© 2016 CAQH, All Rights Reserved CAQH Provider Data Solutions National Credentialing Forum Meeting February 12, 2016

© 2016 CAQH, All Rights Reserved About CAQH CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients and health plans. CAQH member plans include the following: 2

© 2016 CAQH, All Rights Reserved  Accurate and timely provider data is a necessity for both care delivery and financing of healthcare.  With the US healthcare system moving to value-based payment models, the need will continue to expand.  Billions of dollars are being spent each year to collect and maintain this information. –Yet the data quality and related processes have significant room for improvement.  Challenges are being experienced in all sectors including provider organizations, Federal and state government entities and health plans. 3 Growing Industry Need for Accurate, Timely Provider Data

© 2016 CAQH, All Rights Reserved Current and Planned CAQH Provider Data Initiatives CAQH ProView ® SanctionsTrack ® EnrollHub ® Provider Directory Data Confirmation Primary Source Verification  Database of self-reported provider information accessible to health plans, health systems, provider groups and hospitals.  Delivers comprehensive, multi-state information on healthcare provider licensure disciplinary actions.  One-to-many provider enrollment solution for health plan electronic payments and electronic remittance advice.  Provider outreach to review and confirm information to meet Medicare Advantage and other provider directory data requirements. IN DEVELOPMENT: Primary source verification of provider data. 4

© 2016 CAQH, All Rights Reserved  Replaced an aging, obsolete platform.  New platform provides a foundation that can be scaled to support future industry provider data management needs.  Includes additional fields requested by participating organizations for provider data needs, e.g., disclosure of ownership questions, NPI Type 2, state for Medicaid ID.  Enhances provider data privacy and security with more robust standards. Why the Transition to CAQH ProView? 5

© 2016 CAQH, All Rights Reserved  Introduced new functionalities to improve provider usability and drive provider adoption, including: −Electronic document upload; eliminates need for faxing. −Multiple state applications in one workflow design. −Self-registration. −Password re-set capability.  Can supports current and anticipated provider data needs of multiple industry stakeholders. –Network provider directories. –Speed claims adjudication and processing. –Primary source verification. Why the Transition to CAQH ProView? 6

© 2016 CAQH, All Rights Reserved Providers and Health Plans Use and Trust CAQH ProView 7  Standard: MD, DO, DC, DPM, DMD, and DDS.  Allied: All other professional providers. (Through October)  More than 1.3 million providers and 800 plans and other organizations participate.  Providers now review and re-attest to the accuracy of their information every 120 days.  Strong industry support, including MGMA, AAFP, ACP and AMA.  Approved by NCQA, URAC and the Joint Commission for provider self- reported data collection for credentialing.

© 2016 CAQH, All Rights Reserved Dramatic Increase in Provider Directory Regulation 8 * = Regulation is still in draft mode and is expected to become effective by = Regulation contains requirements for data quality, validation, and/or audits. National Initiatives  Medicare Advantage 2016 Call Letter: Beginning January 1, 2016, MA organizations must maintain “Regular, ongoing communications / contacts (at least monthly) with providers...”  NEW CMS Memo 11/13/15: “…Proactively conduct at least quarterly communications with contracted providers to ensure that the required information in the directory is accurate.”  HHS Notice of Benefit and Payment 2016: QHP issuers must update their provider directory information at least once a month. Includes field-level requirements for data.  Medicaid and CHIP Proposed Rule: Medicaid MCOs must update electronic provider directories no later than three business days when they are received from the provider.  NCQA 2016 Health Plan Accreditation Updates: Using valid sampling methods, analyze the accuracy of information within provider directories. National Initiatives  Medicare Advantage 2016 Call Letter: Beginning January 1, 2016, MA organizations must maintain “Regular, ongoing communications / contacts (at least monthly) with providers...”  NEW CMS Memo 11/13/15: “…Proactively conduct at least quarterly communications with contracted providers to ensure that the required information in the directory is accurate.”  HHS Notice of Benefit and Payment 2016: QHP issuers must update their provider directory information at least once a month. Includes field-level requirements for data.  Medicaid and CHIP Proposed Rule: Medicaid MCOs must update electronic provider directories no later than three business days when they are received from the provider.  NCQA 2016 Health Plan Accreditation Updates: Using valid sampling methods, analyze the accuracy of information within provider directories.

© 2016 CAQH, All Rights Reserved CMS Monitoring and Enforcement 9  Monitoring –Direct monitoring using contractors to verify accuracy of online provider directories. –New audit protocol to be tested during calendar year  Enforcement –Sanctions include: suspension of enrollment, payment, and/or of all marketing activities until the CMS is satisfied that the deficiencies have been corrected and are not likely to recur. –May impose civil monetary penalties of up to $25,000 per affected enrollee.

© 2016 CAQH, All Rights Reserved Providers Can Now Confirm Directory Data in CAQH ProView Health Plan 1 Health Plan 2 Health Plan 3 Health Plan 4  Single outreach to each provider.  Leverages current provider data already in CAQH ProView. 10  Providers view and confirm data in a new Provider Directory Snapshot.

© 2016 CAQH, All Rights Reserved CAQH Outreach to Providers to Update Directory Data 11 s Phone Calls 1.CAQH first sends providers s to log in to CAQH ProView account and review their information. 2.If a provider does not respond to the s, CAQH will place a phone call to assist. Within the first four weeks of launch, 56% of providers confirmed their information; the majority doing so after the initial outreach.

© 2016 CAQH, All Rights Reserved 12 Updated Provider Data Reported to Health Plans  Provider Standard Data Extract –Contains all validated directory fields for providers who confirmed their information. –Can be compared against the latest health plan information for the same providers. –Production extracts can be provided via XML.  Directory Summary Report –Indicates whether the provider attested without any changes. –Indicates the specific data fields that have changed. –Presents the previous value and new value for these fields.  Outreach Compliance Report –Contains a log of all communications attempted to invite the provider to confirm. –Serves as a monthly record of communication in case of a CMS audit.

© 2016 CAQH, All Rights Reserved  Common PSV pain points include: –Redundancy: Overlapping, non-differentiating activities across health plans, hospitals and other organizations that credential providers. –Long lead times: Initial end-to-end credentialing can take two to four months, creating billing or reimbursement issues for services rendered when a provider first joins a group, and other operational complications. –Evolving electronic based processes: Significant data entry and manual checking of multiple online and offline datasets (although offshoring and automation are being introduced). –Non-standard requirements: Accreditation and compliance requirements vary across accreditors and states. The Primary Source Verification Industry Challenge 13

© 2016 CAQH, All Rights Reserved Industry Need for Greater PSV Efficiency  Opportunities for greater efficiency in the PSV process: –Centralization: Consolidation of redundant credentialing functions located within different health plans and healthcare organizations to achieve economies of scale. –Standardization: Standardization of processes across health plans can drive improvement in data quality, reduce file turn-around times and reduce overall costs. –Alignment: Alignment of provider re-credentialing cycles across health plans. –Automation: Utilize technology investments to reduce turnaround time and labor. 14

© 2016 CAQH, All Rights Reserved New CAQH PSV Solution in Development  CAQH is developing a PSV solution to streamline the primary source verification process for the healthcare industry.  The CAQH PSV solution will integrate with CAQH ProView and will be available as an additional module.  The solution will be rolled out to CAQH member plans in  Additional information will be available later this year. 15