for Medicaid managed care programs in Florida, Pennsylvania and Illinois and expanded our Missouri Medicaid managed care program into two large regions. Today, Aetna Better Health administers or manages Medicaid health plans providing coverage to over 1.3 million members in 10 states. Our implementations leverage a proven methodology that is rigorous, yet accommodating to the unique needs of any given contract. We initiate certain preliminary implementation activities prior to contract award, creating an infrastructure that expedites subsequent implementation activities. Foremost among these preliminary activities is formation of a Lead Team comprising personnel from every operating division, including any division involved in information systems implementation. Twenty (20) staff members in the following roles/departments will coordinate implementation of the Coordinated Care Network (CCN) Program, providing the direction and prompt, consensus-based, decision-making necessary to keep implementation on task and on schedule. The Lead Team is chaired by the Aetna Better Health Chief Operations Officer (COO).

Louisiana Lead Team Regional Vice President VP of Business Development Finance – CFO Medical Director Information Management and Systems Director

Implementation Director

Compliance Officer Enrollment/Disenrollment Manager Encounter Management Finance – TPL & COB Provider Payment & Reimbursement Human Resources Information Technology (IT) Reporting Member Services Network Management OPKM/Claims Audit/BAM/Claims Provider Data Services Provider Services Appeals/Grievance Training

Aetna Better Health’s Lead Team bears responsibility for leading and coordinating the testing and issue/defect management of all business applications associated with any implementation. With regard to Louisiana, this includes appointing a Technology Lead to manage execution of the DHH-provided test plan and associated activities prior to Contract’s Go-Live Date. Aetna Better Health will initiate regular meetings with DHH personnel upon contract award to


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collaborate on a test approach that best aligns unit, end-to-end and DHH’s Readiness Review testing. Should DHH provide specific test scripts or scenarios, we will endeavor to roll those into our unit and/or end-to-end testing whenever possible. Should the timing of DHH’s request preclude that option, DHH’s test scripts or scenarios will be executed independently. Aetna Better Health’s implementation tests comprise IT-facilitated end-to-end testing of all business and technology functions, daily status meetings, and policies and procedures providing for the prompt resolution and/or escalation of any issue. All testing issues are comprehensively tracked, managed and resolved, allowing anyone from IT or related business function to see all issues and participate in and validate their resolution. Critical and potentially show-stopping issues are escalated to Lead Team for discussion and resolution. Daily meetings allow for any roadblock, issue or defect to be resolved as quickly as possible.

Provider Contract Loads and Associated Business Rules Aetna Better Health’s Business Application Management (BAM) Department is responsible for provider contract loads and the configuration of associated business rules. Business rules may be derived from multiple sources, including but not limited to benefit matrices (developed by Aetna Better Health’s own implementation team) defining covered and non-covered services, DHH documentation and this RFP. Once configured, unit and end-to-end (each lasting 8 weeks) testing will validate the desired functionality. The validated contract will then be moved to the production environment, where Provider Data Services (PDS) staff affiliate providers to the contract accordingly. Related processes will coordinate provider enrollment records with the published list of Louisiana Medicaid provider types, specialty, and sub-specialty codes at www.lamedicaid.com prior to the submission of any provider data to DHH, its Fiscal Intermediary or the Enrollment Broker

Eligibility/Enrollment Data Loads and Associated Business Rules Aetna Better Health’s Information Technology department will be responsible for establishing the technical interfaces necessary to support the member eligibility/enrollment data loads associated with this contract. We currently receive, process and update enrollment files, via the required HIPAA transaction code sets, with ten other state agencies. As such, QNXT™, our core information processing system, will readily accept DHH’s initial file containing twenty-four (24) month’s eligibility and enrollment data, as well as subsequent daily, weekly and monthly transaction files once the necessary interface is established. Eligibility and enrollment files within QNXT™, our core information processing system, will be updated within twenty-four (24) hours of receipt. Business rules will identify, among other things, potential duplicate records for a single member such that, upon confirmation by DHH, Eligibility/Enrollment personnel can link or merge the enrollment, service utilization, and customer interaction histories of the duplicate records accordingly.

Systems-related sub-processes supporting Aetna Better Health’s eligibility/enrollment import process include the following:

• File validation for HIPAA compliancy using Instream (a HIPAA transaction validation tool)

• File reformatting from an 834 (HIPAA eligibility format) into a QNXT™-acceptable format

• Pre-Processor execution to query file data against QNXT™ to identify new member record Adds, existing member record Updates, and existing member record Terminations


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• Pre-Processor identification of member records meeting special-needs review to make available for manual handling by Member Services as opposed to import into QNXT™

• Load of membership data to intermediate tables in preparation for import into QNXT™

• Import of membership to from intermediate tables to QNXT™ production

• Reporting to Member Services which includes notification of successful import, statistics reconciling records received on file to records imported and records rejected for manual review, and detailed listings of each rejected record for manual review and handling

• Archiving of daily file from the State, Member Services reports and historical data for auditing and reporting purposes is performed

Claims Processing and Adjudication Logic Aetna Better Health has a well-defined methodology for building, configuring and testing the claims processing capabilities and adjudication logic associated with any new contract. Prior to Contract award, Business Application Management (BAM) analysts will begin analyzing business requirements to design and configure an optimal and efficient system build that will minimize the need for manual processing. As mentioned earlier, OPKM personnel have already reviewed the claims processing requirements of this RFP, its appendices, attachments and systems guide and determined that our systems currently possess the functionality to support them.

Requirements analysis complete, BAM analysts will load the rules and requirements of the CCN Program, including eligibility file layout, provider contracts, fee schedules and member benefits and prior authorization requirements into QNXT™, our core claims adjudication application. Details of the configuration will be documented as the build progresses. A separate group of analyst(s) will then audit and validate the build based on the rules and requirements provided by the health plan and the implementation team. Once validated, the configuring analysts will jointly perform unit testing with the Operations Process Knowledge Management (OPKM) Testing team to validate that the system is operational and meets business requirements. Finally, they will participate in end-to-end testing to see that the system is operating as expected.

Aetna Better Health’s claims processing activities include the application of comprehensive clinical and data related edits supporting the efficient, effective adjudication of claims. QNXT™ has data related edits configured within its software. These are supplemented by two clinical claims editing solutions. The first, iHealth Technologies’ (iHT) Integrated Claims Management Services (ICM Services), maintains select payment policies from one of the industry’s most comprehensive correct coding and Medical Policy content libraries and edits claims accordingly. The second, McKesson’s ClaimCheck®, expands upon those capabilities by enabling our claims management team to define and combine specific claim criteria, such as provider or diagnosis, to deliver enhanced auditing power.

Inbound claims are initially checked for items such as member eligibility, covered services, excessive or unusual services for gender or age (e.g. “medically unlikely”), duplication of services, prior authorization, invalid procedure codes, and duplicate claims. Claims billed in excess of predetermined limits are automatically pended for review, as are any requiring additional documentation (e.g. medical records) in order to determine the appropriateness of the service provided. Professional claims (CMS 1500s) that reach an adjudicated status of “Pay” are


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automatically reviewed against nationally recognized standards such as the Correct Coding Initiative (CCI), and medical policy requirements [e.g., American Medical Association (AMA)], with recommendations applied during an automatic re-adjudication process. Other methodologies utilized throughout the auto adjudication process include, but are not limited to, Multiple Surgical Reductions and Global Day E & M Bundling.

Encounter Generation and Validation Prior to Submission to DHH. Upon Contract award, Aetna Better Health will submit to DHH and its FI a plan for testing the ASC X12N 837 COB in accordance with the Fiscal Intermediary’s three (3) tiered methodology. The plan will include the following activities:

Prior to testing, Aetna Better Health will supply DHH with documentation of provider information publicly available through the Freedom of Information Act (FOIA) from the National Provider and Plan Enumeration System (NPPES). The documentation will map each provider to the corresponding provider types and specialties provided by DHH.

Tier I Aetna Better Health will request, complete and submit to the FI the EDI application and approval forms necessary to obtain a Trading Partner ID .

During the authorization process, the Chief Operating Officer (COO) will contact the FI’s EDI Department to obtain EDI specifications relative to data and format requirements for EDI claims. We will use these specifications to confirm compliance with required data and format requirements prior to any testing.

Concurrent with EDI enrollment, Aetna Better Health will begin testing – at our own expense – with EDIFECS, Molina’s third-party vendor, to certify HIPAA compliance prior to submission of any test files through the Molina Electronic Data Interchange (EDI). Upon successful certification by EDIFECS, we will begin submitting test encounters to the FI’s EDI Coordinator for data and format validation, seeing to it that the following information is included in each encounter file:

• All test files will be submitted with the required 4509999 identifier.

• ‘RP’ is present in X12 field TX-TYPE-CODE field.

• Aetna Better Health’s Medicaid IDs is in loop 2330B segment NM1 in ‘Other Payer Primary Identification Number’

• If line item Coordinated Care Network (CCN) paid amount is submitted, ‘Other Payer Primary Identifier’ in loop 2430 segment SVD is populated with their Medicaid provider number.

• If a contracted provider has a valid NPI and taxonomy code, Aetna Better Health will submit those values in the 837. If the provider is an atypical provider, we will adhere to 837 atypical provider guidelines.

A representative of the lead team will work with the EDI Coordinator to resolve any submission related issues.


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Tier II Once more than 50% of Aetna Better Health’s encounter claims data has successfully passed the FI’s pre-processor edits, the FI will process the encounters through the MMIS Adjudication cycle and the Payment cycle. The Payment cycle will create an 835 transaction, which Aetna Better Health will retrieve via IDEX. The lead team will examine the returned 835s, comparing them to the encounter data claims (837s) submitted to verify that all claims submitted are accounted for. Should any issues arise, Aetna Better Health will use MMIS’ new edit code reports, as well as the MMIS edit code explanation document provided, to help determine the nature of the problem. We will reach out to the FI for assistance if necessary.

Tier III Once satisfactory test results are documented, and the FI moves Aetna Better Health into production, Aetna Better Health will submit encounter files on a monthly basis. We will have established procedures for recouping post-payments available for DHH’s review during the Readiness Review process. These require that we void encounters for any claim recouped in full. For recoupments that result in an adjusted claim value, we submit replacement encounters accordingly.

Demonstration and Assessment of System Readiness To assist DHH in further assessing our Information Systems readiness, Aetna Better Health will provide the following during System Reading Review:

• Our Global Testing Manger will coordinate and manage systems testing as prescribed by DHH’s test plan and outlined in the CCN-P Systems Companion Guide, executing the test cycles necessary to demonstrate the ability of all external data interfaces - including those with Subcontractors - to transmit, receive and process data in HIPAA compliant or DHH specific formats and/or methods, including, but not limited to secure File Transfer Protocol (FTP) over a secure connection such as Virtual Private Network (VPN). We will provide DHH, or the designated contractor, with test data files for systems and interface testing for all external interfaces as necessary.

