Jared A. Adair Director Office of Operations Management

1. Implementing HIPAACenters for Medicare & Medicaid ServicesFourth National HIPAA SummitApril 25, 2002 Jared A. Adair Director Office of Operations Management

2. CMS’s Commitment to Implementing HIPAA • Office of Operations Management • New • Focal Point for the Agency for Administrative Simplification • Work continues throughout the Agency • HIPAA Steering Committee • HIPAA Roundtable Discussions

3. CMS’s Dual Roles • Responsible for regulations that adopt HIPAA standards… • …and modifications to those standards • Operate health plans that must be compliant • Medicare (fee-for-service and managed care) • Medicaid and SCHIP

4. Medicare Fee-for-Service • CMS directly responsible for readiness • Business partners • Medicare carriers and fiscal intermediaries • Claims processing systems maintainers • Environment: Quarterly systems releases

5. Medicare FFS - Basic Concepts • Can’t do it all at once • Risk • Resources • Used WEDI sequencing white paper as guidance • Minimize changes to ‘core system’ processes

6. Medicare FFS - Implementation Instructions • Effort began almost two years ago • JAD technique, involving our partners extensively • Instructions contain: • Requirements • Flat file formats/crosswalks • Edit documents and other guidance

7. Medicare FFS - Instructions Progress • Published: • Inbound claim and outbound COB (837) • Remittance Advice (835) • Claims status query/response (276/277) • Testing • In Progress: • Eligibility query/response (270/271) • Referral/authorization (278) • Retail Pharmacy (NCPDP)

8. Medicare FFS - Status • Medicare contractors using Claredi for testing and certification • Testing with partners is sequenced by transaction: • Claim - began mid-April • Remittance Advice - mid-May • COB - mid-June • Claims Status - mid-July

9. Medicare Managed Care • Providing technical assistance and oversight • Sponsoring conferences and training • Transactions: • Will use 820 for premium payments • Plans will have the option of batch 270/271 or DDE for eligibility inquiries • Plans will have the option to use 837 to report risk adjustment data to CMS (this transaction does not require a HIPAA standard)

10. State Medicaid Programs • Providing technical assistance and oversight • Developed a HIPAA compliance “road map” for States • CD-based tool • Provides gap analysis, resources • Facilitating cooperative working relationships among States to identify issues

11. CMS Outreach • Tremendous effort to reach entire health care industry - not just Medicare and Medicaid Providers • Website • Periodic satellite broadcasts and video tapes • Industry roundtable conference calls • Participation in major industry conferences • We are challenged to reach everyone...