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

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Presentation on theme: "Centricity™ Business Hidden Gems in Payer Connectivity Sharp HealthCare April 2015."— Presentation transcript:

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

2 2 Track Owners: Zinc Instructions Please update the chart to the right before submitting the presentation into Active Following review and approval in Active, each presentation given by GE employees or customers at Centricity LIVE must be approved through Zinc Jessica Diniz will be uploading each presentation into Zinc following Active review Before submitting this presentation in Active for review, Track Owners must select the appropriate answer to each Legal and Regulatory question ALL QUESTIONS MUST BE ANSWERED If further substantiation is required, please the appropriate permissions, sources, or citations to so she can upload to the Zinc Once the presentation is approved in Zinc, please delete this slide from the final deck before presenting at Centricity LIVE Individual Page Use?: Yes Are all Uses and Applications Discussed or Referenced in the Proposed Material on Label for the Product?: Yes Relates to a Major new Product/Services Launch?:No Includes Product or Service Claims, Features, Benefits or similar information?:YES Contains Competitive or Comparative Claims?:No Includes Return on investment (ROI), quantifiable cost of ownership, reimbursement, or meaningful use claim or reference?: No Include References to Market / Segment Share or Market / Segment Leadership?: No Include identifiable Patient Information / Data?:No If Customer Names are Used, are Necessary and Appropriate Permissions in Writing and on File?: Yes – Permission to use on File (in Gallery) Include Customer Testimonials?:N/A If any non-GE Stock Images are Used, are Necessary and Appropriate Permissions in Writing and on File?: Yes Do the Proposed Materials Contain Images of GE Products?:Yes Do all Product Images Depict the Device(s) Being Promoted in the Piece?:N/A This is a Translation of a Previously Approved Piece in Which no Changes Have Been Made?: No This is a Revision of a Document Previously Approved for Ad / Promo Use?:No

3 ©2015 General Electric Company – All rights reserved. The results expressed in this document may not be applicable to a particular site or installation and individual results may vary. This document and its contents are provided to you for informational purposes only and do not constitute a representation, warranty or performance guarantee. GE disclaims liability for any loss, which may arise from reliance on or use of information, contained in this document. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE. DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE. GE, the GE Monogram, Centricity, and imagination at work are trademarks of General Electric Company. All other product names and logos are trademarks or registered trademarks of their respective companies. General Electric Company, by and through its GE Healthcare division. 3

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

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

6 What are the Benefits? 6 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? 7 Enterprise Visit Management required Centricity Business 5.3 Payer is receiving and responding to 278N transactions

8 How does it Work? 8 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 9

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

11 Trading Partner Integration in HPA 11

12 Trading Partner Integration in HPA continued… 12

13 Interactive Request in HPA 13

14 Interactive Request in HPA continued… 14

15 Interactive Request in HPA continued… 15

16 Background Notification Requests (BNR’s) 16

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

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

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

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

21 Hold Bills and Follow-Up’s 21

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

23 What are the Benefits? 23 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 24

25 277 Process 25

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

27 Claims Overview (OV Action Code) 27

28 Claim Status Screen (CS) 28

29 Drill Down into Results 29

30 X12 Results 30

31 Insurance Follow Up Questions 31

32 Success Factors 32 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 33 About Sharp Health Plan Covered Lives: 75, % 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 34

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

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

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

38 834 File Flow 38

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 39

40 Covered California Enrollment Screen 40

41 EDI 834I Employer Group Custom Enterprise Ruleset 41

42 REF Segments in

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 43

44 Enrollment EDI Select Queue 44

45 EDI 820 Outbound 45 MCA Premium Payment EDI Select Queue Ruleset FDL Application “EMP” MCA.820.O Application Class for Specification New Spec X 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 46

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 47

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 2015 open enrollment 48

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 49

50 Questions?


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