• We will either provide documentation, such as that described in our response to R16 (regarding protecting the confidentiality of member data), or demonstrate our systems’ and facility’s HIPAA compliance, as specified in the Information Security and Access Management section and as otherwise stated in the RFP.

• We will submit to DHH a description of the associated interface, data and process flow for each business processes described in the CCN-P Systems Companion Guide. These include, but are not limited to:

− Encounter Correction Process

− Resubmissions

− Adjustment Process

• We will provide DHH with a summary of all recent external audit reports, including findings and corrective actions, relating to our proposed systems. Aetna Better Health has engaged KPMG, LLC since 2000 to perform SOC I Type II audits (formerly SAS 70). KPMG’s most recent audit (Report on Controls Placed in Operation and Tests of Operating Effectiveness


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for Claims Processing Controls and Related General Computer Controls of the Phoenix Service Center) included the period December 1, 2009 through November 30, 2010 and reflected an unqualified opinion. We will promptly make additional information on the detail of such system audits available to DHH upon request.

• We will provide the following deliverables required for Readiness Review

Systems-related Deliverables Required for Readiness Review

Network Provider and Subcontractor Registry

NCQA PCP-PCMH™ Recognition Report

Provider Directory Template

Predictive Modeling Specifications

Contingency Plan • Disaster Recovery Plan • Business Continuity Plan

Systems Quality Assurance Plan

Marketing Plan (relative to web-based member/provider communications)

Quality Assurance (QA) Report (including following early warning system performance measures) • Percentage of PCP Practices that provide verified 24/7 phone access with ability to speak with a PCP Practice

clinician (MD, DO, NP, PA, RN, LPN) within 30 minutes of member contact. ≥95% • Percentage of regular and expedited service authorization request processed in timeframes in the contract ≥95%

• Percentage of pre-processed claims that take more than two (2) business days to submit to the FI ≤ 5% • Rejected claims returned to provider with reason code within 15 days of receipt of claims submission ≥99% • Percentage of Call Center calls answered by a live person within 30 seconds

• We will demonstrate that personnel for the following systems-related functions have been hired and trained.


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Aetna Better Health maintains a robust implementation process to see to it that we are able to demonstrate the required systems capabilities at Readiness Review. However, in the instance that a deficiency is identified in the course of Readiness Review, we will provide a Corrective Action Plan addressing the deficiency no later than ten (10) calendar days after notification of the deficiency by DHH.

Systems-related Staff Functions Key Positions:

● Information Management and Systems Director ● Business Continuity Planning and Emergency Coordinator ● Claims Administrator ● Provider Claims Educator

Additional Required Personnel: ● Claims Processing Personnel ● Encounter Processing Personnel


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127 R.10



R.10 Describe your reporting and data analytic capabilities including:

● generation and provision to the State of the management reports prescribed in the RFP;

● generation and provision to the State of reports on request;

● the ability in a secure, inquiry-only environment for authorized DHH staff to create and/or generate reports out of your systems on an ad-hoc basis; and

● Reporting back to providers within the network.

Aetna Better Health administers, manages or owns Medicaid health plans in ten states, requiring an integrated reporting and data analytics technology infrastructure that supports responsive, accurate, complete and timely reporting and data analytics capabilities. Our care coordination and managed care programs rely on data analytics to see that we focus case and disease management on those members most at risk.

Informatics personnel work closely with other departments, including Actuarial Services and Medical Economics, and system vendors to integrate reporting data from Aetna Better Health’s core information systems. These include QNXT™ and our web-based care management business application (Dynamo™), the principal stewards of Aetna Better Health’s administrative and clinical data. QNXT™ handles claims, eligibility and enrollment processing, service authorization and provider enrollment and data management functions, while our web-based care management business application (Dynamo™), supports all clinical functions. This centralization of the reporting function supports improved data integrity while providing for the complete, accurate and timely submission of reports. Our Informatics team has worked diligently to consolidate the reporting requirements from each health plan that Aetna Better Health currently engages with to develop comprehensive reporting capabilities. The team has catalogued every statutory, regulatory and compliance based report across the organization, centralized those reports wherever possible, then standardized each report and associated metric. This results in improved data integrity and consistency. Informatics personnel use the report catalog to identify existing reports that may meet – or meet with minor modification - the needs of any new health plan, mitigating the effort required to develop report(s) from scratch whenever possible. A centralized production schedule and quality control process further support the accurate, complete and timely submission of required deliverables. Following is an overview of Aetna Better Health’s reporting capabilities. Below that is a table listing the required system-based reports of this RFP and the Aetna Better Health systems responsible for them.

ASDB – Aetna Better Health’s Actuarial Services Data Base (ASDB) supports reporting and analytical capabilities, such as our multidimensional predictive modeling and statistical outlier analysis. The application houses eligibility, provider, prior authorization and claims data and serves a diverse user base, including Medical Management, Finance and Operations. Analysts can use the proprietary Actuarial Analytics Web Portal (AAWeb), an interactive interface, as a point-and-click query tool to access reports, drill down into data and export information from ASDB. For instance, AAWeb can generate customized analyses to identify favorable and unfavorable cost and utilization trends, measure performance against key benchmarks, and


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review summary information. It is a powerful tool that affords Medical Management personnel access to member and provider profiles, as well as current cost and utilization trends. This gives Aetna Better Health the ability to disseminate analysis results on treatment best practices to providers, who can then identify and prevent unnecessary migrations to higher levels of care and the development of chronic health conditions.

General Risk Model – Aetna Better Health’s General Risk Model (GRM) assimilates information from a variety of sources, including the Actuarial Services Data Base (ASDB) described above, and transforms it into a series of markers measuring both risk and opportunity. It then scores these markers and assigns a rank to every member, reflecting both the level of risk and potential opportunity for improvement, thereby helping Case Managers (CMs) provide the appropriate level of care coordination. In addition to its risk algorithms, the application identifies members who meet specific rules-based criteria for individual treatment interventions.

Consolidated Outreach and Risk Evaluation (CORE) – Aetna Better Health’s Consolidated Outreach and Risk Evaluation (CORE) tool identifies three key risk groups – high risk of ED, high risk of inpatient services and high health risk based on predictive modeling results. Case Managers then use the outcome of the risk stratification in determining the direction of additional assessments, targeting areas of concern identified through the risk stratification process.

ActiveHealth Care Engine – Aetna Better Health maintains an advantage in the integrated care coordination of our members as a result of our affiliate, ActiveHealth’s, CareEngine® System – a claims-based clinical support system combined with an automatic message generator called Care Considerations. The system integrates medical and pharmacy claims data and laboratory results within member-centered records that are then compared to over 1,500 evidence-based clinical rules and related algorithms developed by ActiveHealth’s team of board certified physicians and pharmacists. It then identifies member specific opportunities to optimize care and communicates evidence-based treatment recommendations – “Care Considerations” – to providers. At the same time, the system generates “Wellness Considerations” for members: communiqués focusing on prevention and wellness issues such as childhood immunizations, breast cancer screening, and disease appropriate screening and vaccinations. In addition to the provider messaging, Aetna Better Health receives a Care Considerations data file from Active Health that is uploaded into our care management business application (Dynamo™). Care coordinators and case managers can then address these recommendations (i.e., Care Considerations) with members during regular care planning meetings, as appropriate.

AboveHealth® – Aetna Better Health’s secure, HIPAA-compliant web portal for members and providers, this secure, ASP-based application synchronizes data on a daily basis with QNXT™ through data extract and load processes, allowing members to check eligibility status and review benefits and prior authorization status. Providers are afforded additional functionalities, including:


• Panel roster review

• Searchable provider list

• Claim status search


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• Remittance advice search

• Authorization submittal

• Authorizations search

The portal is configured to provide HEDIS® scorecard data, as well as alerts indicating when a member is due or past due for a HEDIS®-related service (e.g., well-child check-up, need for asthma controller medication, immunizations). This information is integrated within the application’s provider panels/rosters. If a member is due or past due for a service, a “flag” appears next to the member’s name, which, when clicked, permits providers to view a description of the needed service(s).

a) generation and provision to the State of the management reports prescribed in the RFP:

Aetna Better Health’s information system provides for the collection, analysis, integration and reporting of data in compliance with DHH and federal reporting requirements. The system provides information on areas including, but not limited to, utilization, grievances and appeals, and member disenrollment for reasons other than loss of Medicaid eligibility. Our core business and clinical management systems, QNXT™ and our web-based care management business application (Dynamo™), collect data on member and provider characteristics, as well as services furnished to members. Our Informatics Department will create required reports using the electronic formats, instructions, and timeframes specified by DHH and at no cost to DHH. All reports submitted to DHH will be in a format accessible and modifiable by the standard Microsoft Office Suite of products, Version 2003 or later, or in a format accepted and approved by DHH. Any changes to report format will be submitted to DHH for approval prior to implementation. We will provide samples of all reports within forty-five (45) calendar days following the date the Contract is signed to confirm agreement on format and design.

Aetna Better Health will certify all submitted data, documents and reports including, but not limited to, enrollment information, financial reports, encounter data, and other information, as specified within the Contract and this RFP. The certification will attest, based on best knowledge, information, and belief as to the accuracy, completeness and truthfulness of the documents and data. Certifications will be submitted concurrently with the certified data and documents.

The data shall be certified by one of the following:

• CCN’s Chief Executive Officer (CEO);

• CCN’s Chief Financial Officer (CFO); or

• An individual who has the delegated authority to sign for, and who reports directly to the CEO or CFO.

Timeliness: Policies and procedures, aided by automated production schedules whenever possible, will provide that all required reports or files are submitted to DHH in a timely manner for review and approval. In the event that there are no instances to report, Aetna Better Health will submit a report so stating. Unless otherwise specified, deadlines for file and report submission will be as follows:


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Schedule Due Date Daily Within one (1) business day following the due date Weekly The Wednesday following the reporting week Monthly Within fifteen (15) calendar days of the end of each month Quarterly By April 30, July 30, October 30, and January 30, for the quarter immediately preceding the due

date Annual Within thirty (30) calendar days following the twelfth (12th) month; and Ad Hoc Within three (3) business days from the agreed upon date of delivery

Designated health plan personnel will notify DHH via phone, fax, and/or electronic mail within fifteen (15) minutes upon discovery of any problem that results in delays in report distribution or problems in on-line access to critical systems functions and information during a business day, in order for the applicable work activities to be rescheduled or handled based on System unavailability protocol.

Accuracy and completeness: Aetna Better Health will adhere to DHH’s prescribed guidelines in determining whether a report is correct and complete prior to submission. These include:

• The report must contain 100% of the CCN’s data; and

• 99% of the required items for the report must be completed; and

• 99.5% of the data for the report must be accurate as determined by edit specifications/review guidelines set forth by DHH.

Errors: In the event that an error is discovered, either by Aetna Better Health or DHH, subsequent to a file or report’s submission, Aetna Better Health will correct the error(s) and submit accurate reports as follows:

• For encounters - In accordance with the timeframes specified in the Administrative Actions, Monetary Penalties and Sanctions Section of this RFP.

