Avoiding a Wipeout! Spring Conference April 4, 2008 EDI Session 1 Gary Beatty President EC Integrity, Inc Vice-Chair ASC X12

 HIPAA Adopted Versions ◦ May 2000 ◦ Addenda – October 2002  HIPAA Deadlines ◦ October 16, 2002 – Original Implementation ◦ October 16, 2003 – ASCA Extended Implementation ◦ Contingency Plans

 DSMO ◦ Processed over 1000 change requests ◦ ~500 changes since  X12 ◦ Has processed additional industry change requests since ◦ IG’s are now Technical Report Type 3 – TR3  – First X12 TR3  9 - TR3’s for the current HIPAA adopted transactions  10 – Additional TR3’s for possible HIPAA adoption  Acknowledgements  Health Care Claim Attachments

 X12 ◦ Continuous TR3 development cycle ◦ Learning from past experiences ◦ More industry coordination – DSMO  National Uniform Billing Committee (NUBC)  National Uniform Claim Committee (NUCC)  Dental Content Committee (DeCC)  Health Level 7 (HL7)  National Council for Prescription Drug Programs (NCPDP)  X12 Public Comment Period  NPRM Comment Period

 Business value for change ◦ Increasing inability of to support industry business needs. ◦ Ability to synchronize current HIPAA transactions with health care claim attachment transactions ◦ Added flexibility  Moved some codes to external code lists

 ICD-10 Support ◦ Added capability to communicate  ICD-10-CM Diagnosis  ICD-10-PCS Procedure Codes ◦ Improves the capture of information about the increasingly complex delivery of health care. ◦ Greater coding accuracy and flexibility  opportunities for detailed record-keeping and enhanced documentation to support accurate payment.

 Aesthetics ◦ Table of Contents  Reformatted for consistency across all TR3’s  Content ◦ Consistency between TR3’s ◦ Greater flattening of Segments (single functionality) ◦ Added new business functions ◦ Modified existing business function for efficiency ◦ Front Matter improvements ◦ Alignment with HIPAA Privacy Rules ◦ Uniform content for Subscribers, Members, and Dependents

◦ Removed ambiguity  Removed “Should”, “Could”, “May”  Replace with:  Form A —“Required when. If not required by this implementation guide, may be provided at the sender’s discretion but cannot be required by the receiver.”  Form B —“Required when. If not required by this implementation guide, do not send.”  Situations:  More definitive  Closed loopholes to prevent  Payer-specific requirements due to the TR3 not restricting data  Providers from sending data beyond the minimum necessary needed for the business function –which would require explanatory documentation

◦ Clarified mechanism to communicate National Provider Identifier (NPI) ◦ Allows code set changes to occur rapidly using X12’s Code Maintenance Request and HIPAA non- medical code set adoption processes –as dictated by real-time evolving business needs

 270/271 ◦ Added enhanced and highly specific search requirements for matching individuals covered by health plans: subscribers, members, dependents ◦ Added much more detailed eligibility, coverage, or benefit responses  Plan and benefit begin dates  Plan name  Primary care physician (if applicable)  Other health plans (if known)  10 high level benefits  All demographic information needed to identify the individual in all other subsequent EDI transactions

 837 ◦ Modified subscriber and patient hierarchy ◦ Added National Provider Identifier (NPI) reporting rules ◦ Clarified use of Pay-To Provider ◦ Made provider type definitions consistent ◦ Clarified Coordination of Benefit reporting rules ◦ Clarified drug claim reporting rules ◦ Clarified Medicaid subrogation processing rules

 835 ◦ Removed “Not Advised“ code value usage language ◦ Refined reversal and correction instructions; particularly for  Prompt pay discounts  Interest ◦ Added new segments to communicate  Health Care Policy  Remittance Delivery Method ◦ Enhanced claim status definitions

 276/277 ◦ Improved consistency of subscriber and dependent identification data ◦ Improved capabilities for processing prescription claims  Added use of prescription numbers  Added use of NCPDP reject / payment codes ◦ Enhanced capabilities to communicate patient, provider, and payer control / tracking numbers ◦ Expanded capabilities to send more complete and detailed status information

 278 ◦ Restructured to support patient and service event level requests ◦ Enabled service level to support Institutional, Professional and Dental detailed segments ◦ Clarified patient condition segments ◦ Added medical service reservation: Medicaid ◦ Allowed for multiple reject reason codes ◦ Added support for  Reconsideration requests  Subscriber and dependent mailing addresses  Transport  Other UMO

 834 ◦ Clarified the differences and uses of  Change Update  Full File Replacement  Full File Audit ◦ Added new control totals for  Employee Total  Dependent Total  Transaction Total ◦ Added codes to specify reason for Medicare eligibility

 834 ◦ Added capabilities to communicate  Class of Contract  Service Contract Number  Medical Assistance Category  Program Identification Numbers ◦ Added ability to indicate patient confidentiality and alternate information delivery addresses ◦ Added capabilities to report individual financial amounts related to the member’s responsibility; including Medicaid Spend Down amounts

 820 ◦ Added ability to apply adjustments to  Entire transaction –not just individual members  Past payments ◦ Added the capability to communicate additional deductions  Service  Promotion  Allowance  Charge

 Detailed TR3 Changes Documentation ◦ Summary in Appendix D of each TR3 ◦ Body of each TR3

FunctionStandardTR3 Enrollment X220 Premium Payment X218 Eligibility270/ X279 Services Review X217 Professional Claim837P005010X222 Institutional Claim837I005010X223 Dental Claim837D005010X224 Claim Status276/ X212 Claim Payment X221

 All TR3’s are approved for publication ◦ Available at: ◦ Copyright changes

 Federal rule making process to adopt ◦ Draft Proposed Regulation ◦ Internal Clearance  CMS  DHHS  OMB ◦ Publish NPRM for public comment (? Days) ◦ Draft Final Regulation ◦ Respond to comments (in Final Regulation) ◦ Internal Clearance  CMS  DHHS  OMB ◦ Publish Final Regulation (publication date)  30/60 day Congressional Review (effective date)  2 Years for industry to implement (compliance date)

 Claim Attachments ◦ 277 Request for Additional Information ◦ 275 Patient Information  HL7 Clinical Document Architecture  Acknowledgements ◦ 999 Implementation Acknowledgment ◦ TA1/TA3 Interchange Acknowledgments ◦ 824 Application Advice ◦ 277 Health Care Claim Acknowledgment  269 Health Care Benefit Coordination Verification Request and Response

 Be Proactive not Reactive ◦ Do not wait for the NPRM to review TR3’s ◦ If you need more time ask for an extension

Gary Beatty President EC Integrity, Inc Vice-Chair ASC X12 Questions Thank you ! WEDI X12 Pre-conference Forum: HIPAA X Transaction Enhancements Held in conjunction with the 17th Annual WEDI National Conference Monday, May 19, 2008 Hyatt Regency Baltimore on the Inner Harbor