Pilot for End-to-End Testing of Compliance with Administrative Simplification

1. Pilot for End-to-End Testing of Compliance with Administrative Simplification Presented By: National Government Services January 8, 2013 10:00 am to 11:00 am EST

2. Welcome

3. Agenda • Welcome/Opening Remarks Julie McBee 5 minutes • ICP Attendance David Carrier 5 minutes • Ground Rules Julie McBee 2 minutes • Goals, Intended Outcomes & Overview • Definitions David Carrier • End-to-End • Readiness Open Floor 5 minutes • Compliance Open Floor 10 minutes • Readiness Specific (Provider, Payer, Vendor) Open floor 20 Minutes • Questions Team • Closing Remarks Team • How to contact us Julie McBee

4. Industry Collaborative Partners Introductions • Aetna • American Health Insurance Plans (AHIP) • American Hospital Association (AHA) • American Medical Association (AMA) • CMS Medicare FFS • Emdeon • Healthcare Billing & Management Association (HBMA) • IVANS • Medicaid – CSG Government Solutions • Medical Group Management Association (MGMA) • Nachimson Advisors, LLC • Providence Health and Services • TIBCO Foresight • TRICARE • UNC Health Care • Walgreens • WellPoint • Veteran’s Affairs

5. Ground Rules • All participants will be muted upon log in for the start of the webinar. • Once the opening presentation is done, we will open it up for questions. • Please provide your name when asking a question so that we know who is speaking. • Additionally, we ask that only the primary and back-up points of contact be your designated speakers on the webinar. With the number of participants we expectto participate on our webinars, we want to give each Industry Leader ample time to contribute. • Listen to and value all contributions equally. We are trying to make sure this is a collaborative effort where all Industry leaders can be heard. • We value your time so please keep your discussion focused. • Specifically for today’s call, we will be opening the floor for each contributor up to 3 minutes to speak. We will let you know when you are at 2 and 2:30 minutes to finalize your comments.

6. Goals The goals of the pilot are: • To develop and implement a process and methodology for End-To-End testing of the transaction standards, operating rules, code sets, identifiers, and other Administrative Simplification requirements adopted by the Secretary of Health and Human Services (HHS) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Patient Protection and Affordable Care Act of 2010 (ACA) based on industry feedback and participation. • To develop an industry wide “Best Practice” for End-to-End Testing that lays the ground work for a more efficient and less time consuming method for health care provider testing of future standards, leading to more rapid adoption of the future standards.

7. Intended Outcomes The intended outcomes of the pilot are: • To provide documents and artifacts to all industry segments outlining the critical check-points needed to ensure compliance with the current mandates • To provide documents and artifacts to all industry segments outlining the critical check-points which can be used as foundations with future mandates • To provide a universal testing process and methodology that can be adopted by all industry segments • To provide a framework and common understanding around the End-To-End testing process and definitions

8. Overview • Phase I – Business and Gap Analysis started on September 24, 2012 and will run through December 21, 2012 (Completed) • Phase II - Development of Pilot Testing started on December 10, 2012 and will run through June 27, 2013 (approximately six months)* • The planned start date for Phase III - Implementation and Quality Assurance is July 1, 2013, and will run through September 23, 2013 (approximately three months)* *Actual dates are subject to change during detailed schedule development

9. End-to-End Testing The intended outcome of our pilot is to analyze, develop and demonstrate a process and methodology which ensures compliance with legislative mandates and regulations. Based upon discussion and feedback from professional organizations, such as Workgroup for Electronic Data Interchange (WEDI), Healthcare Information and Management Systems Society (HIMSS), North Carolina Healthcare Information Communications Alliance (NCHICA), Healthcare Billing & Management Association (HBMA) and other Associations, there has been strong recommendation that the Industry clearly needs a standard definition for End-To-End testing which is acceptable throughout the Health Care Industry. *Our final definition is as follows: End-to-End testing is a focused process within a defined area, using new or revised applicable products, operating rules or transactions, throughout the entire business and/or clinical exchange cycle, for the purpose of measuring operational predictability and readiness. The End-to-End testing process should be performed in an environment which mirrors actual production as closely as possible, confirming the validation of performance metrics and analytics (reporting). *This is a catalyst from our initial discussion with our Industry Collaborative Partners for establishing a definition of End-To-End testing based on Industry feedback and participation during Phase I of our pilot.

