Committee on Operating Rules For Information Exchange

(CORE®)

Public Town Hall Call

November 25, 2013 2-3pm ET

Additional information/resources available at www.caqh.org

This document is for educational purposes only; in the case of a question between this document and CAQH CORE

Operating Rule text and/or Federal regulations, the latter take precedence.

2 © 2013 CORE. All rights reserved.

• Download a copy of today’s presentation HERE • The phones will be muted upon entry and during the presentation

portion of the session • At any time throughout today’s session, you may communicate with our

panelists via the web – Submit your questions on-line at any time by entering them into the Q&A

panel on the right-hand side of the WebEx desktop – On-line questions will be addressed first

• There will be an opportunity for the audience to submit questions through the telephone during today’s presentation – When directed by the operator, press * followed by the number one (1) on

your keypad

Participating in Today’s Interactive Event

3 © 2013 CORE. All rights reserved.

Agenda

• First Set of ACA Mandated Operating Rules - Eligibility & Claims Status – Update on Industry Adoption

• Second Set of ACA Mandated Operating Rules - EFT & ERA – Overview of CAQH CORE 360: Uniform Use of CARCs and RARCs Rule

– EFT/ERA new CAQH CORE Implementation Tools and Resources

• Discussion with CMS OESS – Matt Albright, Deputy Director, Administrative Simplification Group, CMS

• Third Set of ACA Mandated Operating Rules – Overview: Getting Involved

• Q&A

4 © 2013 CORE. All rights reserved.

CAQH CORE Mission

Mission: Build consensus among the essential healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between health plans and providers

• Support applicable HIPAA transaction requirements

• Enable providers to submit transactions from any system

• Enable stakeholders to implement CAQH CORE in phases

• Facilitate stakeholder commitment to and compliance with CAQH CORE

• Facilitate administrative and clinical data integration

Established in 2005 and designated author of ACA-mandated operating rules

Research and Develop Rules

(based on key criteria and best

practices)

Design Testing and

Offer Certification

Build Awareness

and Educate

Provide Technical

Assistance, e.g., free tools, access to Early Adopters Base

Promote Adoption

Track Progress, ROI

and Report

Maintain and Update

5 © 2013 CORE. All rights reserved.

Current CAQH Initiatives Industry-wide stakeholder collaboration committed to the development and adoption of national operating rules for administrative transactions. The more than 140 CORE Participants represent all key stakeholders including providers, health plans, vendors, clearinghouses, government agencies, Medicaids, banks and standard development organizations.. Utility with over a million providers and 700 health plan/hospital users that replaces multiple paper processes for collecting provider data with a single, electronic, uniform data-collection system (e.g., credentialing). Free to providers. Utility that enables providers to enroll in electronic payments with multiple payers and manage their electronic payment information in one location, automatically sharing updates with selected payer partners. Free to providers.

Collaboration designing a registry of coverage status information that will help health plans and providers correctly identify which claims require coordination of benefits in order to be processed correctly the first time.

Objective industry collaboration tracking progress and savings associated with adopting electronic solutions for administrative transactions across the industry.

COORDINATION OF BENEFITS

6 © 2013 CORE. All rights reserved.

ACA Section 1104 Operating Rule-related Requirements

7 © 2013 CORE. All rights reserved.

Scope: ACA Mandated Operating Rules and Certification Compliance Dates

• Eligibility for health plan • Claim status transactions

HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules

• Electronic funds transfer (EFT) • Health care payment and remittance advice (ERA)

HIPAA covered entities will need to conduct these transactions using the CAQH CORE Operating Rules

• Health claims or equivalent encounter information • Enrollment/disenrollment in a health plan • Health plan premium payments • Referral certification and authorization • Health claims attachments

Compliance in Effect As of January 1, 2013

Mandated requirements available

• Health plans certify via HHS certification program for Eligibility/Claim Status/EFT/ERA rules and underlying standards

Applies only to health plans and includes penalties until certification is complete; existing voluntary CORE Certification is for vendors/PMS/large providers, and health plans

Implement by January 1, 2014

Implement by

January 1, 2014

Implement by

January 1, 2016

HHS will issue NPRM in coming months and re-align implementation date with finalization of program.

CAQH CORE in process of drafting rules for delivery in later in 2014 rather than early 2014.

8 © 2013 CORE. All rights reserved.

First Set of Mandated Healthcare Operating Rules: Eligibility & Claim Status

9 © 2013 CORE. All rights reserved.

Mandated Eligibility & Claim Status Operating Rules High-level Rule Requirements

*NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.”

A PowerPoint overview of the Phase I & II CAQH CORE Rules is available HERE; the complete rule sets are available HERE.

Rules High-Level CAQH CORE Key Requirements

Dat

a C

onte

nt

Eligibility & Benefits

Respond to generic and explicit inquiries for a defined set of 50+ high volume services with: • Health plan name and coverage dates • Static financials (co-pay, co-insurance, base deductibles) • Benefit-specific and base deductible for individual and family • In/Out of network variances • Remaining deductible amounts • Enhanced Patient Identification and Error Reporting requirements

Infr

astr

uctu

re

Eligibility, Benefits &

Claims Status

• Companion Guide – common flow/format • System Availability service levels – minimum 86% availability per calendar week • Real-time and batch turnaround times (e.g., 20 seconds or less for real time and

next day for batch) • Connectivity via Internet and aligned with NHIN direction, e.g., supports plug and

play method (SOAP and digital certificates and clinical/administrative alignment) • Acknowledgements (transactional)*

10 © 2013 CORE. All rights reserved.

Infrastructure Rules

Eligibility & Claim Status Operating Rules Rules in Action

Post-Claim Submission Pre- or At-time of Service

Indicates where a CAQH CORE

Rule comes into play

Provider

Health Plan

Eligibility Inquiry (270)

Eligibility Response (271)

Content: Uniform Error

Reporting

Increased System

Availability

Internet Connectivity and Security

Real-time and Batch Response

Times

Standard Companion

Guides

Provider

Health Plan

Claim Status Request

(276)

Claim Status Response

(277)

Content: Enhanced

Patient Identification Content: Robust

Eligibility Data, e.g., Patient Financials

(YTD deductibles, Co-pay, Co-insurance, in/out network variances)

11 © 2013 CORE. All rights reserved.

Voluntary CORE Certification Update: Eligibility and Claim Status Operating Rules

• Total CORE Certifications and pledges – over 80 organizations – Wide range of plans/payers, vendor products (clearinghouses and PMS)

plus some providers – Certified health plans cover over 130 million lives – Examples of new certifications

− Health Plans – Horizon BCBS NJ, Centene, Rocky Mountain Health Plans, BCBS NE

− Products/Services – HEALTHeNET RHIO, NextGen PMS, GE Centricity Clearinghouse

• CAQH CORE multi-stakeholder Board working with a number of critical entities on completing CORE certification

– Key provider organizations, large PMS with significant marketshare and payers throughout the United States

12 © 2013 CORE. All rights reserved.

CAQH CORE Eligibility & Claim Status Operating Rules Case Study Initiative

• CAQH CORE is currently developing a library of Operating Rule implementation case studies based upon the insights from health plans and providers who are successfully exchanging eligibility, claim status, EFT and ERA transactions with their trading partners in accordance with the CAQH CORE Operating Rules

• The goals of these case studies are to − Address implementation challenges − Share ROI tracking options − Outline operational benefits − Offer inspiration to other implementers − Highlight opportunities for the development of additional implementation tools − Provide industry guidance based on best practices from early adopters

If your organization or one of your trading partners would like to share your

story, please contact CAQH CORE at CORE@caqh.org

13 © 2013 CORE. All rights reserved.

Sample: CAQH CORE in the NEWS

How changes to CORE Rules can reduce uncompensated care November 18, 2013 | Saleem Tahir, Vice president of payer services for Emdeon

- featured in the News section of govhealthit.com

“Among the regulations taking hold are several electronic data interchange (EDI) rules covering transactions and code sets that, while ostensibly low-level in nature, because they are conducted at

the time of patient registration or scheduling, can reduce the chance that practices and hospitals provide uncompensated care.”

• Key insights from article − Although the government has taken steps to create standards and formats for eligibility

transactions to improve real-time eligibility capabilities and limit the variability between Health Plans, these regulations didn’t address the quality or quantity of information being provided. To address these issues, the government required inclusion of operating rules, maintained by CAQH CORE, in the regulations

− Inclusion of these operating rules has created opportunities for healthcare entities (Health Plans, Clearinghouses, Vendors, etc.) to further streamline the real-time eligibility process and develop innovative products and solutions to take advantage of this progress

− Eligibility & Claim Status Operating Rules can help the industry achieve a substantial reduction in administrative costs by encouraging innovative electronic interactions that accelerate payer-provider communication times and eliminate administrative burdens

14 © 2013 CORE. All rights reserved.

