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Centricity™ Business Hidden Gems in Payer Connectivity

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Presentation on theme: "Centricity™ Business Hidden Gems in Payer Connectivity"— Presentation transcript:

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

2 Track Owners: Zinc Instructions Please update the chart to the right before submitting the presentation into Active Individual Page Use?: Yes Are all Uses and Applications Discussed or Referenced in the Proposed Material on Label for the Product?: 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?: Includes Return on investment (ROI), quantifiable cost of ownership, reimbursement, or meaningful use claim or reference?: Include References to Market / Segment Share or Market / Segment Leadership?: Include identifiable Patient Information / Data?: 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?: Do the Proposed Materials Contain Images of GE Products?: Do all Product Images Depict the Device(s) Being Promoted in the Piece?: This is a Translation of a Previously Approved Piece in Which no Changes Have Been Made?: This is a Revision of a Document Previously Approved for Ad / Promo Use?: 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 Gallery Once the presentation is approved in Zinc, please delete this slide from the final deck before presenting at Centricity LIVE


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


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