10. Readiness Webinar Feedback #1 Shawn Turner-Concerned that Readiness definition is too focused on “testing”.  She would like to see the words “validation & verification”. George Arges-“Published standard” at the end of the definition is too narrow.  What is a specific level/target goal of testing to be completed in order to be considered successful? Godwin-What would be an acceptable level of testing/validation?  Is it appropriate to specify the rate of success? Rob Tennant- would like to take out the word “internal testing”.  Concerned with “external training”.  Likes George’s idea of taking out “published standard.” Could we say “Training of appropriate personnel”? Dean-We need to keep external training in the definition and be sure we distinguish between internal and external Godwin-Looking at last sentence-what if you want to test what is in the regulatory compliance? Dean-Everything we will do will be a regulatory or published requirement.  Admin Simp, ACA, HIPAA Next and ICD-10 implementations will all be affected. Sherri Dumford-Definition should be attached to Reg. Requirements or we are going to open the door to interpretation. Rob Tennant- You can argue there are transactions that haven’t been mandated (275?)  We’re trying to produce an environment where published or unpublished requirements could be tested E2E.  We need to keep it generic for early pilot environment.

11. Readiness Webinar Feedback #2 Michele Lanzetta-We have now carved external trading partners out of E2E.  We need to add external testing/validation back into definition. Stanley-Think about the two levels of readiness; phase 1 and phase 2.  Readiness to being E2E and Readiness that you have done your testing, completed testing & ready to implement in the 2nd phase. Shawn Turner-Making distinction between internal and external.  Concerned with the word “internal”.  Success criteria for E2E defines that we’ve demonstrated successfully.  Not so much regulatory requirements, but establishing criteria for achieving readiness….the measurements have been achieved or met.  Our definition is still too limited. Iagree, internal needs to be removed. As we look at our E2E definition and the measurement of it, here in Readiness, we are meeting our defined success criteria (vs. the regulatory requirement). Each organization should have defined and established success criteria that meet the readiness levels for implementation of all regs prior to the compliance date or regulatory requirements. For any given initiative you may have dependencies where some parts of the industry need to be ready before others can come into compliance. Those success criteria are the measurements that have been demonstrated during E2E. Don't want to prescribe percentages, just use as an example. Provider has defined dependencies - those are dependencies that can vary across the industry Dean-We agree, but would like to keep the general definition of Readiness general and then drill down in the entity readiness definitions. Steve Moore - Training appropriate to all affected entities. External training could include setting up new or modified communications protocols (data lines, transmission software, etc.)

12. Readiness Readiness is a state of preparedness that includes defining needs, identifying risk and implementing a planned sequence of actions to successfully operate and maintain a new/upgraded system, and or processes, with each published standard by the regulatory implementation date. *Our revised definition is as follows: Readiness is a state of preparedness in which an Entity has completed verification and validation of applicable policies, procedures, guidelines, laws, regulations, and contractual arrangements with expected results. Additionally, entities will demonstrate readiness by completing internal documentation, establishing communication mechanisms and validation with external trading partners, training of appropriate personnel , scheduled deployments, and software migration for each regulatory requirements. *This is a catalyst for our initial discussions with our Industry Collaborative Partners for establishing a clearly refined definition of Readiness based on Industry feedback and participation on January 3rd, 2013 webinar.

13. Compliance Webinar Feedback Stanley-Contractual agreements-not sure it belongs in Compliance definitions.Probably need to change the "and" to "or" David-This came from the HIMSS definition. Cathy Carter-Why are we defining Compliance “for, by or after”?   Does not agree with “prior”. Godwin-Doesn’t see anything wrong with stating being compliant before compliance date.  Rob Tennant-Agrees with Stanley on contractual agreement.  Agrees with Cathy; we don’t want to require they are compliant before date. Sherri Dumford-Agrees with Stanley on contractual agreements.  Could use the word “maintaining” after Regulatory Implementation date? George Arges - Compliance is a process that demonstrates adherence to those policies, procedures, guidelines, laws, regulations, and contractual arrangements in advance of, by , and after the regulatory implementation date. How about "collaborate in the development of internal and external training of personnel?” “For each regulatory or other mutually agreed upon requirement."

14. Compliance *Our revised definition is as follows: Compliance– Demonstrated adherence to those policies, procedures, guidelines, laws, regulations to which the business process is subject in advance of, by or after the regulatory implementation date. *This is a catalyst for our initial discussions with our Industry Collaborative Partners for establishing a clearly refined definition of Compliance based on Industry feedback and participation on January 3rd, 2013 webinar.

15. Provider Readiness Webinar Feedback George Arges-Vendors should have products available well in advance of implementation date.  How can we add that into this definition.  Small Providers are dependent on vendor making their products available well in advance. Godwin-Contractual arrangement was removed-Small Providers don’t actually see testing, but relying on Vendor.  We should add this into definition or checklist. Rob Tennant-Agrees Small Providers are reliant on vendors.  Instead of “testing with a %”, we should say “test with vendors and % of mission-critical external TP’s such as Vendors and Payers.” Should we say “their vendor” in definition “A Provider is considered ready when they or their business associates have completed internal testing and tested with their vendor”

16. Provider Readiness *Our revised definition is as follows: A Provider is considered ready when they or their business associates have completed internal testing and tested with a (%) of mission critical external trading partners including vendors, clearinghouses and payers. Additionally, they will have completed internal documentationand established communication mechanisms with external trading partners, internal and external training, scheduled deployments and/or software migration for each published standard in advance of, by or after the regulatory implementation date. *This is a catalyst for our initial discussions with our Industry Collaborative Partners for establishing a clearly refined definition of Provider Readiness based on Industry feedback and participation on January 3rd, 2013 webinar.

