Presented by: Laurie Darst Mayo Clinic

1. 2010 Health Care Reform Legislation ‘Administration Simplification Provisions and the Impact to 5010’ HIPAA COW Meeting October 15, 2010 Presented by: Laurie Darst Mayo Clinic

2. Administrative Simplification • Patient Protection and Affordability Act (PPACA) – H.R. 3590 – now referred to as Affordable Care Act (ACA) • Administrative Provisions identified in two sections of health care reform bill • Section 1104 – Administrative Simplification • Section 10109 – Development of Standards for Financial and Administrative Transactions • Significant Changes to the HIPAA requirements • Allows for adoption of standards and operating rules via Interim Final Rules, eliminating the need for NPRMs

3. Operating Rules • New Concept of Operating Rules • are defined as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted” • Requires that standards and operating rules • “to the extent feasible and appropriate, enable determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care;” and • “provide for timely acknowledgment, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals)” • Operating Rules to be developed by a non-profit entity meeting specific conditions

4. Operating Rules • Operating Rules – Implementation • HHS required to adopt operating rules, based on recommendations from developer of rules, NCVHS and consultation with providers • Eligibility and Claims status • July 1, 2011 – adoption of operating rules • January 1, 2013 – effective date of operating rules • EFT, Claims payment / remittance advices • July 1, 2012 – adoption of operating rules • January 1, 2014 – effective date of operating rules • Health Claims, health plan enrollment / disenrollment, health plan premium payment, referral certification and authorization • July 1, 2014 – adoption of operating rules • January 1, 2016 – effective date of operating rules • HHS may use expedite rulemaking (interim final rule with 60 day comment)

5. Requirements to Adopt Standards • HHS to adopt: • National Plan ID to be effective not later than Oct 1, 2012 • an EFT standard, to be adopted no later than Jan 1, 2012 and effective not later than Jan 1, 2014 • a claims attachment standard and set of operating rules, to be adopted no later than Jan 1, 2014 and effective not later than Jan 1, 2016

6. Periodic Updating of Standards and Operating Rules • Beginning April 1, 2014 review committee will meet and recommend updates. • Committee to meet not less than every two years after that • Recommendations for updates to be adopted by an interim final rule not later than 90 days after receipt of the committee’s report.

7. Certification Requirements and New Penalties for Health Plans • Health Plan Certification Requirements • Health plans must file certification statement with HHS attesting they are compliant with standards and operating rules • Health plans must extend requirements to business associates (BAA), BAA must certify that they are compliant • Certification statement must be accompanied by evidence of compliance and end to end testing with trading partners. • Penalties for Not Certifying • $1 per covered life per day not certified up to a max of $20 per covered life per year • Double penalties if false statements submitted

8. Timelines

9. Timelines

10. Operating Rules What We Know: What We Don’t Know Definition of “necessary business rules” The entity(s) who will develop operating rules How Operating Rules and the Standards will be coordinated What changes will be needed to 5010 as result of Operating Rules • Operating rules defined as “necessary business rules” • Adoption and Effective Dates Established • Eligibility & Claim Status Effective Date Jan 1, 2013 • Rulemaking process may be expedited

11. Operating Rules – NCVHS Recommendations to HHS Recommendations: Operating Rules Recommendations Performance and system availability requirements Connectivity and transport requirements Security and authentication requirements Business scenarios and expected responses Data content refinements (to situational data elements and codes used with specific data elements • Entities recommended are only for the eligibility and claim status transactions at this time • Recommend CAQH CORE develop the operating rules to support the ANS X12 270/271 and 276/277 transactions • Adopt CORE Phase I and Phase II operating rules • Pharmacy related operating rules continue to be defined by NCPDP • Changes to content of a standard’s implementation guide must be evaluated by the DSMO • Allow only limited use of companion guides

12. National Health Plan Identifier What We Know: What We Don’t Know: What is the purpose of the NHPI What will it look like NHPI granularity Who will be the enumerator Will the NHPI implementation impact the different 5010 transactions • Final Rule Expected to be released “soon” • Effective Date for NHPI is October 1, 2012

13. High Level Summary of Other Recommendations to NCVHS • Stakeholders from all sectors of the industry provided testimony at the July 19, 2010 NCHVS Hearing • General Agreement • Division of opinion • No agreement could be reached on HPID purpose (business use cases) and the level of granularity needed • Definition of health plans under HPID

14. Other Recommendations to NCVHS General Agreement • Identification of the recipient of a transaction • Pharmacy current method of identifying payers is working. Any changes to this process should be vetted through the pharmacy industry • Grandfather provision for entities having ISO U.S. Healthcare Identifiers assigned prior to the availability of the HPID • Industry has concerns about the date and the ability to fully implement by October 2012

15. Other Recommendations to NCVHSDefinition of Health Plans- Division of Opinion • Definition of health plans • Some felt only entities defined by HIPAA statute should be defined as “health plans” for the purpose of assigning HPID • Others felt the definition should include administrators, contractors, networks, repricers, property and casualty insurers, subrogation firms, and others to support the business use cases

16. Other Recommendations to NCVHS Levels of Enumeration - Division of Opinion • Levels of Enumeration • Some felt there should be no HPID enumeration hierarchy established • Others felt there be the following enumeration hierarchy: • HPID Type 1 {Parent} • HPID Type 2 {Subpart(s)}