Second Set of Mandated Healthcare Operating Rules: EFT & ERA

15 © 2013 CORE. All rights reserved.

Mandated EFT & ERA Operating Rules: January 1, 2014 Requirements Scope

Rule High-Level Requirements

Dat

a C

onte

nt

Uniform Use of CARCs and RARCs (835) Rule Claim Adjustment Reason Code (CARC) Remittance Advice Remark Code (RARC)

• Identifies a minimum set of four CAQH CORE-defined Business Scenarios with a maximum set of CAQH CORE-required code combinations that can be applied to convey details of the claim denial or payment to the provider

Infr

astr

uctu

re

EFT Enrollment Data Rule • Identifies a maximum set of standard data elements for EFT enrollment • Outlines a flow and format for paper and electronic collection of the data

elements • Requires health plan to offer electronic EFT enrollment

ERA Enrollment Data Rule • Similar to EFT Enrollment Data Rule

EFT & ERA Reassociation (CCD+/835) Rule

• Addresses provider receipt of the CAQH CORE-required Minimum ACH CCD+ Data Elements required for re-association

• Addresses elapsed time between the sending of the v5010 835 and the CCD+ transactions

• Requirements for resolving late/missing EFT and ERA transactions • Recognition of the role of NACHA Operating Rules for financial institutions

Health Care Claim Payment/Advice (835)

• Specifies use of the CAQH CORE Master Companion Guide Template for the flow and format of such guides

• Requires entities to support the Phase II CAQH CORE Connectivity Rule. • Includes batch Acknowledgement requirements* • Defines a dual-delivery (paper/electronic) to facilitate provider transition to

electronic remits

* CMS-0028-IFC excludes requirements pertaining to acknowledgements. The complete Rule Set is available HERE.

16 © 2013 CORE. All rights reserved.

EFT & ERA Operating Rules Rules in Action

Pre- Payment: Provider Enrollment

EFT Enrollment Data Rule

ERA Enrollment Data Rule

Content: Provider first enrolls in EFT and ERA with Health

Plan(s) and works with bank to ensure receipt of the CORE-

required Minimum ACH CCD+ Data Elements for

reassociation

Indicates where a CAQH CORE EFT/ERA Rule comes into play

Infrastructure Rules

Increased System

Availability

Internet Connectivity and Security

Real-time and Batch Response

Times

Standard Companion

Guides

Provider

Health Plan

Claims Processing

Billing & Collections

Payment/Advice (835)

Treasury Treasury Bank Bank Electronic Funds Transfer

(CCD+/TRN)

Claims Payment Process

Stage 1: Initiate EFT

Infrastructure Rules

Content: EFT & ERA

Reassociation (CD+/835) Rule

Content: Uniform Use of CARCs & RARCs Rule

17 © 2013 CORE. All rights reserved.

Implementation Best Practices and Lessons Learned Insight from Industry Implementers

• Education is key – Fully understand your business processes and the mandates

• Get executive buy-in early – Among payers and their trading partners, penalties for non-compliance help make this a priority

• Communication is critical – Both internally and externally – engage trading partners early and often

• Determine Scope of Project – Perform Gap Analysis to identify the affected departments, processes, systems and trading partners

• Treat like any other major business project – Identify staff resources, e.g.

• Best to have at least one PM overseeing all implementation efforts • Include heads of all affected departments, IT Leadership, EDI SME’s, etc.

– Realistic timelines, e.g. don’t underestimate the complexity of the systems and adjustments involved

• TEST! – Test your compliance with your trading partners and with your clients – Leverage Voluntary CORE Certification as a quality check

• Get Involved with CAQH CORE – Give input on rule-writing maintenance, and stay up-to-date on implementation developments

18 © 2013 CORE. All rights reserved.

Implementation Steps for HIPAA Covered Entities: Where Are You?

Just Getting Started

Analysis and planning

(budgeted, resources

assigned, impact analysis)

Systems design

(software or hardware upgrades identified,

coordinating with vendors)

Systems implementation

(software/hardware and vendor services

upgrades fully implemented)

Integration & testing

(internal and trading partners

testing)

Deployment/ maintenance (full production use with one or

more trading partners)

FAQs: New EFT & ERA FAQs

are being posted regularly

Voluntary CORE Certification Test Site for conformance testing of

the EFT & ERA Operating Rules; jointly offered by CAQH CORE-authorized testing entity Edifecs

Free CAQH CORE Analysis and Planning Guide

19 © 2013 CORE. All rights reserved.

CAQH CORE 360: Uniform Use of CARCs and RARCs Rule

20 © 2013 CORE. All rights reserved.

243 CARCs

899 RARCs

4 CAGCs

Inconsistent Use of Tens of Thousands of Potential Code

Combinations

Post CORE Rules

CORE Business Scenario #1:

Additional Information Required –

Missing/Invalid/ Incomplete

Documentation (332 code combos)

CORE Business Scenario #2:

Additional Information Required –

Missing/Invalid/ Incomplete Data from Submitted

Claim (306 code combos)

CORE Business Scenario #3:

Billed Service Not Covered by Health

Plan (453 code combos)

CORE Business Scenario #4:

Benefit for Billed Service Not

Separately Payable (40 code combos)

Code Combinations not included in the CORE-defined Business Scenarios may be used with other non-CORE Business Scenarios

Four Common Business Scenarios

CORE 360 Rule: Uniform Use of CARCs and RARCs Four Business Scenarios

Pre-CORE Rules

21 © 2013 CORE. All rights reserved.

CAQH CORE Code Combinations Maintenance Process CORE Business

Scenario #1: Additional Information

Required – Missing/Invalid/

Incomplete Documentation

(332 code combos)

CORE Business Scenario #2:

Additional Information Required –

Missing/Invalid/ Incomplete Data from

Submitted Claim (306 code combos)

CORE Business Scenario #3:

Billed Service Not Covered by Health

Plan (453 code combos)

CORE Business Scenario #4:

Benefit for Billed Service Not Separately

Payable (40 code combos)

CAQH CORE Compliance-based Reviews • Occur 3x per year • Triggered by tri-annual updates to the published CARC/RARC lists by code authors • Include only adjustments to code combinations to align with the published code list

updates (e.g. additions, modifications, deactivations)

CAQH CORE Market-based Reviews • Occur 1x per year • Considers industry submissions for adjustments to the CORE Code Combinations

based on business needs (addition/removal of code combinations and potential new Business Scenarios)

• Opportunity to refine the CORE Code Combinations as necessary to ensure the CORE Code Combinations reflect industry usage and evolving business needs

Stability of CORE Code

Combinations maintained

Supports ongoing improvement of the CORE Code Combinations

22

CARCs and RARCs Code List Maintenance External to CAQH CORE

As the recognized Federal standard/code authors, ASC X12 and the Code Maintenance Committees (which are separate from ASC X12) are responsible for maintaining CARC/RARC/CAGC definitions. Adjustments to the definition of such codes must be addressed via the specific author.

CARCs (CARC Code Committee)

• Total # of CARCs: 241

− not all in CORE Code Combinations

• There are approximately 35 CARC Committee members representing a variety of stakeholder including health plans, associations, vendors, and government entities

• Entities can complete the CARC Change Request Form found HERE*

RARCs (RARC Code Committee)

• Total # of RARCs: 880

− not all in CORE Code Combinations

• The RARC Committee members represent various components of CMS

• Entities can complete the RARC Change Request Form found HERE

*Before submitting a CARC Change Request Form, entities are first encouraged by the Committee to contact a member of the committee to “facilitate their request by allowing someone familiar with the approval process to discuss an alternate solution (if appropriate) for their need, or enabling that committee member to obtain additional background information which could help with the request”. Committee list is available HERE

CAGCs (ASC X12)

• Total # of CAGCs: 4

− All are in CORE Code Combinations

• Part of the ASC X12 standard, therefore, can only be revised when a new HIPAA mandated version of X12 standards is issued; current version is ASC X12 v5010

• Entities can submit a request to ASC X12

23 © 2013 CORE. All rights reserved.