17. Provider Readiness Dependent on the regulation, one or more of the following examples may apply: • All analytics, clinical, Electronic Healthcare Records (EHR’s), Electronic Medical Records (EMR’s) and practice management system upgrades have been completed • Confirmation of successful testing with submission payers • Confirmation of successful testing with vendors • Confirmation of successful testing with clearinghouses • Confirmation of successful submission of claims (837) and receive TA1, 824, 999, 277CA responses. • Confirmation of successful retrieval of the claims’ associated remittance (835) • Confirmation of successful acceptance of claim status inquiry submission (276) • Confirmation of successful return of claim status inquiry response (277) • Confirmation of successful receipt of claims eligibility status request(270) • Confirmation of successful return of claims eligibility status (271) • Confirmation of successful submission of services review inquiry (278) • Confirmation of successful receipt of services review response (278)

18. Payer Readiness A Payer is considered ready when the Payer or the Payer’s business associates have completed all internal testing and tested with a (%) of mission-critical external trading partners including vendors, clearinghouses, and providers. Additionally, they will have completed internal documentation and established communication mechanisms with external trading partners, internal and external training, scheduled deployments and/or software migration for each published standard in advance of, by or after the regulatory implementation date.

19. Payer Readiness Dependent on the regulation, one or more of the following examples may apply: • All system upgrades – front end translation and back end adjudication system – have been loaded • Confirmation of successful testing with submitting providers • Confirmation of successful testing with submitting vendors • Confirmation of successful testing with clearinghouses • Confirmation of successful acceptance of production like claims (837) submission • Confirmation of successful return of the claims’ associated remittance (835) • Confirmation of successful acceptance of claim status inquiry submission (276) • Confirmation of successful return of claim status inquiry response (277) • Confirmation of successful receipt of claims eligibility status request (270) • Confirmation of successful return of claims eligibility status (271) • Confirmation of successful receipt of services review inquiry (278) • Confirmation of successful return of services review response (278) • Confirmation of successful receipt benefit enrollment (834) • Confirmation of successful return of benefit maintenance (834)

20. Vendor Readiness A Vendor is considered ready when they or their business associates have completed internal testing and tested with a (%) of mission critical external trading partners including providers, clearinghouses/vendors and payers. Additionally, they will have completed internal documentation and established communication mechanisms with external trading partners, internal and external training, new/change processes, completed scheduled deployments and/or software migration for each published standard in advance of, by and after the regulatory implementation date.

21. Vendor Readiness Depending on the type of vendor your organization is and the regulation change, one or more of the following examples may apply: • All system upgrades – front end translation and back end adjudication system – have been loaded • Confirmation of successful testing with submitting providers • Confirmation of successful testing with submitting payers and/or vendors • Confirmation of successful testing with clearinghouses • Confirmation of successful acceptance of production claims submission (837) • Confirmation of successful return of the claims’ associated remittance (835) • Confirmation of successful acceptance of claim status inquiry submission (276) • Confirmation of successful return of claim status response (277) • Confirmation of successful acceptance of eligibility status (270) • Confirmation of successful return of eligibility status (271) • Confirmation of successful receipt of services review inquiry (278) • Confirmation of successful return of services review response (278) • Confirmation of successful receipt benefit enrollment (834) • Confirmation of successful return of benefit maintenance (834)

22. Questions ?

23. Closing Remarks • Hope to finalize the Readiness and Compliance Definitions soon. If you have any feedback on the definitions, please send it no later than Friday, January 11, 2013. • Next ICP webinar session is Thursday, January 10, 2013 from 10am to 11am EST • Listening Sessions have begun: • Participants can join via a CMS website link. Below is the link for those sessions. http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/index.html

24. Suggested Audience for Listening Session Definitions Small providers will include small/medium sized organizations comprised of 99 or less physicians/staff, independent practices, dentists, durable medical suppliers, pharmacy, home health agencies/hospices and specialty practices. Large providers will include organizations comprised of 100 or more physicians/staff, clinical labs, hospitals, critical access hospitals, nursing homes, rehab centers, skilled nursing facilities, ambulatory surgical centers, pharmacy and Federally Qualified Health Centers (FQHC). Payers will include organizations comprised of Commercial, Medicaid, Medicare, Pharmacy Benefit Management (PBM) and Workers Compensation Government Contractors. Vendors will include organizations comprised of Billing Services, Clearinghouses, Electronic Health Record/Electronic Medical Record Systems, Network Service Vendors, Practice Management Systems and Value Added Networks.

25. How to contact us • All questions may be sent to ngs.compliancetesting@wellpoint.com • Our expected level of service is to acknowledge all e-mails within 24 hours • Additional Contact Resources: