centricity™ business hidden gems in payer connectivity sharp healthcare april 2015
TRANSCRIPT
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Centricity™ Business Hidden Gems in Payer ConnectivitySharp HealthCareApril 2015
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©2015 General Electric Company – All rights reserved.
The results expressed in this document may not be applicable to a particular site or installation and individual results may vary. This document and its contents are provided to you for informational purposes only and do not constitute a representation, warranty or performance guarantee. GE disclaims liability for any loss, which may arise from reliance on or use of information, contained in this document. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE.
DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE.
GE, the GE Monogram, Centricity, and imagination at work are trademarks of General Electric Company.
All other product names and logos are trademarks or registered trademarks of their respective companies.
General Electric Company, by and through its GE Healthcare division.
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Agenda
• Hospital Admission Notification (278N)
• Claim Status/Claim Acknowledgments (276/277)
• Benefit Enrollment (MCA 834)
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Hospital Admission Notification 278N
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This transaction is a request and response to a Healthcare Payer for authorization of admission for inpatient hospital services.
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What are the Benefits?
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• Streamline administrative tasks and increase productivity
• Reduce administrative costs through automation
• Increase data accuracy by reducing manual errors
• Accomplish more with less – fewer phone calls, faxes or keying
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What are the Requirements?
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• Enterprise Visit Management required
• Centricity Business 5.3
• Payer is receiving and responding to 278N transactions
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How does it Work?
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• You can manually send a notification for a particular visit
• You can use the Notification Manager in the GE Healthcare EDI Toolkit to queue up multiple visits to have notifications automatically sent to the payer
• Responses are viewable directly from HPA
• There is the ability to Hold Bills if a claim requires notification and a response has not been received
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Technical Description
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The 278 is a hierarchical structure
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• Sender•Receiver
•Subscriber•Dependent
• Patient Event• Patient Event Providers
• Services • Services Providers
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Trading Partner Integration in HPA
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Trading Partner Integration in HPA continued…
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Interactive Request in HPA
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Interactive Request in HPA continued…
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Interactive Request in HPA continued…
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Background Notification Requests (BNR’s)
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Background Notification Requests (BNR’s) continued…
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Background Notification Requests (BNR’s) continued…
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Background Notification Requests (BNR’s) continued…
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Background Notification Requests (BNR’s) continued…
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Hold Bills and Follow-Up’s
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Claim Status/Claim Acknowledgement 276/277
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• The 276 transaction set is the EDI X12 health care claim status request
• The 277 is the EDI X12 health care claim status response
276
277
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What are the Benefits?
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• EDI verification eliminates the need for follow up reps to go outside of Centricity Business and manually check payor websites or call for claim status.
• HPA 276/277 was originally developed as a real-time tool for users
• Batch allows for automated claim status retrieval, eliminating or reducing user interaction
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276 Process
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277 Process
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Current Trading Partners
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• Aetna• Anthem Blue Cross• Blue Shield• United HealthCare• Managed Care Application
(internal Sharp payer)
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Claims Overview (OV Action Code)
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Claim Status Screen (CS)
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Drill Down into Results
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X12 Results
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Insurance Follow Up Questions
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Success Factors
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Since January 1, 2015*, Sharp HealthCare has sent 9496 requests and received 7855 responses.
That’s nearly 8,000 phone calls or website research login’s that weren’t necessary! *(Data period 1/1/15 – 3/12/15)
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MCA 834 Enrollment and Covered California
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About Sharp Health PlanCovered Lives: 75,000+
• 23% of SHC Commercial Managed Care
• Best Health: 8,000 Additional Lives
High Customer and Employee Satisfaction
• Highest CAHPS Scores (2013), 88th Nat’l percentile
• Broker (97.6%)and Employer (93.9%)
• Provider (93.2%) 90th percentile (The Myers Group)
Above Market Retention (12 Month Average)
NCQA Accreditation – Status of Excellence
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Sharp Health Plan and Covered California – 2014 aka Year 1
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Types of Coverage
• Individual
• Small Business Health Options (SHOP < 50 Employees)
• Employers > 50 Employees
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Off Exchange
Health plans are required to offer same coverage for off exchange as on the exchange.
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Changes to GE Healthcare Centricity Business
834 Inbound
834 Outbound
999, TA1
Premium Billing & Statements
820 Premium Billing
Capitation
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834 File Flow
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EDI 834 Inbound
• Member matching
• Contract matching
• Demographics fatal edits
• Covered California DBMS columns
• Covered California fields in Enrollment
• EDI 834I Employer Group Ruleset
• Modified REF segments in 834I specification
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Covered California Enrollment Screen
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EDI 834I Employer Group Custom Enterprise Ruleset
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REF Segments in 834
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Outbound 834
Capture the 834 Inbound data in enrollment
MCA Enrollment EDI Select Queue Ruleset
FDL application “EME” - MCA Benefit Enrollment Forms (834)
MCA.834.O application class for specification
834 Outbound Run Manager
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Enrollment EDI Select Queue
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EDI 820 Outbound
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• MCA Premium Payment EDI Select Queue Ruleset
• FDL Application “EMP”
• MCA.820.O Application Class for Specification
• New Spec 005010X306
• 820 Outbound Run Manager
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Premium Billing Enhancements
• Individual Billing
• Fixed Rates based on data from inbound 834 (Yearly)
• Welcome Letters to Members via Optum prior to first payment
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Premium Billing
Turned on MCA AES MAP #156 to modify premium during compile
Modified custom direct bill statements
Created new custom activity for Covered California direct bill statements
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Covered California – Year 2
• Covered California sends multiple enrollment transactions per member/family. Many are duplicates or corrections for previous transactions
• During 2014 – Sharp worked with GE Healthcare Centricity Business to customize the 834 member and contract matching as much as possible
THEN
• Covered California introduced 14 new issues/failures with the 2015 open enrollment
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Ongoing Issues
• Who’s right? The Exchange says they are the source of truth for all demographic data but Sharp also has a Master Patient Index group
• A reconciliation process has not been established to report demographic discrepancies
• Since we don’t know if the member has paid on initial enrollment – we have to manually term members/enrollment until payment is received
• Exchange sends multiple add/change records for members that are out of sequence
• Ongoing issue with retro dates on change transactions – this is causing billing issues 49
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Questions?