Level Set: Scope of 2013 Market-based Review

• A Call for Industry Submission for the 2013 Market-based Review will be distributed via email from CAQH CORE and announced on the webpage

• Per the CAQH CORE Code Combination Maintenance Process, the 2013 Market-based Reviews (MRB) consider two types of industry submissions – Code Combination Adjustments and ideas for potential New Business Scenarios

1. Code Combination Adjustments

• Scope: Includes code

additions/removals for existing CORE-defined Business Scenarios

• High-Level Approval Process: Submissions are reviewed and approved by CAQH CORE Code Combinations Task Group

• Status for 2013 MBR: Task Group will collect industry submissions for code combination additions/removals

2. New Business Scenarios

• Scope: Includes addition of new CORE-defined Business Scenarios and/or substantive adjustments to existing CORE-defined Business Scenarios

• High-Level Approval Process: Any adjustment or addition to the CORE-defined Business Scenarios will require substantive adjustment to CAQH CORE 360 Rule and thus require formal CAQH CORE Approval and Voting Process:

Task Group Rules Work Group All-CORE Vote

• Status for 2013 MBR: Given rule is not yet mandated and ongoing industry implementation, an “Early Call for Submissions of New Business Scenario Ideas” will occur; Task Group will only be collecting ideas for potential New Business Scenarios in 2013 – no voting will occur and a second, “Formal Call” will occur in 2014

24 © 2013 CORE. All rights reserved.

Submission Process: Market-based Code Addition and Removal Requests

• CAQH CORE will hold training webinars to assist entities in completing the Market-based Submission Process

• Online MBR Form will allow entities to submit requests for additions and removals to the existing CORE Code Combinations; potential code(s) additions and removals to the CORE-defined Business Scenarios for CAQH CORE 360 Rule may include:

Types of Additions Types of Removals

1. Add CARC and RARC along with a CAGC(s) 1. Remove CARC and all associated RARCs and CAGC(s)

2. Add CARC along with a CAGC(s) 2. Remove RARC and associated CAGC(s) from existing CARC

3. Add RARC to an existing CARC along with a CAGC(s) 3. Remove CAGC(s) from existing CARC

4. Add CAGC(s) to an existing CARC 4. Remove CAGC(s) from existing CARC and associated RARC

5. Add CAGC(s) to an existing CARC and its associated RARC

25 © 2013 CORE. All rights reserved.

Submission Process: Supporting Information for Each Requested Code Addition/Removal • Submitters must also include additional information to support their

request for each potential code addition and/or removal including: An assessment of whether the requested addition or removal meets the

CORE Code Combination Evaluation Criteria A Strong Business Case for the addition or removal A summary of Real World Usage Data to support the Business Case for

each requested code(s) addition or removal • NOTE: Submitters can exercise discretion whether or not to provide Real World

Usage Data, recognizing that providing such an analysis can strengthen a Business Case for the requested addition or removal

26 © 2013 CORE. All rights reserved.

Submission Process: Early Call for New Business Scenarios

• Online MBR Form will also allow entities to submit ideas for potential New Business Scenarios

• To support a request for a New Business Scenario, submitters must provide: Name and description of potential New Business Scenario One or more examples of CARC(s) that meet the Potential New Business

Scenario An assessment of whether the Business Scenario meets the CORE New

Business Scenario Evaluation Criteria A simple Business Case to support rationale for adding New Business

Scenario A summary of Real World Usage Data to support rationale for adding New

Business Scenario • NOTE: Submitters can exercise discretion whether or not to provide Real World

Usage Data, recognizing that providing such an analysis can strengthen a Business Case

27 © 2013 CORE. All rights reserved.

CAQH CORE Implementation Resources New Tools and Initiatives

28 © 2013 CORE. All rights reserved.

New CAQH CORE 360 Rule and the Code Combinations Maintenance Process Website

• A free and accessible “one stop shop” webpage to provide resources and tools to implementers of the CAQH CORE 360 Rule

• Interactive website includes easy to access information and valuable tools for implementers including:

– Access to current and past versions of the CORE Code Combinations – Publication schedule and Compliance Dates for updated versions of the

CORE Code Combinations – Status of CORE Code Combinations Task Group efforts – Process for Market-based Reviews including access to online submission

form – Outline the impact of updated versions of the CORE Code Combinations for

each stakeholder – Online submission of questions/feedback regarding the CORE Code

Combinations Maintenance Process – Lists of Internal and External Resources Related to the CARCs and RARCs

Please send any additional ideas or needs for this

website to CORE@caqh.org

29

Sample Tool: New Provider EFT/ERA Reassociation Data Request Letter

• In order for providers to maximize the benefits available to them through the CAQH CORE Reassociation Rule, they must reach out to their financial institutions and request that the necessary data for reassociation of an EFT and ERA be sent with each payment

• To help facilitate this request, CAQH CORE developed the Sample Provider EFT Reassociation Data Request Letter

• Providers can use this sample letter as – A template that can be customized with your organization’s information and

emailed directly to your bank contacts – An outline of talking points for a phone or in-person meeting with bank

contacts • The Sample Provider Letter document consists of four main parts

– Background information on the benefits of the sample letter – Key steps for requesting delivery of the reassociation data – The actual letter itself—with customizable sections clearly identified – Glossary of key terms

NOTE: Given January 1, 2014 deadline, CAQH CORE will issue a similar sample letter in the coming weeks that provider can use to request payment via EFT from health plans.