17. Other Recommendations to NCVHSPurpose (Use Cases)- Division of OpinionPerspective I • Purpose(s) or business use cases of HPID: • Identify entities that fall into the definition for administering the standard transactions. • Payers would identify the need for additional enumeration based on the health plans’ business needs as related to the transactions • Other data needs can and should be addressed through the standards and operating rules in the same time frame as HPID

18. Other Recommendations to NCVHSPurpose (Use Cases)- Division of OpinionPerspective II • In addition to utilizing the HPID for the routing of transactions, the HPID could address a number of existing challenges impacting the provider community • These challenges are a result of increased complexities due to the numerous entities serving in health plan roles • Discrete data (i.e. HPID) was needed versus free-form text fields already available in the transaction standard to successfully address these issues

19. Other Recommendations to NCVHSPurpose (Use Cases)- Division of OpinionPerspective II • At time of registration, the appropriate entities need to be identified so expectations of the payer/provider relationship can be handled appropriately before the services are provided (out-of-network determination and payment expectations) (referral and authorization criteria) • Information sent back to providers in the Eligibility transaction only reflect a patient’s global benefit information, it does not reflect patient benefits specific to the requesting provider (benefit information is not provided regarding the provider/payer contractual relationship) • If enumerated beyond routing of the transactions, there could be a reduction in phone calls and better management of patient expectations

20. Other Recommendations to NCVHSPurpose (Use Cases)- Division of OpinionPerspective II • The enumeration of these entities would also be returned in the remit so the payment posting process can be automated and the appropriate contractual amounts applied

21. Other Recommendations to NCVHSPurpose (Use Cases)- Division of OpinionPerspective II • Enumerate each of the discrete attributes of the complex third-party payment process to facilitate automation (focus on eligibility and remit transactions) • Entity responsible for receiving the claim (eligibility only) • Entity responsible for administering the claim (eligibility & remit) • Plan/product description (must be synched with 835) (eligibility & remit) • Entity that has the direct contract with the provider (eligibility & remit) • Fee schedule that applies to the claim (eligibility & remit)* • Entity responsible for funding the benefit (eligibility only)

22. Other Recommendations to NCVHSPurpose (Use Cases)- Division of OpinionPerspective I and Perspective II Discussion between the two perspective groups revealed: • Perspective I respondents did not support the use of HPID as a solution for other administrative challenges. However, they did acknowledge the challenges outlined were a concern, but recommended the use of the standard transactions and operating rules as a potential solution • Perspective II respondents did not feel the standard transactions and operating rules would address these issues adequately due to the need for discrete information and a number of other factors

23. National Health Plan Identifier– NCVHS Recommendations to HHS • HHS should: • Clarify definition of health plan • Work with stakeholders to reach consensus on names and definition for intermediary entities • Request stakeholders work with groups such as WEDI, AHIP, NAIC, DSMO for definition of products to be used in plan enumeration by October 31, 2010 • Coordinate with other aspects of the ACA

24. National Health Plan Identifier– NCVHS Recommendations to HHS • HHS should: • Initially enumerate all health plan legal entities as defined in HIPAA legislation • Determine at what level, including product (benefit package) level should also be enumerated • Adopt HPID that follows ISO Standard 7812 with Luhn check-digit • Adopt an HPID that contains no embedded intelligence

25. National Health Plan Identifier– NCVHS Recommendations to HHS • HHS should: • Establish an HPID enumeration system and process to support a robust online directory database • Related to Pharmacy • Not require the HPID to be used in place of exiting RxBIN/PCN • Consider effective date of October 2012 be interpreted as date to begin registering for an HPID • October 1, 2012 – March 31, 2013: Enumeration • April 1, 2012 – September 30, 2013: Testing • October 1, 2013: Implementation

26. NCVHS Recommendations to HHS • Keep in mind: • NCHVS is an advisory body to HHS, but the information listed on the previous slides should be considered only recommendations to HHS for Operating Rules and HPID • HHS will publish the mandated requirements in a Interim Final Rule by next summer Stay tuned…..

27. National Health Plan Identifier High Level Analysis from X12 ASC X12 Summary Level Analysis: • NPHI is accommodated in all of the ASC X12 transactions • NHPI occurs 30 times in the 005010 version • It is referenced 19 times in situational rules or segment and data element notes • This does not account for any trading partner use of NHPI within the transaction envelopes Input provided by ASC X12 (July 2010)

28. National Health Plan Identifier High Level Analysis from X12 ASC X12 Implementation Highlight: • 837 Claim Transaction • The Claim Filing Indicator (SBR09) is no longer allowed one the NHPI is mandated. • This field is used today in front end edit routines • May be impact to the level of NHPI granularity needed Input provided by ASC X12 (July 2010)

29. National Health Plan Identifier High Level Analysis from X12 ASC X12 Implementation Highlight: • 271 Eligibility Transaction • Both the Subscriber Benefit Related Entity (Loop 2120C) and the Dependent Benefit Related Entity (Loop 2120D) require the use of the NHPI when the benefit related entity is a payer. This would occur when the benefit related entity is a different payer than that identified as the Information Source or when the Information Source is an entity other than a payer. Input provided by ASC X12 (July 2010)

30. Questions & Discussion Laurie DarstMayo clinicDARST.LAURA@MAYO.EDU(507) 266-3054