• For all reports – Fifteen (15) calendar days from the date of discovery by Aetna Better Health or date of written notification by DHH (whichever is earlier).

The following table lists the required system-based reports of this RFP and the Aetna Better Health systems responsible for them:


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Reporting on behalf of Subcontractors: Aetna Better Health accepts responsibility for the oversight of subcontractors’ performance and assumes accountability for functions and responsibilities delegated to subcontractors. Administrative oversight of subcontractors is performed through Aetna Better Health’s delegation oversight function, whereby we monitor and enforce contractual performance and compliance by way of regular meetings, activity summary reports, and annual delegated entity audits. We maintain written agreements between Aetna Better Health and subcontractors specifying the activities and reporting responsibilities delegated to the subcontractor and providing for the revocation of delegated functions or imposing of other sanctions if the subcontractor's performance is inadequate. Should Aetna Better Health contract for the provision of any covered services during the course of this Contract, and we hold that contractor responsible for processing claims, Aetna Better Health will submit a claims payment accuracy percentage report for the claims processed by said contractor.

b) generation and provision to the State of reports on request; Aetna Better Health’s ability to meet the ad hoc report requests of state agencies, such as DHH, their designees and/or CMS is proven. All ad hoc requests are forwarded from the respective health plan to our Informatics Department, where they are time stamped and queued accordingly. Informatics analysts review the requirements, submitting any requests for clarification or additional direction to the originating health plan, which follows up with the appropriate – in this instance - DHH contact. Once the requirements are clearly understood, the analyst determines whether or not an existing report may be leveraged to satisfy the ad hoc request. If so, the necessary modifications are made, the deliverable validated by the Health Plan, and the finalized report submitted to the requestor. If not, the report is designed and developed from scratch, validated, and the finalized report submitted to the requestor. Production schedules are updated as necessary, proprietary information identified accordingly, and certifications attesting to the accuracy, completeness and truthfulness of the documents and data attached as required.

Policies and procedures provide the development of ad hoc reports within allotted timeframes; however, should the estimated time to complete a report fall beyond the allotted time, the Informatics department will notify the health plan, which will then work with DHH until the issue is resolved.

c) the ability in a secure, inquiry-only environment for authorized DHH staff to create and/or generate reports out of your systems on an ad-hoc basis; and

Aetna Better Health takes the security of our members’ data very seriously and so maintains significant protocols and controls with regard its external use. Per our standard operating procedure regarding requests for system access by an external agency, we will configure an Aetna Better Health-supplied PC or laptop such that authorized external users have access – via Citrix – to a secure, inquiry-only environment wherein they may create and/or generate reports on an ad-hoc basis. We will assign designated DHH staff members an NID number granting them role-based access as a non-Aetna Better Health user. In addition, authorized users will have access to SPOC, Aetna Medicaid’s Single Point of Contact Help Desk, providing toll-free system and technical support 24/7/365. SPOC personnel will answer questions regarding Aetna Better Health’s System functions and capabilities; report recurring programmatic and operation problems to appropriate personnel for follow-up; redirect problems or queries that are not


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supported by the Systems Help Desk, as appropriate, via a telephone transfer or other agreed upon methodology; and redirect problems or queries specific to data access authorization to the appropriate DHH personnel. Recurring problems not specific to Systems unavailability identified by the Systems Help Desk will be documented and reported to Aetna Better Health management within one (1) business day of recognition so that deficiencies can be promptly corrected. An issue management system will assist in that regard, providing SPOC personnel an automated means to record, track and report all questions and/or problems reported to the Systems Help Desk.

d) Reporting back to providers within the network. Aetna Better Health shares information with our providers by way of the following distribution channels:

Care Coordination Activities – Case managers may share information, such as a change in a member’s risk profile, with providers in the course of coordinating that member’s care.

Provider Services – In addition to accessing their Provider Profile via AboveHealth®, Provider Service Representatives may hand-deliver providers’ Provider Profiles as part of their regularly scheduled site visits.

Quality Management/Performance Improvement Initiatives – Aetna Better Health may distribute the results of performance improvement initiatives to providers via blanket or targeted mailings.

ActiveHealth Care Engine – Aetna Better Health maintains an advantage in the integrated care coordination of our members as a result of our affiliate, ActiveHealth’s, CareEngine® System – a claims-based clinical support system combined with an automatic message generator called Care Considerations. The system integrates medical and pharmacy claims data and laboratory results within member-centered records that are then compared to over 1,500 evidence-based clinical rules and related algorithms developed by ActiveHealth’s team of board certified physicians and pharmacists. It then identifies member specific opportunities to optimize care and communicates evidence-based treatment recommendations – “Care Considerations” – to providers.

AboveHealth® – Aetna Better Health’s secure, HIPAA-compliant web portal for members and providers, this secure, ASP-based application synchronizes data on a daily basis with QNXT™ through data extract and load processes, allowing members to check eligibility status and review benefits and prior authorization status. Providers are afforded additional functionalities, including:






• Authorization submittal

• Authorizations search


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The portal is configured to provide HEDIS® scorecard data, as well as alerts indicating when a member is due or past due for a HEDIS®-related service (e.g., well-child check-up, need for asthma controller medication, immunizations). This information is integrated within the application’s provider panels/rosters. If a member is due or past due for a service, a “flag” appears next to the member’s name, which, when clicked, permits providers to view a description of the needed service(s).

Automated Clearinghouse Vendors - Aetna Better Health’s EDI vendors have automated procedures whereby providers are notified of any batch rejection. The report provides, at a minimum, the following information, permitting the provider to troubleshoot the issue and resubmit accordingly:

• Date batch was received by the CCN;

• Date of rejection report;

• Name or identification number of CCN issuing batch rejection report;

• Batch submitters name or identification number; and

• Reason batch is rejected.


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128 R.11



R.11 Provide a detailed profile of the key information systems within your span of control.

Aetna Better Health and its affiliates have over 25 years experience designing, implementing, and maintaining information systems for our respective healthcare plans. Today, our information system collects, stores, integrates, analyzes, validates, and reports data on over 1.3 million members in health plans spanning 10 states, assimilating the case management, service provision, claims and reimbursement data necessary to support their financial, medical and operational management. Our Information Systems (IS) team, led by a Vice President of Technology Support with over 15 years’ experience, includes 71 experienced FTEs. Together, they coordinate and perform key functions, including the system architecture and operations design, application development, software engineering, quality assurance and Electronic Data Interchange (EDI) support, necessary to support our members and providers, state and regulatory organizations.

Aetna Better Health’s Information Management and Systems Director will have the necessary training and experience in information systems, data processing and reporting to oversee all our information systems functions. This includes, but is not limited to, establishing and maintaining connectivity with DHH information systems and providing necessary and timely reports to DHH. The Information Management and Systems Director will work closely with IS personnel to develop and maintain written policies, procedures, and job descriptions necessary to “lock in” system and operational improvements. Annual reviews will verify policies and procedures (P&Ps) continued agreement with current practices.

Hardware When Aetna Medicaid designed the information systems for Aetna Better Health, the goal was to use powerful, reliable and expandable data processing systems to serve the needs of Aetna Better Health and its affiliates’ members now and far into the future. High speed LAN and WAN, in addition to clusters of servers, provide the foundation for our information system, and multiple levels of redundancy support uninterrupted access. Should one server node go down, others temporarily assume its processing burden such that the event is virtually imperceptible to the end user. In fact, this methodology provided 99.99 percent uptime for all core business systems in 2010.

In addition, servers can be added to the cluster to increase performance vertically, and servers can accept increases in RAM and processing power to grow horizontally – all without ever bringing the applications down. Such scalability will allow our systems to match any escalation in demand associated with DHH’s performance requirements while at the same time maintaining system uptime and performance.

Data Communications Hardware Aetna Medicaid’s network infrastructure consists entirely of Cisco routers, switches and firewalls, providing 99.99 percent uptime on the network for 2010. Standardizing on Cisco has provided maximum latitude in equipment configurations. Cisco was chosen because it provides the most reliable hardware in the industry, with worldwide ‘follow-the-sun’ technical support.


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Cisco routers support the MPLS network, external traffic to the Internet, and connections to other private networks.

Application Server Hardware Aetna Medicaid’s core business applications run on a cluster of Hewlett Packard ProLiant DL 380/580 BL 460 servers. Each server is equipped with a minimum of two dual-core Intel processors and 4GB of RAM. This configuration provided core business application users 99.99 percent or better uptime in 2010. These servers utilize f5 Global Load Balancing services for load balancing network traffic and for user access to the core business applications. Applications loaded on this server pool access data from high-end database servers. These 64-bit, Itanium class servers attach to EMC, Hitachi HDS and HP EVA storage arrays via Brocade switches. This configuration provides all necessary computing power and redundancy and can be scaled dynamically to meet growing requirements.

Telecommunications Hardware Aetna Medicaid chose the industry leading systems from Avaya to build an enterprise level telecommunications system. The corporate office runs on Avaya’s Communications Manager Platform, which maintains extra capacity to cover any unforeseen spikes and growth spurts, handling up to 375,000 calls an hour if necessary. This server is one part of a cluster of Avaya PBXs that provide virtually unlimited growth potential. Data can be shared between servers through distributed IP support, allowing real-time backup of data to the hot-site and dynamic distribution of calls if needed. They are managed 24 hours a day by Aetna Better Health telecommunications personnel. The telecommunications system is configured with multiple levels of redundancy to maximize uptime. In fact, it would take four separate points of failure throughout the nation to bring the system down. Should such an interruption ever occur, an agent could securely configure the PBX to support a Work-at-Home (WAH) strategy, providing authorized personnel remote connectivity. This provides members and providers with a virtually fail-safe means to reach Aetna Better Health whenever necessary. Our call management system currently satisfies the Automated Call Distribution (ACD) system requirements provided in section 12.16.1 of this RFP.

Desktop Workstation Hardware and Software Aetna Better Health’s Information Management and Systems Director will work closely with Aetna Medicaid’s IT personnel to see to it that employee workstations are configured in accordance with contract requirements. The two have reviewed the Coordinated Care Network (CCN) Program requirements provided in section 16.3.11 of this RFP and confirmed that the following departments, or their operational equivalent, will be compatible with DHH requirements at Systems Readiness Review:

• Call Center Operations

• Claims EDI Operations

• Authorized Services Operations

• Member Services Operations Software QNXT™ - At the core of Aetna Medicaid’s application architecture is QNXT™, a rules-based information processing system comprising 28 integrated modules that maintain the following:


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• Claims data, including associated adjudication, COB and TPL processes

• Demographic, eligibility and enrollment data, including prior coverage

• Provider contract configuration, including network and services

• EDI processes

• QM/UM including, but not limited to Prior Authorizations and concurrent reviews

QNXT™ leverages Microsoft’s .NET architecture, providing for flexible, scalable, and seamless systems integration. In addition, the system’s foundational database is Microsoft’s SQL Server, permitting a wide variety of applications to analyze the data, display results, and print standardized and customized reports.