30

Building Awareness and Driving Adoption: EFT & ERA Digital Campaign by CAQH CORE Board • Goals

– Use new channels to increase awareness of the EFT & ERA Operating Rules as industry gets closer to January 1, 2014 compliance deadline.

– Target audience are those who are mandated to comply (health plans, clearinghouses and providers using transactions) and those who are not (providers who do not currently use electronic transactions).

– Provide direct access to implementation tools and resources.

• Components – Campaign website landing page

• Action-oriented page - highlights deadline dates, key steps and tools from CAQH CORE and others

– Provider awareness survey • Benchmark online survey of UPD users and provider association

members – Targeted content marketing

• Google Search Engine Marketing (SEM) • Facebook ads targeted to providers (3.1 million-person targeted

community) • CAQH-sponsored post on Sermo (largest online community

exclusive to physicians; 140,000+ users) • WebMD Provider Professional eBlast

31

Discussion with CMS OESS

Matt Albright, Director, Administrative Simplification Group, CMS

Geanelle Herring, Policy Analyst, Administrative Simplification group, CMS

32

Receiving Health Care Payment Electronically (EFT)

• If you (provider) are using paper checks to receive payments, EFT operating rules have made it easier to enroll in EFT across different health plans by requiring a standard form.

– All providers should consider switching to EFT, and providers who have Medicare patients are required to use EFT in 2014.

• Health care EFT payment through the ACH Network, in contrast to payments through card payments or FedWire, is the adopted standard for EFT.

– While other methods of EFT are not prohibited, a health plan must transmit health care payments through the ACH Network (as Medicare does) if requested by the provider.

– In general, a health plan cannot incentivize a provider to use an alternate transaction method other than the adopted standard or dis-incentivize a provider from using a standard transaction.

33

Health Plan Certification of Compliance in Section 1104 of ACA

• Health plans must certify compliance with standards and operating rules.

• HHS plans to issue a proposed and final rule; that rule has not yet been issued.

• HHS does not expect to require any documentation that would have had to be produced prior to the effective date of the final rule.

34

Scope of Operating Rules as Reflected in HHS Regulations Adopted to Date

• Requirements that facilitate transactions.

• Data content of standards (cannot “duplicate” or “conflict”).

• Processes for updating certain elements of the operating rules.

• Requirements to use standards yet unnamed under HIPAA that support HIPAA transactions.

• “Standard transaction” is a transaction that complies with both applicable standards and operating rules.

35

Polling Question #1: EFT & ERA Implementation Challenges Please identify which of these challenges you have found to be the MOST substantial to your organization’s implementation of the CAQH CORE EFT and ERA Operating Rules:

a) Fully Understanding the Rule Requirements

b) Identifying the Resources Needed for Implementation

c) Making the Necessary Adjustments to your Internal Systems, Business Processes and Software

d) Working with Trading Partners (e.g. communication, understanding roles, etc.)

e) Coordinating and Conducting Internal and External Compliance Testing

f) Other

g) Not applicable (not a HIPAA covered entity)

36 © 2013 CORE. All rights reserved.

Third Set of Mandated Healthcare Operating Rules

37 © 2013 CORE. All rights reserved.

• The remaining ACA-driven operating rule mandate will address the following transactions:

– Health claims or equivalent encounter information – Enrollment and disenrollment in a health plan – Health plan premium payments – Referral, certification, and authorization – Claims attachments

• Process (Note: timeline was delayed by several months given market status) – Q1-3 2013: Build industry awareness of upcoming option to participate in rule writing, ACA goals,

CORE Guiding Principles and existing operating rules; Conduct environmental assessment, e.g., research key opportunities, identify out of scope items, draft White Papers/environmental scans, conduct public surveying

