1. Centricity™ Business Hidden Gems in Payer Connectivity
Sharp HealthCare
April 2015

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4. Agenda Hospital Admission Notification (278N)
Claim Status/Claim Acknowledgments (276/277)
Benefit Enrollment (MCA 834)

5. Hospital Admission Notification 278N
This transaction is a request and response to a Healthcare Payer for authorization of admission for inpatient hospital services.

6. What are the Benefits?
Streamline administrative tasks and increase productivity
Reduce administrative costs through automation
Increase data accuracy by reducing manual errors
Accomplish more with less – fewer phone calls, faxes or keying

7. What are the Requirements?
Enterprise Visit Management required
Centricity Business 5.3
Payer is receiving and responding to 278N transactions

8. How does it Work?
You can manually send a notification for a particular visit
You can use the Notification Manager in the GE Healthcare EDI Toolkit to queue up multiple visits to have notifications automatically sent to the payer
Responses are viewable directly from HPA
There is the ability to Hold Bills if a claim requires notification and a response has not been received

9. Technical Description

10. The 278 is a hierarchical structure
Sender
Receiver
Subscriber
Dependent
Patient Event
Patient Event Providers
Services
Services Providers

11. Trading Partner Integration in HPA

12. Trading Partner Integration in HPA continued…

13. Interactive Request in HPA

14. Interactive Request in HPA continued…

15. Interactive Request in HPA continued…

16. Background Notification Requests (BNR’s)

17. Background Notification Requests (BNR’s) continued…

18. Background Notification Requests (BNR’s) continued…

19. Background Notification Requests (BNR’s) continued…

20. Background Notification Requests (BNR’s) continued…

21. Hold Bills and Follow-Up’s

22. Claim Status/Claim Acknowledgement 276/277
The 276 transaction set is the EDI X12 health care claim status request
The 277 is the EDI X12 health care claim status response
276
277

23. What are the Benefits?
EDI verification eliminates the need for follow up reps to go outside of Centricity Business and manually check payor websites or call for claim status.
HPA 276/277 was originally developed as a real- time tool for users
Batch allows for automated claim status retrieval, eliminating or reducing user interaction

24. 276 Process

25. 277 Process

26. Current Trading Partners
Aetna
Anthem Blue Cross
Blue Shield
United HealthCare
Managed Care Application (internal Sharp payer)

27. Claims Overview (OV Action Code)

28. Claim Status Screen (CS)

29. Drill Down into Results

30. X12 Results

31. Insurance Follow Up Questions

32. Success Factors
Since January 1, 2015*, Sharp HealthCare has sent 9496 requests and received 7855 responses. 
That’s nearly 8,000 phone calls or website research login’s that weren’t necessary! 
*(Data period 1/1/15 – 3/12/15)

33. MCA 834 Enrollment and Covered California
About Sharp Health Plan
Covered Lives: 75,000+
23% of SHC Commercial Managed Care
Best Health: 8,000 Additional Lives
High Customer and Employee Satisfaction
Highest CAHPS Scores (2013), 88th Nat’l percentile
Broker (97.6%)and Employer (93.9%)
Provider (93.2%) 90th percentile (The Myers Group)
Above Market Retention (12 Month Average)
NCQA Accreditation – Status of Excellence

34. Sharp Health Plan and Covered California – 2014 aka Year 1

35. Types of Coverage Individual
Small Business Health Options (SHOP < 50 Employees)
Employers > 50 Employees

36. Off Exchange
Health plans are required to offer same coverage for off exchange as on the exchange.

37. Changes to GE Healthcare Centricity Business
834 Inbound 834 Outbound 999, TA1 Premium Billing & Statements 820 Premium Billing Capitation

38. 834 File Flow

39. EDI 834 Inbound Member matching Contract matching
Demographics fatal edits
Covered California DBMS columns
Covered California fields in Enrollment
EDI 834I Employer Group Ruleset
Modified REF segments in 834I specification

40. Covered California Enrollment Screen

41. EDI 834I Employer Group Custom Enterprise Ruleset

42. REF Segments in 834

43. Outbound 834
Capture the 834 Inbound data in enrollment MCA Enrollment EDI Select Queue Ruleset FDL application “EME” - MCA Benefit Enrollment Forms (834) MCA.834.O application class for specification 834 Outbound Run Manager

44. Enrollment EDI Select Queue

45. EDI 820 Outbound MCA Premium Payment EDI Select Queue Ruleset
FDL Application “EMP”
MCA.820.O Application Class for Specification
New Spec X306
820 Outbound Run Manager

46. Premium Billing Enhancements
Individual Billing
Fixed Rates based on data from inbound 834 (Yearly)
Welcome Letters to Members via Optum prior to first payment

47. Premium Billing
Turned on MCA AES MAP #156 to modify premium during compile Modified custom direct bill statements Created new custom activity for Covered California direct bill statements

48. Covered California – Year 2
Covered California sends multiple enrollment transactions per member/family. Many are duplicates or corrections for previous transactions
During 2014 – Sharp worked with GE Healthcare Centricity Business to customize the 834 member and contract matching as much as possible
THEN
Covered California introduced 14 new issues/failures with the open enrollment

49. Ongoing Issues
Who’s right? The Exchange says they are the source of truth for all demographic data but Sharp also has a Master Patient Index group
A reconciliation process has not been established to report demographic discrepancies
Since we don’t know if the member has paid on initial enrollment – we have to manually term members/enrollment until payment is received
Exchange sends multiple add/change records for members that are out of sequence
Ongoing issue with retro dates on change transactions – this is causing billing issues