The cornerstone of Aetna Medicaid’s claims adjudication process, QNXT™ accepts – via the supporting technical interfaces – daily enrollment files from each health plan’s respective Enrollment Broker, then updates our member records accordingly. Automated processes will reconcile QNXT™’s resident member files with DHH’s monthly update and record the results for DHH’s review should it be necessary. Aetna Better Health’s enrollment team then validates the data for accuracy, auditing relevant files and reviewing any resultant fallout reports. Should the process bring any errors to light, enrollment personnel will promptly notify DHH and work the issue to resolution.

QNXT™ will use regular downloads of provider data from DHH’s website, www.lamedicaid.com, to coordinate provider enrollment records. Enrollment personnel will then use unassigned enrollment reports to verify each member’s assignment to an individual PCP, seeing to it that our PCP assignment file is as current and complete as possible. System queries identify new enrollments and generate welcome letters accordingly. These are added to new member welcome packets, which are then mailed to new members. Updated date-sensitive PCP assignment information is available to DHH in electronic format upon request.

QNXT™ supports automation of routine processes, thus introducing improved efficiencies and accuracy to the adjudication process. For example, three-tier logic matches claims and authorizations based on criteria such as member, provider, service code, and dates of service. The system automatically deducts claimed services from authorized units, thus reducing the need for manual affiliation by claims analysts.

Several applications compliment QNXT™’s claims processing functionality. The first, iHealth, enforces select payment policies from one of the industry’s most comprehensive correct coding and medical policy content libraries. The second, McKesson’s ClaimCheck®, expands upon those capabilities by allowing claims leadership to define and combine specific claims data criteria, such as provider or diagnosis, to set up unique edits that deliver enhanced auditing power.

As the steward of our members’ demographic, capitation, PCP, and eligibility and enrollment data, QNXT™ serves as the primary source of data for multiple applications, including our web-based care management business application (Dynamo™), our principal member and Medical Management application, VisionPro and Encounter Management (EMS) systems. Our systems


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architecture diagram, provided at the end of this section, illustrates how the exchange of data between these systems, and throughout our organization, addresses the needs of our members.

Our Web-based Care Management Business Application (Dynamo™)– Aetna Better Health’s primary care management platform, our web-based care management business application (Dynamo™), supports the Integrated Care Management (ICM) model activities including; but not limited to CM, DM and BH assignment, assessment, and care planning. The application’s ability to enforce preconfigured workflow rules and prompt predefined, event-driven actions supports compliance with associated standards. Branched logic provides case managers context sensitive information, such as: assessment deadlines, case management notes and service accessibility data, thereby supporting more effective case management. Our web-based care management business application (Dynamo™) allows providers and members alike web-based access by which they may perform such tasks as update care plans, complete assessments and submit updates to assigned Case managers via a secure, HIPAA compliant web portal. The result is a highly collaborative care management environment.

Encounter Management System – EMS, a proprietary Aetna Medicaid system, warehouses claims data, formats encounter data to contract requirements and processes CMS1500, UB04, dental, and pharmacy claims. Current coding protocols (e.g., standard CMS procedure or service codes, such as ICD-9, CPT-4, HCPCS-I, II) are kept on file as well. The system uses state provider and medical coding information – in conjunction with claims data culled from QNXT™’s data tables – to produce reports for the purposes of tracking, trending, reporting process improvement and monitoring submissions of encounters and encounter revisions.

General Risk Model (GRM) – Aetna Medicaid’s predictive modeling tool assimilates information from a variety of sources, including the Actuarial Services Data Base (ASDB) described below, and transforms it into a series of markers measuring both risk and opportunity. It then scores these markers and assigns a rank to every member, reflecting both the level of risk and potential opportunity for improvement, thereby helping CMs provide the appropriate level of care coordination. In addition to its risk algorithms, the application identifies members who meet specific rules-based criteria for individual treatment interventions.

ASDB – Aetna Medicaid’s Actuarial Services Data Base (ASDB) supports Aetna Better Health’s reporting and analytical capabilities, such as our multidimensional predictive modeling and statistical outlier analysis. The application houses eligibility, provider, prior authorization and claims data and serves as a key data source for a diverse user base, including Medical Management, Finance and Operations.

Analysts can use the proprietary Actuarial Analytics Web Portal (AAWeb), an interactive interface, as a point-and-click query tool to access reports, drill down into data and export information from ASDB. For instance, AAWeb can generate customized analyses to identify favorable and unfavorable cost and utilization trends, measure performance against key benchmarks, and review summary information. It is a powerful tool that affords Aetna Better Health’s Medical Management personnel access to member and provider profiles, as well as current cost and utilization trends. This gives Aetna Better Health the ability to disseminate analysis results on treatment best practices to providers, who can then identify and prevent


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unnecessary migrations to higher levels of care and the development of chronic health conditions.

Aetna Better Health reporting analysts will cull data from ASDB, QNXT™ and our web-based care management business application (Dynamo™) as necessary to satisfy the chart of deliverables provided in section 18.8 of this RFP, supporting compliance with stated timeliness, accuracy and completeness standards. We maintain strict P&Ps providing for the review of all deliverable prior to submission to DHH.

ActiveHealth Care Engine – Aetna Better Health maintains an advantage in the integrated care coordination of our health plan members as a result of our affiliate ActiveHealth’s CareEngine® System – a claims-based clinical support system combined with an automatic message generator called Care Considerations. The system integrates medical and pharmacy claims data and laboratory results within member-centered records that are then compared to over 1,500 evidence-based clinical rules and related algorithms developed by ActiveHealth’s team of board certified physicians and pharmacists. It then identifies member-specific opportunities to optimize care and communicates evidence-based treatment recommendations – “Care Considerations” – to providers. At the same time, the system generates “Wellness Considerations” for members: communiqués focusing on prevention and wellness issues such as childhood immunizations, breast cancer screening, and disease appropriate screening and vaccinations.

Grievance and Appeals Database – Aetna Medicaid maintains an internal, proprietary application that supports the Grievance and Appeals process by tracking member and provider issues from inception to resolution. This affords us the means to address not only issues affecting individual member and provider satisfaction, but potential trends in the delivery system as a whole, permitting health plan personnel to take prompt, corrective steps to minimizing risks to performance standards.

www.AetnaMedicaid.com – Aetna Medicaid maintains a public website for Aetna Better Health, with separate web pages providing static information tailored to health plan members’ and providers’ respective needs. Members and providers wishing to take advantage of Aetna Better Health’s secure web capabilities are provided a link to Aetna Better Health’s secure web portal, AboveHealth®, described below.

AboveHealth® – AboveHealth® is a secure HIPAA-compliant web portal for Aetna Better Health’s members and providers. Designed to foster open communication and facilitate access to a variety of data in a multitude of ways, this secure, ASP-based application synchronizes data on a daily basis with QNXT™ through data extract and load processes, allowing members to check eligibility status, review benefits and prior authorization status, and send secure emails to Aetna Better Health’s member services personnel. Providers are afforded additional functionalities, including:






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• Submit authorizations

• Search authorizations

We configure the portal to provide HEDIS® scorecard data, as well as alerts indicating when a member is due or past due for a HEDIS®-related service (e.g., well-child check-up, need for asthma controller medication, immunizations). This information is integrated within the application’s provider panels/rosters. If a member is due or past due for a service, a “flag” appears next to the member’s name, which, when clicked, permits providers to view a description of the needed service(s).

Policies and Procedures (P&Ps) dictate that our website and portal comply with applicable provisions of the Americans with Disabilities Act. In addition, our websites will satisfy the respective requirements stipulated in sections 10.3 and 12.10 of this RFP.

Information Systems Monitoring Aetna Medicaid’s core business systems maintained a 99.99 percent uptime through the 2010 calendar year, due largely to the combined efforts of personnel at our Network Operation Center (NOC), Operation Command Center and Production Services and System Platform Performance Departments. The four share one common goal: the optimization of our core business systems’ performance. Our NOC and Operation Command Centers, for example, monitor systems performance 24/7/365 via state-of-the-art applications and tools, such as IBM Tivoli Monitoring (ITM) products. ITM is an event management/problem detection tool that can monitor Windows Server system attributes and System Event logs, as well as ASCII logs. It interfaces with other enterprise monitoring tools to provide a comprehensive yet consolidated view of problems across the enterprise. Production outages and system issues are managed by the Production Services Department which assembles and coordinates teams and vendors to facilitate quick resolution and provide escalation when needed. And finally, the System Platform Performance (SPP) Department provides enterprise-wide performance monitoring, tuning, trend analysis and reporting for large-scale and midrange systems/platforms and mainframe systems and applications in support of business operations. SPP aims to promote optimum throughput and efficient use of resources to meet established service level agreements and availability goals.

Disaster Recovery and Business Continuity Aetna Medicaid's disaster backup and recovery strategy is to provide and maintain an internal disaster recovery capability. This strategy leverages the internal computer processing capacity of two state of the art, hardened computer centers located in Middletown and Windsor, Connecticut. Both facilities have extensive fire suppression systems, dual incoming power feeds, UPS, and backup diesel generators supporting 24/7/365 operation. Physical access is strictly controlled and monitored, and access to vital areas is segregated by floor and business function as appropriate. The two data centers house Aetna Medicaid’s computer processing capabilities on three major platforms, mainframe (Z/OS), mid-range (Various UNIX versions), and LAN (Windows on X86 processors). The data centers are load balanced and supplemented by quick-ship and capacity-on-demand contracts, permitting each center to back the other up in the event of disaster. We maintain contracts with national vendors providing for replacement equipment and supplemental capacity as needed, further promoting compliance with recovery time objectives (RTO).


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In the event of a data center disaster, the RTO to resume most production processing is four days from disaster declaration for all mainframe and mid-range systems and five days for LAN systems. Portfolios of highly available applications, such as web and pharmacy, have RTO’s of six hours or less. These applications utilize mirroring and/or load balancing technologies between the datacenters to make certain that the reduced RTO’s can be met. Aetna Medicaid’s voice and data network backbones are fully redundant using SONET ring technology and are recovered within 1 hour of a data center outage. In short, Aetna Medicaid’s data center recovery strategy and its application RTO’s are consistent with or better than industry standards.

Data Backup Infrastructure and application data is secured and stored offsite on a daily basis. Backed-up data is cross vaulted between the two computer centers, with mainframe backups stored primarily on disk media and mid-range/LAN backups stored primarily on tape. Additionally, all mainframe disk data is mirrored to the alternate data center providing a simplified and timelier recovery for that piece of the environment. Any customer data lost as a result of a data center catastrophe will be recovered through re-submittals by service providers and/or recovery reconciliation teams.

Systems Refresh Plan On an annual basis, Aetna Better Health will provide DHH an annual Systems Refresh Plan. The plan will outline how we will systematically assess the information systems within our span of control to determine the need to modify, upgrade and/or replace application software, operating hardware and software, telecommunications capabilities, information management policies and procedures, and/or systems management policies and procedures in response to changes in business requirements, technology obsolescence, personnel turnover and other relevant factors. The plan will also outline the steps we will take to see that the version and/or release level of all of systems components (application software, operating hardware, operating software) is always formally supported by the Original Equipment Manufacturer (OEM), Software Development Firm (SDF), or a third party authorized by the OEM and/or SDF to support the systems component.