– Q4 2013: Launch Subgroups to review and develop potential rule options and seek input • First Subgroup (Connectivity and Infrastructure launched; meeting Thursdays. • Draft rules already written for Prior Authorization and Claims will be revisited; data content group will be meeting

on Tuesdays. – Q1 2013-Q3 2014: Subgroups continue their work – Q3 2014: Detailed draft rule requirements developed in preparation for Work Group ballot – Q3/4 2014: Finalize rule requirements in preparation for full CORE vote

Third Set of Mandated Operating Rules Effective Date of January 2016

38

Third Set of ACA Mandated Operating Rules: Content and Infrastructure

Response Time Rules (batch and real-time)

System Availability Rules

Companion Guide Requirements

CORE Connectivity Rule v2.2.0 (Safe Harbor)

Other Connectivity

Methods

• Data content rules can apply to all transactions. Trace numbers and uniform code usage, in which rule includes ongoing/evolving code maintenance, identified as key opportunities.

• Infrastructure opportunities were rated extremely high. Batch turnaround time for all transactions, real-time for some actions, e.g., provision of Prior Auth requirements (not approval; rule exists), Claim submission (not RTA). Acknowledgements viewed as critical (draft rule exists for Claim); however, regulations yet to recognize acknowledgements to date. Evolved connectivity and Companion Guide template have very high support. Employer role with infrastructure viewed as critical; however, regulations can only reach employer indirectly via health plans.

• CAQH CORE Connectivity and other infrastructure rules currently apply to all operating rules with the exception of EFT which uses different infrastructure (ACH network)

• Safe Harbor principle applies only to CAQH CORE Connectivity Rule. Connectivity approaches outside Safe Harbor still need to comply with all other rule requirements (infrastructure and content).

Data Content Rules:

Support use of

X12, HL7 and industry

neutral payloads, e.g. PDF

Other infrastructure rules e.g., dual delivery

39

Third Set of ACA Mandated Operating Rules: Landscape of Legislative and National Connectivity Initiatives

Interoperability Initiatives

CAQH CORE

eHealth Exchange (formerly NwHIN); HealtheWay

ONC S&I esMD has adopted CAQH CORE Connectivity

Trust policy frameworks developed by DirectTrust, white papers by ONC S&I esMD Author of Record

Technical Impact of Direct Connectivity

Need to support standards in new areas such as attachment

Need for reliability and security in support of the new business transactions

Legislative Movement HIPAA covered entities are implementing

CAQH CORE Connectivity for ACA Section 1104 compliance

Meaningful Use Stage 2 has transport requirements for Providers/EHR systems, e.g. ONC DIRECT

HITECH Act has greater security requirements, penalties for lack of security

Market Movement

Market movement from paper based to Internet based electronic transactions.

Efficiencies of scale gained as more trading partners support electronic transactions

Improved efficiency as more electronic transactions become standards based

Market Movement towards increased Connectivity, new Business Needs

Legislative and National Initiatives Movement towards increased adoption of Standards

Government PKI Infrastructures Federal Bridge is built and operational

supporting cross-certification of trusted PKIs

40 © 2013 CORE. All rights reserved.

General CORE Connectivity Criteria Applicable to Third ACA Set General Principles

• Supports large Batch transaction files • Supports Real-time transaction processing

• Supports large volume of single Real-time transaction processing

• Has extensive message attributes

• Supports Synchronous (i.e., request/response on single connection) and Asynchronous (i.e., response initiated by responder on separate connection) message exchanges

• Supports Point-to-Point message exchanges

• Supports push and pull messaging

• Supports rules based routing

Security Principles • Supports Submitter (Initiating System or

Client) Authentication

• Supports Encrypted Authentication

• Supports Digital Certificates

Reliable Messaging • Payload Independence

• Message Metadata

Implementation Business Principles • Language Neutral

• Platform Neutral

Interoperability Principles • Compatible with emerging clinical

standards for interoperability

41 © 2013 CORE. All rights reserved.

