IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS

1. IMPLEMENTING THE HIPAA TRANSACTIONS AND CODE SETS Presentation to the Coalition of Voluntary Mental Health Agencies April 30, 2002 Prepared By: Robert Belfort Kalkines, Arky, Zall & Bernstein LLP 1675 Broadway, Suite 2700 New York, New York 10019 (212) 830-7270 rbelfort@kazb.com

2. WHAT DO THE RULES MANDATE? Covered entitiesconducting any of theHIPAA transactions electronicallymust use standardizedformats and codes.

3. WHAT ARE THE HIPAA TRANSACTIONS? • Claims submission or encounter data • Verification of health plan eligibility • Pre-certification and authorization of referrals • Claims status • Claims payment and remittance advice • Coordination of benefits • Plan enrollment and disenrollment • Premium payments Health plans only

4. Provider Billing Pre-authorization Eligibility Health Plan Payment Pre-authorization Eligibility TRANSACTION FLOW CHART Claim submission Claim payment Claim status inquiry Claim status response Request for authorization Approval or denial Eligibility inquiry Eligibility response

5. ANSI TRANSACTION FORMATS Claim submission ANSI X12N 837 Claim payment 835 Claim status inquiry 276 Claim status response 277 Request for referral/pre-authorization 278 Response to referral/pre-authorization request 278 Eligibility inquiry 270 Eligibility response 271

6. Code Type of Service Code Set Administrator Physician services CPT-4 American Medical Association Diagnosis and hospital inpatient services ICD-9-CM Center for Medicare and Medicaid Services Other health-related services HCFA Common Procedure Center for Medicare and (e.g., DME, labs, pharmacy) Coding System (HCPCS) Medicaid Services Dental services Code on Dental Procedures American Dental Association Procedures and Nomedature MEDICAL CODE SETS

7. STATUS OF IDENTIFIERS Date Date Rule Proposed Finalized Comments Provider Identifier November 3, 1999 Final rule delayed due to lack of funding Employer Identifier June 16, 1998 Final rule pending Health Plan Identifier Rule under development Patient Identifier Suspended due to privacy concerns

8. MODIFICATION OF STANDARDS • New versions • Modifications by DSMOs • 180-day notice period

9. KEY ELEMENTS OF TRANSACTION RULES • Cannot use non-standard format even if both parties agree • No local codes • Maximum data set • Compliance by business associates • No cost or time impediments • Non-electronic transactions still permitted

10. ARE YOU A HEALTH CARE PROVIDER? • A provider under Section 1861(s) or (u) of the Social Security Act • “Any other person or organization who furnishes, bills or is paid for health care in the normal course of business” • “Health care” means care, counseling, service, assessment or procedures related to the physical or mental condition or functional status of an individual - includes case management

11. DO YOU CONDUCT ELECTRONIC TRANSACTIONS? Electronic Non-Electronic Internet Fax Extranet Telephone Leased lines Mail Dial-up lines Private networks Tape or disk Direct data entry* Telephone voice response* * Standard content required but not standard format

12. CAN YOU AVOID ELECTRONIC TRANSACTIONS? • Increased labor costs • Claims payment lag • Demands by payors • Medicare electronic billing requirement

13. MEDICARE ELECTRONIC BILLING REQUIREMENT • Effective October 16, 2003 • Exception for “small providers ” • facilities • other providers 25 FTEs 10 FTEs

14. PENALTIES FOR NON-COMPLIANCE • $100 per violation • $25,000 per year cap per violation • You won’t get paid!!

15. COMPLIANCE DATE • October 16, 2002 • ASCA delay until October 16, 2003

16. KEY FEATURES OF ASCA • Option to delay to October 16, 2003 • Must file compliance plan by October 15, 2002 • Must begin testing by April 16, 2003 • Medicare exclusion penalty

17. ELEMENTS OF ASCA COMPLIANCE PLAN • Description of covered entity • Reason for extension • Implementation budget • Submission options • Electronic form at www.cms.gov/hipaa/hipaa2/ascaform.asp

18. SHOULD YOU FILE FOR AN EXTENSION? • Status of your remediation efforts • Readiness of your software or billing vendor • Readiness of your trading partners • Medicare and Medicaid seeking extension