Aetna Better Health maintains systems process and procedure manuals documenting and describing the manual and automated procedures associated with our management information systems. We will develop, prepare, print, maintain, produce, and distribute to DHH distinct Systems design and management manuals, user manuals, quick reference guides, and any updates as necessary. These will contain information about, and instruction for, using applicable systems functions and accessing applicable system data. All manuals will be made available in printed form and on-line, with electronic versions updated immediately, and printed versions updated within ten (10) business days of any system change or update taking effect.

The following pages provide a diagram illustrating Aetna Better Health’s Information Systems Infrastructure, as well a table listing our core business applications, the number of years Aetna Medicaid or the respective vendor has supported them, and associated information.


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129 R.12



R.12 Provide a profile of your current and proposed Information Systems (IS) organization.

Aetna Better Health, together with its affiliates, has more than 25 years experience designing, implementing, and maintaining information systems for our respective healthcare plans. Today, our information system collects, stores, integrates, analyzes, validates, and reports data on over 1.3 million members in health plans spanning 10 states, assimilating the case management, service provision, claims and reimbursement data necessary to support their financial, medical and operational management. Our Information Systems (IS) team, led by a Vice President of Technology Support with over 15 years’ experience, includes 71 experienced FTEs. Together, they coordinate and perform key functions, including the system architecture and operations design, application development, software engineering, quality assurance and Electronic Data Interchange (EDI) support, necessary to support members and providers, state and regulatory organizations.

Aetna Better Health’s Information Management and Systems Director will have the necessary training and experience in information systems, data processing and reporting to oversee all our information systems functions. This includes, but is not limited to, establishing and maintaining connectivity with DHH information systems and providing necessary and timely reports to DHH. The Information Management and Systems Director will work closely with DHH representatives, health plan leadership, IS personnel and other stakeholders to continuously improve the quality and responsiveness of health plan services for members and providers alike. This includes monitoring and evaluating the cross-functional flow of data between Case, Quality, Utilization Management, Provider, and Member Services departments to identify and implement improvements supporting timely access to the accurate information necessary to address the unique needs of CCN Program members. The Director will work closely with IS personnel to develop and maintain written policies, procedures, and job descriptions necessary to “lock in” system and operational improvements. Annual reviews will verify policies and procedures (P&Ps) continued agreement with current practices.

Aetna Better Health’s information systems currently possess the scalability to accommodate Louisiana’s CCN Program. Our extensive use of proven, automated processes minimizes the need to hire personnel to support less efficient, more error-prone manual processes. With the exception of the addition of the Information Management and Systems Director role, we anticipate that our current Information Systems organizational structure will allow us to satisfy the unique needs of Louisiana’s CCN Program.

Aetna Better Health has engaged KPMG since 2000 to perform SOC I TYPE II audits, including Operating Effectiveness for Claims Processing Controls and Related General Computer Controls. All audit reports have reflected unbiased opinions.

The following pages include our Information Systems department’s organizational structure and staffing model.


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Aetna Better Health’s Information Systems Organizational Profile

Job Class: In-

House FTE's

Average Years of Exp in Field

Average Years in

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FTE's

Average Years of Exp in Field

Average Years in

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Software Developer 19 12 6 10 8 1

System Analyst/Project Mgmt 24 10 6 11 7 1

Data Reporting 5 10 5 1 5 0.5

Database Administration 4 12 5 2 5 0.5

Electronic Data Interchange (EDI) 11 9 5 4 4 1

Quality Assurance/Testing 1 10 6 6 5 0.5

Network Engineer 2 11 7

Control/Computer Operations 6 8 7

Controls and Processes 7 11 7

IT Leadership/Administration 3 15 9 Total FTE’s 71 34


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130 R.13



R.13 Describe what you will do to promote and advance electronic claims submissions and assist providers to accept electronic funds transfers.

Aetna Better Health continually looks for opportunities to improve service to our participating and non-participating providers. To that end, we accept and generate HIPAA compliant electronic transactions from/to any provider interested in and capable of electronic claims submission [i.e. Electronic Data Interchange (EDI)], electronic remittance advices (ERA), and/or claims payment via electronic funds transfer (EFT).

Our proven ability to promote and advance electronic claims submissions is illustrated below. EDI submissions for all Aetna Better Health’s plans averaged 80% for the twelve months ending April 30th 2011, reaching a high of 85% that same month. EFT payments as a percentage of dollars paid averaged 50% over the same twelve month period.

Aetna Better Health will bring that same experience to DHH’s CCN Program, applying the following four-step strategy to move providers along the EDI/ERA/EFT adoption continuum:

Step 1: Provider education and outreach will emphasize the advantages of EDI, ERA and EFT adoption. Provider Services Representatives (PSRs) will use new provider orientations as an opportunity to explain the benefits of each. They will also cover related administrative and system requirements. On a quarterly basis, PSRs will conduct site training for network providers which may include: 1) initial on-site orientation for new providers, 2) follow-up visits with established providers, and 3) focused trainings as indicated by provider request, performance, complaints, or member grievances.

During these face-to-face training sessions, PSRs will promote the benefits of EDI, ERA and EFT transactions, explain the process and provide enrollment forms (ERA/EFT) or instructions (EDI) to interested providers. The same information will be readily accessible at Aetna Better Health’s provider website. Step-by-step instructions on how to initiate EDI services and EDI vendor contact information will also be available via Aetna Better Health’s Provider Manual. Supplemental information may be distributed via Provider Claims Reference Materials – also


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available via the provider website – and provider newsletters, where electronic services transactions will remain a standing item.

Listed below are some of highlights of provider EDI, ERA, and EFT education.

Benefits Requirements

EDI ● Accurate submission and immediate notification of submission errors from the EDI clearinghouse

● Faster processing resulting in prompt payment● Ability to track claim processing status via

Aetna Better Health website ● Aetna Better Health pays certain EDI

transaction fees, depending on the vendor

● Agreement with an electronic clearinghouse

● Software to transmit electronic claims

EFT ● Automatic deposit of payment ● Faster receipt of payment ● No paper checks to deposit ● Immediate verification of payment

● Bank account number ● A voided check/savings account deposit slip ● Signed EFT Authorization Form

ERA ● Electronic file of processed claims from Aetna Better Health

● Electronically posts payments to the provider’s practice management system

● Faster reconciliation of account receivables ● Simplified reconciliation process

● Ability to accept HIPAA standard 835 electronic remit transactions

Step 2: To facilitate electronic claims submission, Aetna Better Health maintains a strong relationship with Emdeon, the largest, most experienced automated claims clearinghouse in the country. Emdeon offers an additional level of support to providers that utilize their services, including technical support, training and tutorials. In addition, providers receive prompt, detailed reports regarding claims submission accuracy, allowing them to better target related opportunities for improvement.

Step 3: Provider education and outreach will address the advantages and steps necessary to initiate Electronic Remittance Advices (ERAs), affording providers a means to introduce added efficiencies to their claims management process. The enrollment process will mirror that required to initiate EFT, allowing providers to easily initiate a service that can deliver substantial cost savings.

Step 4: DHH’s monthly claims dashboard will provide Aetna Better Health’s Provider Services Manager an overview of EDI utilization. In addition, Aetna Better Health Finance Department produces a Claims Data Summary report that identifies 1) providers submitting large volumes of paper claims, and 2) high-dollar provider payments not made via EFT. The Provider Services Manager reviews the report to identify providers for targeted outreach. Additional education and outreach may be initiated if existing EDI providers fall below submission averages.


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Aetna Better Health will work closely with DHH, providers and provider associations to continuously promote and advance EDI, EFT and ERA adoption. We will begin provider education and outreach prior to go-live in each GSA, giving providers ready access to the instruction and information necessary to initiate the desired service or services.


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131 R.14



R.14 Indicate how many years your IT organization or software vendor has supported the current or proposed information system software version you are currently operating. If your software is vendor supported, include vendor name(s), address, contact person and version(s) being used.

Aetna Better Health, through a subcontract arrangement with Aetna Medicaid, has access to a comprehensive suite of IT tools and solutions. Our IT organization today serves over 1.3 million Medicaid health plan members in 10 states. It is flexible and responsive, led by a Vice President of Technology Support with over 15 years’ experience. The IT organization manages the selection, maintenance and operation of software applications, leveraging the deep skill set of personnel with an average of over 10 years’ role-related experience each. In some instances, software vendors staff their own personnel at Aetna Better Health’s offices to better assist in the support and maintenance of their respective software. The following table provides details of the software applications comprising Aetna Better Health’s core business applications.


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193

132 R.15



R.15 Describe your plans and ability to support network providers’ “meaningful use” of Electronic Health Records (EHR) and current and future IT Federal mandates. Describe your plans to utilizing ICD-10 and 5010.

Aetna Better Health and its affiliates have been collaborating with multiple state agencies in the development of HIT and related [e.g., Electronic Health Record (EHR)] technology since its inception. We continually monitor Federal and state initiatives supporting implementation of the technical and administrative infrastructure necessary to develop, support and maintain local, regional and national Health Information Exchanges and coordinate our own support initiatives accordingly.

Delaware Physicians Care, Inc. (DPCI), an Aetna Better Health affiliate has been actively involved in the development and deployment of a clinical information sharing utility as part of the Delaware Health Information Network (DHIN) initiative. This health information network, acknowledged as the nation's first self-sustaining statewide Health Information Exchange, provides electronic sharing of Electronic Medical Record (EMR) patient information among participating healthcare providers, whether primary care, specialist, hospital or ancillary. In addition, Aetna Better Health’s affiliate in Arizona continues to work with AHCCCS (the Arizona State Medicaid agency), providing resources and technology in support of the Arizona Health Information Exchange (HIE) platform and ongoing enhancements. These efforts have culminated in the development of a highly accomplished data analysis and reporting team, powerful predictive modeling capabilities, and personnel that has been collaborating with State entities on development of HIE and EHR for many years.

Our longstanding participation in initiatives such as these has allowed us to compile best practices and lessons learned into a comprehensive knowledge base from which we develop mechanisms aimed at promoting providers’ meaningful use of HIT:

These include:

1) Provider Manual – A section within the Aetna Better Health Provider Manual provides an overview of HIT.

2) Provider Newsletters/Email – Provider newsletters and e-mails inform providers of time-sensitive provider education and training opportunities provided by Aetna Better Health’s Provider Relations personnel or offered through external entities, such as Louisiana’s Health Information Technology (LHIT) Resource Center.

3) Aetna Better Health Website – The provider section of Aetna Better Health’s website affords providers access to the summary and time-sensitive information described above, in addition to hyperlinks directing them to other resources, such as the Agency for Healthcare Research and Quality’s National Resource Center website and its virtual Health IT Toolbox.