Your Opportunity to Contribute to Development

• Entities are encouraged to join CAQH CORE to directly contribute: – The most effective way for individual organizations to assure they have direct input

on the mandated and voluntary operating rules is by becoming a CORE Participating Organization; any entity may join. Cost is extremely low or free. Benefits include:

• Participation on Subgroup/Work Group rules-writing calls, surveys, straw polls, and ballots; eligibility to Co-Chair

• Entity vote on CAQH CORE Operating Rules at Work Group and Full CORE Membership voting levels

• Access to CAQH CORE Education Sessions specific to CORE Participating Organizations

• Entities unable to join CAQH CORE can contribute via: – CAQH CORE Town Hall Calls

• CAQH CORE holds bi-monthly Town Hall calls which provide attendees an update on recent activities including status of rule development; email core@caqh.org to be added to the distribution list

– CAQH CORE Industry Surveys • CAQH CORE periodically conducts industry-wide surveys for directional feedback on

operating rule opportunities; email core@caqh.org to be added to the distribution list

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Q&A

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APPENDIX

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Compliance with Updated Versions of the CORE Code Combinations

How long do HIPAA covered entities have to comply with the updated versions of the CORE-required Code Combinations for the CORE-defined Business Scenarios (e.g. the CORE Code Combinations)? HIPAA covered entities have 90 days from the date of publication of an updated version of the CORE Code Combinations until compliance with that version is required. Exceptions: When CARCs and RARCs have modification or deactivation/stop dates after the CORE Code Combinations Compliance Date (6 months after publication on the WPC website):

1. Deactivated CARCs and RARCs may continue to be used in the CORE-defined Business Scenario in which they

were included until their deactivation/stop date. After the deactivation/stop date the code can only be used in derivative business transactions (See FAQs on the WPC website HERE).

2. Modified CARCs and RARCs may continue to be used with their previous description in the CORE-defined Business Scenario in which they were included until the date the modification is effective. After the date modification is effective the previous description can only be used in derivative business transactions.

NOTE: CAQH CORE has established a policy to publish updated versions of the CORE Code Combinations on February 1st, June 1st, and October 1st of each year (e.g. approximately 3 months after the code list updates). Thus compliance with the updated versions will be required 3 months after the CORE Code Combinations publication dates, e.g. May 1st, September 1st, and January 1st of each year.

Proposed CORE Code Combinations Timeline

Projected Code List Updates

CORE Code Combos Publication Date

CORE Code Combos Compliance Date

(90 days from date of publication)

~November 1 February 1 May 1 ~March 1 June 1 September 1 ~July 1 October 1 January 1

45

CAQH CORE Rules Approval Process

*CAQH CORE Body CAQH CORE Requirements for Rules Approval

Level 1: Subgroup and Task

Groups Not addressed in governing procedures, but must occur to ensure consensus building.

Level 2: Work Groups

Work Groups require for a quorum that 60% of all organizational participants are voting. Simple majority vote (greater than 50%) by this quorum is needed to approve a rule.

Level 3: Full Voting

Membership

Full CORE Voting Membership vote requires for a quorum that 60% of all Full CORE Voting Member organizations (i.e., CORE Participants that create, transmit, or use transactions) vote on the proposed rule at this stage. With a quorum, a 66.67% approval vote is needed to approve a rule.

Level 4: CAQH CORE Board

The CAQH CORE Board’s normal voting procedures would apply. If the Board does not approve any proposed Operating Rule, the Board will issue a memorandum setting forth the reasons it did not approve the proposed Operating Rule and will ask the CORE Subgroups and Work Groups to revisit the proposed Operating Rule.

*NOTES: Either the CAQH CORE Board or CAQH does not have veto or voting power over the CAQH CORE Operating Rules. Any entity that is a CAQH CORE participant per the CAQH CORE application process has a right to vote on the rules, understanding that at Level 3 only entities that will implement the rules vote on the rules. CORE Work Groups/Subgroups do not meet on a constant basis, only during rule writing or maintenance periods.

46 © 2013 CORE. All rights reserved.

Two New CAQH Initiatives

• CAQH EFT Enrollment Solution (http://www.caqh.org/PR201301.php) – Instead of enrolling individually with each payer, CAQH offers a secure, online

system that allows providers to enroll in electronic payments with multiple payers at no cost

• CAQH Coordination of Benefits Solution (http://www.caqh.org/PR201302.php) – Creates a source of timely and accurate coverage status, enabling providers to

determine primary and secondary coverage for patients who are insured by more than one policy; confusion over insurance status can occur with patients who have lost or changed jobs or have multiple sources of coverage

– Committed health plans include Aetna, AultCare, BCBS of Michigan, BCBS of North Carolina, BCBS of Tennessee, CareFirst BCBS, Cigna, Health Net, Inc., Horizon Healthcare Services, Inc., Kaiser Permanente, UnitedHealth Group, and WellPoint, Inc., on behalf of its affiliated health plans; together these organizations cover more than 165 million lives