Day 1, Track 5

1. Day 1, Track 5 L. Carl Volpe

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3. Today�s Agenda CAQH Improving Access to Eligibility and Benefits Information Committee on Operating Rules for Information Exchange (CORE) Goal Participation Work Groups Timeline

4. An Introduction to CAQH The Council for Affordable Quality Healthcare (CAQH) is a not-for-profit alliance of health plans and networks that promotes collaborative initiatives to: Make healthcare more affordable Share knowledge to improve quality of care Make administration easier for physicians and their patients

5. Areas of Focus CAQH designs and implements achievable, concrete initiatives to make administration easier for physicians and consumers Universal Credentialing DataSource Simplified Prescribing Standard Billing Terminology Online Eligibility and Benefits Inquiry

7. Focus On Eligibility and Benefits HIPAA does not offer relief for the current eligibility problems Data scope is limited; elements needed by providers are not mandated Does not standardize data definitions, so translation is difficult Offers no business requirements, e.g. timely response Individual plan web sites are not the solution for providers Providers do not want to toggle between numerous websites that each offer varying, limited information in inconsistent formats Vendors cannot offer a provider-friendly solution since they depend upon health plan information that is not available Data interpretations vary from plan to plan and can not be accurately translated by vendors Data elements available from plans vary and are very limited, requiring providers to still call the health plans Access is not available for all plans and/or plan products Vendors maintain multiple interfaces, yet have minimal provider uptake

8. Online Eligibility and Benefits Inquiry: Vision Providers will send an on-line inquiry and know: Which health plan covers the patient * Whether the service to be rendered is a covered benefit (including copays, coinsurance levels and base deductible levels as defined in member contract) What amount the patient owes for the service** What amount the health plan will pay for authorized services**

9. Online Eligibility and Benefits Inquiry: Vision As with credit card transactions, the provider will be able to submit these inquiries and receive a real-time response*: From a single point of entry Using an electronic system of their choice For any patient For any participating health plan *CAQH initiative will initially support batch and real-time.

10. Industry Operating Rules Are The Key What are operating rules? Agreed upon business rules for utilizing and processing transactions Encourages the marketplace to achieve a desired outcome � interoperable network governing specific electronic transactions Key components Rights and responsibilities of all parties Transmission standards and formats Response timing standards Liabilities Exception processing Error resolution Security CAQH to serve as facilitator of cross-industry operating rules development

11. Industry Support

12. Committee on Operating Rules for Information Exchange A multi-stakeholder initiative organized and facilitated by CAQH to create, disseminate and maintain Operating Rules and to enable healthcare providers to obtain patient-specific information about the patient�s healthcare benefits

13. CAQH Role: Facilitator This graphic illustrates the steps by which we envision the initiative playing out. We have just launched Step 1 Soon, we will be contacting those organizations represented on this Committee as well as others to participate in the process. The stakeholders, together, will establish the vision and charter and will be responsibility for the development of the operating rules and tools for their implementation. This graphic illustrates the steps by which we envision the initiative playing out. We have just launched Step 1 Soon, we will be contacting those organizations represented on this Committee as well as others to participate in the process. The stakeholders, together, will establish the vision and charter and will be responsibility for the development of the operating rules and tools for their implementation.

14. Initiative Status Orientation Meeting held January 11, 2005 More than 125 representatives from 70 organizations Payer community Provider community Technology vendors Critical standard-setting organizations Banking industry Government agencies (CMS, ONCHIT) CORE Participants More than 60 organizations to date Three Work Groups in process of crafting draft rules

15. Current Participants as of April 21, 2005 Health Plans Aetna, Inc. Blue Cross Blue Shield of Michigan BlueCross BlueShield of Tennessee CareFirst BlueCross BlueShield Empire Blue Cross Blue Shield Excellus BlueCross BlueShield Health Net, Inc. Health Plan of Michigan Humana, Inc. Independence Blue Cross Kaiser Permanente WellPoint, Inc. Associations / Regional Entities / Standard Setting Organizations America�s Health Insurance Plans (AHIP) ASC X12 Blue Cross and Blue Shield Association (BCBSA) eHealth Initiative Healthcare Financial Management Association (HFMA) National Committee for Quality Assurance (NCQA) National Council for Prescription Drug Programs (NCPDP) Utah Health Information Network (UHIN) Utilization Review Accreditation Commission (URAC) Work Group for Electronic Data Interchange (WEDI) Government Agencies Louisiana Medicaid � Unisys Michigan Department of Community Health Michigan Public Health Institute TRICARE United States Centers for Medicare and Medicaid Services (CMS) Other ABN AMRO Accenture Data Processing Solutions PNC Bank PricewaterhouseCoopers LLP Providers American Academy of Family Physicians (AAFP) American College of Physicians (ACP) American College of Radiology (ACR) American Medical Association (AMA) Greater New York Hospital Association HCA Healthcare Laboratory Corporation of America (LabCorp) Medical Group Management Association (MGMA) Montefiore Medical Center of New York University of Wisconsin Medical Foundation (UWMF) University Physicians, Inc. (University of Maryland) Vendors ACS State Healthcare Affiliated Network Services Availity LLC Benefitfocus.com, Inc. CareMedic Systems, Inc. Electronic Data Systems (EDS) Health Transaction Network Healthvision HTP, Inc. InterPayNet MedCom USA Passport Health Post-N-Track ProxyMed Quovadx Siemens / HDX The TriZetto Group, Inc. ViPS (a Division of WebMD) WebMD

16. Functionality to be Addressed CORE will begin by drafting rules for the following: Confirm which health plan covers this patient Confirm health benefit plan coverage Confirm Service Type (e.g., major medical, long-term care, laboratory, etc.) Provide Co-Pay Amount* Provide Base Deductible* Provide Co-insurance Level* *Not accumulator, but amount defined in contract Data elements will be based upon HIPAA 270/271 standards. Additional functionalities will be addressed after rules are written for the scope above.

17. Topics for Consideration Standard and clear definitions and interpretations of the data elements Roles and responsibilities of all parties Technical transmission standards and formats Standards for data timeliness of batch and real-time transactions; encourage market to move to real-time transactions over a specified timeline Error resolution Exception processing Certification Security Standardized response reporting

18. CORE Structure - Phase I

19. Maintenance Phase � Later Phases

20. CORE Steering Committee

21. Participants Health plans Providers Technology companies Clearinghouses Government entities Trade and professional associations Vendors Standard setting organizations Consultants Other interested organizations

22. Categories of CORE Membership Full Health Plan or Vendor Member Full Provider Member Private Advisory Member Standard Setting / Technical Advisory Member Government / Government Advisory

23. Work Groups Initial Work Groups Policy Work Group Rules Work Group Technical Work Group Potential Future Work Groups Communications Work Group Legal and Regulatory Issues Work Group

24. Policy Work Group (Chair: Bruce Goodman, Humana) Charge Identifies policies/procedures CORE should develop and makes recommendations to the Steering Committee Key areas Standard agreement between participants and CORE Certification and auditing Enforcement Third party service provider requirements Granting variances to the rules Exception processing Participants Management-level staff who are able to make policy decisions and are familiar with relevant industry issues as well as various stakeholder perspectives

25. Technical Work Group (Chair: Mitch Icenhower, Siemens) Charge Determines technical specifications for CORE Key areas Connectivity Security Technical requirements of organizations either initiating and transmitting inquiries or receiving inquiries and generating responses Test protocols Participants Individuals familiar with the technical implications of supporting the exchange of information between trading partners, the various technology solutions and options, and the individual system requirements of their organization

26. Rules Work Group (Chair: J. Steven Stone, PNC Bank) Charge Writes the detailed business rules that will be reviewed by the Steering Committee and then voted on by CORE Ensures CORE and its operating rules are coordinated with standard setting entities such as X12 Key areas Detailed requirements of organizations initiating and transmitting inquiries and organizations receiving inquiries and generating responses Definition of data terms Methodology to address member search criteria Acknowledgements Response time Participants Individuals with experience in the business requirements for exchanging information between trading partners and a background in coordinating transaction specifications with daily operations

27. 2005 Timeline Highlights

28. Participation vs. Adoption Participation is voluntary CORE participation only commits an organization to participate in the creation of the rules Once the rules are approved by CORE, each member will decide on its own whether to adopt the rules Adoption of the rules may require changes in contracts between relevant CORE parties

29. From Vision to Reality Provide easier access to consistent, predictable eligibility and benefits information at the point of care Build upon HIPAA to promote the interoperability required Recognize that no single organization, or any one segment of the industry, can do it alone Come together to take the next step and fundamentally change the way that eligibility and benefits information is exchanged

30. www.CAQH.org