4) Provider education and training – Provider orientations offer Aetna Better Health the opportunity to introduce network providers to the various HIT resources.


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Aetna Better Health will, as requested by DHH, meet with work groups or committees to coordinate activities and develop system strategies that will actively promote healthcare reform initiatives in Louisiana. Our core information systems have the flexibility and interoperability necessary to accommodate the State’s pending consolidation of all hospital, physician and other provider information into a statewide health information exchange. We understand that health information exchange is an important, inherent part of meaningful use and so continually survey the HIT/HIE environment in order to keep our information technology infrastructure strategically aligned. We will use our knowledge of Louisiana’s HIE landscape, in conjunction with our understanding of our provider’s relative HIT maturity levels, to help integrate our provider population into relevant Health Information Exchanges.

Provider Support Provider Relations personnel will work closely with CCN Program providers, giving clear, concise, and consistent information on the HIE/HIT resources at their disposal. In doing so, we will enable them to plan and implement their HIT initiatives in concert with the State’s own, thereby positioning themselves for the maximum incentive reimbursement allowable under CMS’ Meaningful Use Rule.

As registration for Louisiana’s Medicaid EHR Incentive Program opened on January 3, 2011, we expect that many providers will already be actively involved in implementing the required capabilities by the Contract’s go-live date. As in other states, however, we will position ourselves to assist providers at any point along the HIT adoption and implementation continuum. This may include any of the following activities:

1) Directing providers to CMS’ Official Website for the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs. The website contains not only User Guides to Registration and Attestation to assist providers in completing the registration and attestation process, but a list of EHR technology that is certified for the program and specification sheets with additional information on each Meaningful Use objective. The website also assists providers in determining their eligibility for the appropriate Medicare and/or Medicaid program. Eligible professionals eligible for both the Medicare and Medicaid EHR Incentive Programs must choose which incentive program they wish to participate in when they register.

2) Providers need not possess a certified EHR in order to register for the Medicare and/or Medicaid EHR Incentive Program(s). Hence, we encourage them to register as soon as possible to avoid payment delays.

3) Calling providers’ attention to the following items required for enrollment.

Eligible Professionals

• National Provider Identifier (NPI).

• National Plan and Provider Enumeration System (NPPES) User ID and Password.

• Payee Tax Identification Number (if you are reassigning your benefits).

• Payee National Provider Identifier (NPI) (if you are reassigning their benefits).


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Hospitals

• CMS Identity and Access Management (I&A) User ID and Password.

• CMS Certification Number (CCN).

• National Provider Identifier (NPI).

• Hospital Tax Identification Number

− Reminding providers to verify that they have enrollment records in the appropriate systems, including the following: National Provider Identifier; National Plan and Provider Enumeration System; and Provider Enrollment, Chain and Ownership System (PECOS).

− Encouraging providers to contact the Louisiana Health Information Technology (LHIT) Resource Center. As the Regional Extension Center for Louisiana, the LHIT Resource Center is the local resource for technical assistance, guidance and information to support and accelerate healthcare providers’ efforts to adopt and meaningfully use EHRs. Services offered are based on the provider’s current level of electronic health record adoption.

TIER 1: Assistance converting from a paper office to an EHR system and then achieving meaningful use

TIER 2: Assistance in achieving meaningful use if the provider has an EHR system but has not implemented the required components

TIER 3: Meaningful use gap analysis for a provider who has fully implemented an EHR system

The LHIT Resource Center:

• Manages project timelines, expectations and accountability for contract requirements

• Serves as a neutral, credible source for information on health IT and EHRs

• Offers volume pricing discounts on the purchase of IT hardware and software (through supported vendors)

• Offers access to low interest loans to help finance EHR adoption, implementation or upgrade

• Provides continued support beyond EHR installation and meaningful use achievement

• Serves as s meaningful use expert as new regulations in Phases 2 and 3 are released

• Facilitates timely registration to receive meaningful use incentive payments, if applicable

• Facilitates reimbursement for staff training through the Louisiana Workforce Commission’s Small Business Employee Training Program

• Provides programming to assist providers in meeting additional goals such as NCQA Patient-Centered Medical Home (PCMH) recognition

− Providing technical support (e.g., education, training, tools, and provision of data relevant to patient clinical care management) to assist in providers’ transformation to PPC®-PCMH recognition or JCAHO PCH accreditation. Both PPC-PCMH and JCAHO- PCH accreditations are tightly tied to Meaningful Use outcomes, and Aetna Better Health has strategically aligned PCMH criteria to facilitate providers’ achievement of CMS’ Phase 1


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requirements for demonstrating Meaningful Use (MU). Thus, as we assist providers in satisfying the broader requirements necessary to obtain PPC®-PCMH recognition or JCAHO PCH accreditation per the following DHH targets, we are at the same time seeing to it that they satisfy the subset of those requirements necessary to earn MU Phase 1 certification.

PPC®-PCMH recognition or JCAHO PCH accreditation targets Contract Year Level 1 Level 2 Level 3

1 20% * *

2 30% 10% * 3 10% 40% 10%

* No target set

We facilitate data interchange between PCMH practices, specialists, labs, pharmacies, and other providers throughout their MU evolution using tools such as our affiliate, ActiveHealth’s, CareEngine® System. The system integrates medical and pharmacy claims data and laboratory results within member-centered records that are then compared to over 1,500 evidence-based clinical rules and related algorithms developed by a team of board certified physicians and pharmacists. It then identifies member specific opportunities to optimize care and communicates evidence-based treatment recommendations, or “Care Considerations,” to providers, allowing them to modify treatment plans and/or communicate evidence-based treatment recommendations accordingly.

The following page contains a chart mapping each MU criterion to the corresponding PCMH level. A provider need only indicate what level they occupy relative to PCMH criterion, and Aetna Better Health provider relations personnel can immediately determine where they sit with regard to Meaningful Use and help plan next steps accordingly.


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Crosswalk: PPC-PCMH Recognition/Meaningful Use NCQA PPC-PCMH Recognition Standards Meaningful Use Health Outcome Policy Priority Access and Communication

• Written standards for patient access and patient communication

Engage Patients and families in their health care • Provide patients with an electronic copy of health

info • Provide patients with timely electronic access to

health info • Provide Clinical Summaries for each visit

Patient Tracking and Registry Functions • Basic non-clinical data • Searchable Clinical Data • Uses paper or electronic based charting tools for

clinical info • Uses data to identify important diagnoses • Generates lists of patients and reminds patients

and clinicians of needs services.

Improving quality, safety, efficiency, and reducing health disparities

• Maintain an up-to-date problem list of diagnoses • Record demographics • Record changes in vital signs • Generates lists of patients by specific conditions • Implement 5 clinical decision support rules

Care Management • Adopts evidence-based guidelines for 3 conditions • Conducts care-management • Coordinates Care

Improve Care Coordination • Capability to exchange key clinical information

among providers of care • Provide summary care record for each transition of

care Patient Self-Management Support

• Actively supports patient self-management Engage patients and families in their health care

• Send reminders to patients • Provide patients with an electronic copy of their

health information • Provide patients with timely electronic access to

their health information Electronic Prescribing

• Uses electronic system to write prescriptions • Has electronic prescription writer with safety and

cost checks


• Generate and transmit permissible prescriptions electronically

• Maintain active medication list • Maintain active medication allergy list

Test Tracking • Tracks Tests and identifies abnormal results • Uses electronic systems to order and retrieve

tests


• Use CPOE • Incorporate clinical laboratory-test results into EHR

as structured data Referral Tracking

• Tracks referrals using paper-based or electronic system

Improve Care Coordination • Capability to exchange key clinical information

among providers of care • Provide summary care record for each transition of

care and referral


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Performance Reporting • Measures Clinical Performance • Reports Performance • Transmits Reports with standardized measures

electronically to external entities


• Report ambulatory quality measures to CMS or the States

Advanced Electronic Communications Verify adequate privacy and security protections for personal health information

Aetna Better Health understands that providers may demonstrate some reticence towards HIE/HIT-related expenditures. We have trained our Provider Relations and Information Systems personnel to address what existing providers have indicated are their primary concerns with regard to HIT adoption and implementation. These include:

Uncertainties Surrounding Meaningful Use The Centers for Medicare & Medicaid Services’ (CMS) July 2010 release of the finalized definition of “meaningful use” as it pertains to certified Electronic Health Record (EHR) technology addresses many providers’ questions concerning incentive payments for the meaningful use of certified EHR technology, providing detailed explanations of the following:

• Incentive Eligible Professionals (EPs) and eligible hospitals

• Incentive payment amounts, the basis for payments, and the process for making payments

• The methodology for demonstrating adoption, implementation and upgrading, and the requirements for monitoring these activities

• Prior approval conditions that must be met in order to receive Federal Financial Participation (FFP) for reasonable administrative expenses

• Financial oversight requirements/measures to combat fraud and abuse

• “Meaningful Use,” its three main components (below) and the phased approach to its implementation:

− The use of a certified EHR in a meaningful manner, such as e-prescribing.

− The use of certified EHR technology for electronic exchange of health information to improve quality of health care.

− The use of certified EHR technology to submit clinical quality and other measures. Uncertainty regarding Return on Investment CMS’ Finalized Rule for Meaningful Use provides details regarding how, under the Medicaid incentive plan, eligible physicians can receive up to $63,750 to purchase and use qualified EMRs. For practices that have not deployed an EMR, the Medicaid program offers up to $21,250 per physician to help purchase and implement a system (the physician must purchase before 2016 to be eligible). Thereafter, the Medicaid incentives offer up to $8,500 per physician for “meaningful use” of the EMR. The “meaningful use” payments will be available for up to five years (with no payments being made after 2021). Medicaid-eligible professionals must pay at least 15 percent of the cost to purchase and maintain their EMR technology.

In addition, the Agency for Healthcare Research and Quality’s (AHRQ) National Resource Center (NRC) for Health IT’s Knowledge Library contains extensive research concerning HIT’s return on investment, including how to quantify associated benefits related to:


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• Improved patient safety outcomes

• Reduced complications rates

• Reduced cost per patient episode of care

• Enhanced cost and quality performance accountability

• Improved quality performance

Other factors potentially impacting ROI include the section 179 tax write-off permitting practices to deduct up to $500,000 of software and related equipment.

Lack of Available Technical Assistance As described earlier, Aetna Better Health will assist CCN providers in registering for the appropriate EHR incentive program. In addition, we will refer them to Louisiana’s Health Information Technology (LHIT) Resource Center for technical assistance, guidance and information. Finally, we will provide technical support (e.g., education, training, tools, and provision of data relevant to patient clinical care management) to assist in providers’ transformation to PPC®-PCMH recognition or JCAHO PCH accreditation.

Workflow burdens, particularly in small offices Among the tools accessible via AHRQ’s NRC website is the “Time and Motion Database,” enabling organizations to measure the impact of Health IT systems on clinical workflow through the collection of time-motion study data.