19. FIVE STAGES OF HIPAA COMPLIANCE(Theoretical) • Education • Gap analysis • Remediation • Testing • Training

20. FIVE STAGES OF HIPAA COMPLIANCE(Actual) • Denial • Anger • Grief • Acceptance • Hope

21. BUILDING THE COMPLIANCE TEAM • Oversight by senior management • Coordination by CIO or IT staff • Participation by affected departments • Scheduling • Registration • Coding • Clinical • Billing • Accounts receivable

22. ESTABLISING A COMPLIANCE TIMELINE April 2002 December 2002 April, 2003 October 2003 Education Gap Analysis Remediation Testing Training 248191

23. PERFORMING A GAP ANALYSIS High Moderate Low Internal Staff STAFFRESOURCES Commercial Self-Assessment Tool On-Site Consultant Low Moderate High COST

24. DEFINING THE SCOPE OF COMPLIANCE • Which transactions do you conduct electronically now? • Which transactions would you like to conduct electronically in the future? • Priority considerations • continuity • complexity • ROI • vendor readiness • partner readiness

25. GAP ANALYSIS OF CLAIMS SUBMISSION • Download ANSI implementation guide at www.wpc-edi.com • Prepare HCFA 1500-ANSI 837 crosswalk (see afehct.org/aspire.asp) • Compare data elements and codes

26. FORMAT GAPS VS. CONTENT GAPS • Format Gaps Content Gaps • Coding changes • Missing data elements • Different field sizes • Different syntax • Remedied by change Remedied by change in business • in technology processes/data capture

27. CURRENT ELECTRONIC BILLING MECHANISM • Billing company/clearinghouse • Commercial software package • Home grown system

28. QUESTIONS FOR SOFTWARE VENDORS • Will HIPAA-complaint upgrade be issued? • What is timetable? • Is there a cost? • Will it be tested before distribution? • Will it be certified by a third party? • What training and support will be provided? • How will further upgrades be handled?

29. SELECTING A NEW SOFTWARE VENDOR • Size and financial stability of company • Portion of revenues from health care industry • Level of HIPAA compliance resources • Status of HIPAA compliance efforts • Contractual commitment to future upgrades

30. BILLING COMPANY ISSUES • Will the billing company function as a clearinghouse or subcontract out this function? • Who is in charge of HIPAA compliance? • When will the company be HIPAA compliant? • When will the company be ready to test? • Has the company discussed testing with payors? • Will the company seek third party certification of compliance?

31. OTHER TRANSACTIONS • Medicaid upgrading EMEVS in 2003 • Some HMOs using Internet-based systems • Significant ROI potential

32. SYSTEM REMEDIATION OPTIONS Remediation Option Pros Cons Reprogramming  Maintains system simplicity  High up-front costs  Maximum organizational control  Need for ongoing revisions  No per transaction fees Translator Software  Lower up-front costs  Adds complexity to system  Vendor responsible for  Reliance on vendor for future upgrades future upgrades  No per transaction fees Clearinghouse  No up-front costs  Per transaction fees  Vendor responsibility  Maximum reliance on outside for compliance and upgrades entity

33. COORDINATION AND TESTING • Prepare list of trading partners • Obtain HIPAA compliance status report and timeline • Monitor compliance with timeline • Test transactions (April 16, 2003 ASCA target) • Execute trading partner agreements

34. TRADING PARTNER AGREEMENTS Yes No • Change definition, data condition or use of data • Add data elements or segments to maximum defined data set • Use any code or data elements marked “not used” • Change meaning or intent of implementation specifications • Mechanism for connectivity • Responsibility for telecommunication costs • Use of codes not yet specified • Size limitations on batch transactions

35. NYS MEDICAID TIMELINE Late 2002 Spring 2003 Late 2003/Early 2004?? 2005?? In-house testing External Testing Upgrade of PACES Direct electronic interface

36. EMPLOYEE TRAINING • Data capture • Data processing

37. HELPFUL WEB SITES http://aspe.hhs.gov/admnsimp www.wpc-edi.com/hipaa www.wedi.org www.afehct.org www.ahima.org 250527.ppt