Workforce development and training needs The “Health IT Adoption Toolbox.” available via AHRQ’s NRC website, contains a range of resources relevant to the various stages of considering, planning, executing, and evaluating the implementation of Health IT. This includes tools supporting the gap analyses and skills assessments necessary to identify workforce development and training needs requiring attention prior to any provider’s conversion to an EMR.

Existing Legacy Health IT Systems Louisiana’s Health Information Technology (LHIT) Resource Center is charged with assisting health professionals in implementing and becoming “meaningful users” of electronic health records. This includes assisting providers in the assessment of existing legacy Health IT systems and their viability in light of the ARRA’s meaningful use requirements. Available resources include technical personnel skilled in the development and execution of conversion plans facilitating the seamless conversion from legacy Health IT systems to certified EMRs.

Legal Requirements and Privacy Concerns Yet another tool accessible via AHRQ’s NRC website is the “The Health Information Privacy and Security Collaboration (HISPC) Toolkit”, providing guidance on conducting organization-level assessments of business practices, policies, and state laws that govern the privacy and security of Health Information Exchange (HIE).

ICD-10 and 5010 Compliance Aetna Better Health has an efficient and effective IT organization that serves over 1.3 million Medicaid health plan members in 10 states. Aetna Better Health’s IT organization is flexible and responsive, led by a Vice President of Technology Support with over 15 years’ experience.


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Aetna Better Health’s Chief Operating Officer (COO) has the authority and responsibility to direct the activities, performance and outcomes of the IT subcontract.

Under the direction of our COO, Aetna Better Health’s IT organization maintains systems migration plans supporting compliance with current and future Federal IT mandates. In addition, Aetna Better Health dedicates considerable resources towards the development and maintenance of the business and systems infrastructure necessary to support such mandates, recent examples including HIPAA 5010 implementation and the adoption of ICD-10. Aetna Better Health has implemented solutions specifically engineered to address these mandates and their evolving requirements. For example, ClaimCheck® and iHealth, two claims auditing applications, enforce business rules pertaining to “medically unlikely” services and possess the functionality necessary to accommodate future edits.

The various steps, or stages, of our systems migration plan follow:

Migration Planning: Aetna Better Health’s systems migration plans align with our standard Change Order Process (COP), beginning with a readiness assessment comprising a high level analysis of the strategy required to implement the requirements. Once the readiness assessment is completed, the project team defines the scope of work by developing a project charter with realistic and actionable plans for the overall project implementation. Key stakeholders are identified and a communication plan established and executed along with the project plan.

Gap Analysis/Impact Assessment: Aetna Better Health performs a gap analysis and impact assessments prior to any system conversion/upgrade, determining the potential impact to current business operations and defining and developing specific business and technical requirements within and across transactions. Each gap, as well as its respective solution, is then documented for subsequent validation via use case or test scenario.

System Implementation: Aetna Better Health will base system implementation planning on an inventory of systems and environments requiring modification prior to implementation of any additional functionality. Once systems are aligned and environments have been identified, associated translators are modified to accommodate required formats. This includes:

• Reviewing and updating mappings

• Modifying existing and incorporating new business rules as necessary

• Updating and applying custom edits

Testing: Aetna Better Health’s testing plans include defined transaction based test scenarios covering all systems, interfaces, transactions, and reports, including end-to-end testing with all clearinghouses, providers, system/software vendors and third-party administrators as applicable. Data and results are reviewed and communicated with any entity involved in data submission, acceptance or processing to verify that expected results are accurate and issues resolved. Reports track results and validate testing activities, provide verification of the enhancements and serve as the platform for their migration to the production environment.

Monitoring and Management of Performance: Aetna Better Health performs post implementation reviews subsequent to any migration, monitoring the success rate of functionalities including, but not limited to: 1) Claim processing; 2) Timely claim adjudication; 3) Return of requested benefit information; 4) Accurate claim status inquiries; and 5) Accurate


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payment remittance advice and fund transfer. Aetna Better Health will develop control plans for compliance auditing and develop and distribute procedure manuals to help guide best practices around new business features and data. Perhaps most importantly, understanding that the changes in any one migration will not necessarily resolve every issue associated with its predecessor, we continuously assess our business operations for opportunities to enhance operational workflow and productivity. Aetna Better Health’s systems configuration supports migration from one HIPAA version to another in the following ways:

• Microsoft’s BizTalk with HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, allowing Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Microsoft BizTalk with HIPAA Accelerator™ is a data transformation application that translates data to and from the full spectrum of HIPAA transactions sets in a highly customizable, flexible, and robust server-based environment. Moreover, Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.

• Foresight’s HIPAA Validator™ InStream™ is a fully functional HIPAA editing and validation application. It validates HIPAA transactions through all seven levels of edits as defined by the Workgroup for Electronic Data Interchange and Strategic National Implementation Process (WEDI/SNIP), has all standard HIPAA code sets embedded, and can support custom, trading-partner-specific companion guides and validation requirements. In addition, it supports validation at the individual edit level, allowing Aetna Better Health to accept all compliant records that pass at a lower level of edit, rather than requiring all seven levels of edits. The application also provides descriptive error reports to submitters to facilitate quick error resolution.

Aetna Better Health follows the Strategic National Implementation Project (SNIP) recommendations for testing created by the Workgroup for Electronic Data Interchange (WEDI), further promoting system compliance with federal IT mandates. Following the WEDI, Aetna Better Health complies with the following federally mandated HIPAA transactions:

• ASC X12N 834 Benefit Enrollment and Maintenance

• ASC X12N 835 Claims Payment Remittance Advice Transaction

• ASC X12N 837I Institutional Claim/Encounter Transaction

• ASC X12N 837P Professional Claim/Encounter Transaction

• ASC X12N 276 Claims Status Inquiry

• ASC X12N 277 Claims Status Response

• ASC X12N 278 Utilization Review Inquiry/Response

• ASC X12N 820 Payroll Deducted and Other Group Premium Payment for Insurance Products

To support successful implementation of ICD-10-Clinical Modification (CM) and ICD-10-Procedure Coding System (PCS) on October 1, 2013, Aetna Better Health has taken the following steps:


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• An assessment was completed in 2010 to identify all operational and technical processes and systems that will be impacted by the upgrade to ICD-10 codes. This resulted in the identification of work streams that have started efforts to analyze, develop, test, and implement the upgrade of our processes to the new coding.

• Development and testing of the ASC X12 version of 5010 claim and encounter transactions was performed in 2010 to allow the receipt and delivery of ICD-10 codes. Production target dates for utilizing these transactions have been determined, and deployment will be completed by the January 1, 2012 compliance date.

• The version upgrade that supports the acceptance and consumption of the ICD-10 codes within our QNXT™ adjudication system is targeted for 3rd quarter 2011.

• Workgroups have been developed to identify milestones for all ICD code-dependent processes and systems.

Aetna Better Health is currently compliant with all HIPAA and other federal IT mandates, and Aetna Better Health’s IT personnel regularly attend national seminars, review professional journals, and monitor the U.S. Department of Health and Human Services and contracting states’ websites to monitor and prepare for any future mandate. All Aetna Better Health personnel are required to attend mandatory HIPAA awareness training, where they are instructed on confidentiality, privacy, information safeguards, and penalties imposed for noncompliance.

Aetna Better Health is prepared to respond to any DHH or Federal programmatic changes that would impact IT processes, requirements, or systems.


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133 R.16



R.16 Describe the procedures that will be used to protect the confidentiality of records in DHH databases, including records in databases that may be transmitted electronically via e-mail or the Internet.

Aetna Better Health has more than 25 years experience designing, implementing, and managing privacy programs. We currently own, manage or administer health plans serving more than 1.3 million Medicaid members in 10 states. Aetna Better Health is committed to the proper use and disclosure of confidential information in full compliance with federal and state laws and regulations. We maintain and actively enforce policies and procedures protecting the confidentiality of member records in compliance with all applicable federal and state laws, rules and regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy requirements. All information concerning members or potential members is treated as privileged communication, held confidential, and divulged only upon written consent of DHH or the member/potential member. We maintain written safeguards that:

• State that the Aetna Better Health will identify and comply with any stricter state or federal confidentiality standards which apply to specific types of information or information obtained from outside sources;

• Require a written authorization from the member or potential member before disclosure of information about him or her under circumstances requiring such authorization

• Do not prohibit the release of statistical or aggregate data which cannot be traced back to particular individuals; and

• Specify appropriate personnel actions to sanction violators.

Responsibility for Maintaining Confidentiality Aetna Better Health’s Chief Executive Officer (CEO) will be responsible for privacy compliance activities. Responsibilities include:

• Verifying an individual’s identity and authorization to request medical records

• Reviewing and responding to requests in compliance with HIPAA guidelines

• Documenting privacy-related questions and requests and responses

• Tracking and reporting monthly member privacy and compliance-related requests and actions taken

• Per contract or state mandate, notifying the appropriate state agencies if a subpoena or other formal legal process requesting member confidential or PHI is received

Aetna Better Health conducts privacy and security training for all workforce members (regular and contingent employees, i.e. temporary and independent contractors) and requires all new personnel sign an agreement to acknowledge receipt and understanding of the Workforce Confidentiality policy upon hire. In addition, we contractually require all network providers to safeguard member protected health information and treat members’ records as confidential in accordance with all applicable federal and state laws, rules, and regulations governing medical records. In accordance with the provisions of Appendix C of this RFP, we will execute business


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associate agreements with business partners that may use and disclose protected health information. In addition, we include confidentiality and privacy requirements in all provider and subcontractor contracts. Provider representatives emphasize the importance of these requirements during pre-contract and subsequent visits.

Use and Disclosure of Confidential Information Aetna Better Health maintains written safeguards restricting the use and disclosure of information concerning members or potential members to purposes directly related to the performance of any workforce member’s role. Aetna Better Health apprises employees, contractors and providers of members’ rights during orientation, ongoing training and contract negotiation.

We will release medical records of members only as authorized by the member, as may be directed by authorized personnel of DHH, appropriate agencies of the state of Louisiana, or the United States Government. Policies and procedures will mandate that release of medical records of CCN Program members remain consistent with the provisions of confidentiality in this RFP.

In accordance with HIPAA standards, we provide members with a Notice of Privacy Practices on how Aetna Better Health uses and discloses protected health information. The Notice of Privacy Practices explains members’ rights to access, amend, request confidential communication of, request privacy protection of, restrict use and disclosure of, and receive an accounting of disclosures of protected health information. The Notice of Privacy Practices is available on Aetna Better Health’s website in English and Spanish.

Standards for electronic and physical security To best protect the privacy and confidentiality of our members’ information, Aetna Better Health will implement and enforce the following administrative, physical and technical security measures prohibiting unauthorized access to regions of the data communications network inside our span of control. We will conduct a security risk assessment and communicate the results in an information security plan provided no later than fifteen (15) calendar days after Contract award. The risk assessment will also be made available to appropriate federal agencies.

Administrative Safeguards In accordance with its Workforce Confidentiality policy, Aetna Better Health has implemented administrative safeguards providing for the security of members’ protected health information. Members of Aetna Better Health’s workforce have access to confidential information only as necessary to perform their work activities. In working with that information, they are required to:

• Protect confidential information used in the course of work activities against inadvertent or intentional disclosure to unauthorized parties.

• File all confidential information when not using it, and must not discuss the information with any individual who does not have a legitimate business need to know that information.

• Not release their authentication codes or devices or passwords to any other person, and do not allow anyone access to Aetna Better Health systems under their authentication codes or devices or passwords.

• Not allow any unauthorized person to use or access Aetna Better Health systems.


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• Use an appropriate Aetna Better Health cover sheet, which contains a statement describing the limitations on the release of confidential information when faxing information.

• Immediately remove confidential information from a printer or copier.

• Not solicit confidential information from outside sources except as necessary to perform their job functions. Workforce members must not disclose to Aetna Better Health confidential information of a former employer.

• Not remove from the premises those materials or information that contain or disclose confidential information at any time, whether during employment, or upon termination of employment.

• Upon termination of employment of contract for any reason, return all Aetna Better Health property, documents, and records and must not release or share any confidential information obtained during employment by or while contracting with Aetna Better Health.

• Dispose of confidential information in specially designated disposal bins.

Aetna Better Health workforce members who violate the Workforce Confidentiality policy may be subject to disciplinary action, up to and including termination and legal action.

Physical Safeguards Aetna Better Health Security Every Aetna Better Health employee is issued a photo identification card key following background check and hire. The key grants access to the suite during business hours only. Managers can request extended suite access for their employees; however, this requires approval from senior management. Aetna Better Health strictly monitors visitor access. Lost or stolen keys are reported immediately so that the key card can be de-activated.

MBU Facility Security Aetna Better Health’s administrative facilities are staffed around the clock, with special emphasis placed on physical security and controlled access. Only authorized individuals have access to the building to their particular work area. Aetna Better Health uses electronic card readers, unique access badges, surveillance cameras and security guards to promote a secure physical environment.

All entry points to the facility are automatically secured during business and non-business hours. Access to the building, via electronic card reader, is only granted during times established for each cardholder based on the access needs of the user and the user’s department. A person having a business purpose in the building is assigned a unique access badge for entry into the building and interior areas. Employees must pass through at least two separate access points to reach their final work area. Visitor access is tightly controlled through the use of visitor badges provided at the time of sign-in at the reception desk and through visitor escort at all times during their visit. Camera surveillance and security guards provide security support.

Card keys control physical access to the corporate data center and network operations center. The Facilities Department coordinates the issuance of the card keys.

In addition, Aetna Better Health requires outside vendors, even those under a business associate agreement, who are on-site for an extended time frame (e.g., audit) to sign a site-visit


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confidentiality agreement. All records, such as authorization and access activity, are maintained in a secure database for reporting and analysis.

Data Center Security Physical access to Aetna Better Health’s data center is restricted to designated and approved personnel. Three access points are required to enter the corporate data center. Transaction usage into this area is compiled and reviewed regularly to see that only authorized personnel with legitimate business purposes have access to this sensitive area.

Other Physical Safeguards: Aetna Better Health’s privacy and confidentiality measures include physical security features designed to safeguard processor sites through required provision of fire retardant capabilities, as well as smoke and electrical alarms, monitored by security personnel

Technical Safeguards Aetna Better Health maintains an automated Management Information System (MIS) which accepts and processes provider claims, verifies eligibility, collects and reports encounter data and validates prior authorization and pre-certification in accordance with DHH and federal reporting requirements. Policies and procedures facilitate compliance with all HIPAA requirements across all systems and services, including transaction, common identifier, and privacy and security standards. We maintain a secure, password-protected email system for the submittal and receipt of all personal health information.

Electronic Health Information Transactions Aetna Better Health’s management information system currently supports DHH’s required technical interfaces and complies with all applicable requirements of the Health Insurance Portability and Accountability Act (HIPAA). We are, and will continue to be, responsive, within a reasonable timeframe, to any and all adjustments or modifications to future HIPAA procedures, policies, rules and statutes that may be required during the term of our contract. Our management information system configuration supports migration from one HIPAA version to another in the following ways:

• Microsoft’s BizTalk with HIPAA Accelerator™ processes HIPAA-compliant transactions easily and efficiently, enabling Aetna Better Health to accept information electronically from almost any HIPAA-compliant contractor or provider. Accelerator has the Washington Publishing Company (WPC) Implementation Guide schemas for each HIPAA ANSI X12 transaction embedded directly into its application engine, including a facility to update these schemas automatically as the transaction sets are updated over time.


Aetna Better Health follows the Strategic National Implementation Project (SNIP) recommendations for testing created by the Workgroup for Electronic Data Interchange (WEDI),


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further promoting system compliance with federal IT mandates. Aetna Better Health complies with the following federally mandated HIPAA transactions:

Federally Mandated HIPAA Transactions:

• ASC X12N 834 Benefit Enrollment and Maintenance • ASC X12N 835 Claims Payment Remittance Advice Transaction • ASC X12N 837I Institutional Claim/Encounter Transaction • ASC X12N 837P Professional Claim/Encounter Transaction • ASC X12N 276 Claims Status Inquiry • ASC X12N 277 Claims Status Response • ASC X12N 278 Utilization Review Inquiry/Response • ASC X12N 820 Payroll Deducted and Other Group Premium Payment for Insurance Products

We will provide DHH documentation on systems and facility security and provide evidence or demonstrate HIPAA compliance as part of this contract’s associated Transition Phase.

System Safeguards Role-Based Access: Electronic security measures are in place at a number of different levels. Personal computer access is controlled via network security. For all access (logical and physical) to the network, operating systems and data applications, all levels of management are required to review and formally affirm user access rights. Periodic and routine reports are generated and distributed to functional management for their review, edit, comments and corrections. If an employee changes department or position, management is required to re-assess the employee’s access based on the new and different job responsibility and request the new or appropriate access rights for both system and physical access. QNXT™ and our web-based care management business application (Dynamo™), for example, use a hierarchical, role-based security configuration to control online inquiry and update activities. Specific, standardized user profiles, or “roles”, have been defined and the appropriate security rights granted to each role. Users are assigned to a role based on the requirements of their job duties.

This role-based configuration, common to all Aetna Better health core business systems, restricts access to information on a “least privilege” basis, limiting not only users’ access to application modules, but their rights to modify data accordingly. Any access point is automatically locked down upon three (3) unsuccessful logon attempts, and a record maintained of all such incidents.

Aetna Better Health takes the security of our members’ data very seriously and so maintains significant protocols and controls with regard its external use. Per our standard operating procedure regarding requests for system access by an external agency, we will configure a DHH-supplied PC or laptop such that authorized external users have access – via Citrix – to a secure, inquiry-only environment wherein they may create and/or generate reports on an ad-hoc basis. We will reach mutual agreement with DHH on the number staff members that need a NID number granting them role-based access as a non-Aetna Better Health user. Authorized users will have access to SPOC, Aetna’s Single Point of Contact Help Desk, providing toll-free system and technical support 24/7/365. SPOC personnel will answer questions regarding Aetna Better Health’s System functions and capabilities; report recurring programmatic and operation problems to appropriate personnel for follow-up; redirect problems or queries that are not supported by the Systems Help Desk, as appropriate, via a telephone transfer or other agreed


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upon methodology; and redirect problems or queries specific to data access authorization to the appropriate DHH personnel. Recurring problems not specific to Systems unavailability identified by the Systems Help Desk will be documented and reported to Aetna Better Health management within one (1) business day of recognition so that deficiencies can be promptly corrected. An issue management system will assist in that regard, providing SPOC personnel an automated means to record, track and report all questions and/or problems reported to the Systems Help Desk.

With regard to this contract, global access to all functions will be restricted to specified personnel jointly agreed upon by DHH and Aetna Better Health. Aetna Better Health executive management will approve all other access roles. Once approved, only authorized individuals will be allowed to make changes or revisions to these roles.

System Passwords: All system passwords must be periodically changed, and policies require that employees may not share passwords or access applications for which they are not authorized. Passwords must be changed every sixty (60) days and the system tracks the previous five passwords and does not allow reuse. After three (3) incorrect password entries, all access is prevented until security personnel working through the Help Desk reset the password. Policies provide that any software loaded to the network or individual workstations must be authorized and monitored by Information Services.

Audit Trails: Aetna Better Health’s information system’s configuration places the controls necessary to preserve information integrity at key areas throughout the processing sequence, including core application data extraction, transformation, cleansing, load, refresh and access points. We will work with DHH to develop a methodology supporting the testing and periodic and spot audits of these controls upon contract award.

We incorporate audit trails within our core business systems that allow information on source data files and documents to be traced through the processing stages to the point where the information is finally recorded. These audit trails contain, at a minimum:

• The unique log-on or terminal ID, the date, and time of any create/modify/delete action and, if applicable, the ID of the system job that effected the action

• The date and identification “stamp” displayed on any on-line inquiry

These measures provide auditors or other authorized parties the means to trace data from the final place of recording back to its source data file and/or document if necessary. In addition, the systems are able to generate listings, transaction/update reports and transaction/error logs upon request, further facilitating the auditing of individual records and batch audits.

Database Security: On a database level, Aetna Better Health information is stored in separate databases with separate security access at Aetna Medicaid’s data center. Database access rights are granted on a table and user/user group basis. Only specified individuals may make changes or revisions to these settings based on authorized documentation from authorized personnel.

All systems are accessed through the Local Area Network (LAN), the Wide Area Network (WAN) for remote locations or via the Internet. Each user who needs access to the network or the Internet must have the proper authorizations and a unique password. Internet access is also protected by firewall hardware and software to prevent unauthorized use and to allow


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appropriate monitoring capabilities. Each system has its own security, limiting what an individual may see or transact based on the individual security level. In addition, each system contains data integrity controls preventing the alteration of finalized records.

Remote Access: Under the direction of Aetna Better Health’s corporate Chief Information Officer (CIO), remote access is established, controlled and maintained by IT network engineering personnel. Policies and procedures require two-factor user authentication via Virtual Private Network (VPN) or similar means, which we will submit for DHH’s approval no later than fifteen (15) calendar days after Contract award. Aetna Better Health currently manages remote access according to the following standards:

• Secured VPN provides secure access for system inquiry and update

• Secure remote access is strictly controlled and is enforced via one-time password authentication or public/private keys with strong password phrases

• Company employees with remote access privileges must make sure that the computer remotely connected to the corporate network is not connected to any other network.

• Remote access is provided only to the following classes of employees:

• IT employees regularly providing on-call production support

• Executives of the company

• Employees whose positions require remote access due to job requirements as approved by their department management

Confidentiality and Privacy Risk Assessment The Audit Services Department provides independent oversight and risk assessment to assure that critical risks are identified, mitigated and managed to an acceptable level to achieve operating objectives. The Audit Services Department engages in many different types of reviews using accepted industry and governmental standards and collaborates with all operating departments to assess, document and test compliance with procedures. Moreover, it investigates opportunities to make the security process more effective and efficient.


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