Eligibility and Claim Status Operating Rules and …UnitedHealth Group: Corporate Profile OUR HEALTH...

© 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 1

Timothy Kaja, MBA, CPCSenior Vice President, UnitedHealth GroupPresident, Provider and Network Service Operations, UnitedHealthcare

The 21st Annual HIPAA Summit West

Eligibility and Claim Status Operating Rules and HPID (Health Plan ID)

February 21, 2013 9:30 am EST


• Administrative Simplification Provisions of the Affordable Care Act• Overview of UnitedHealth Group• Review of Operating Rules for Eligibility and Claim Status• UHG’s Transactions and Our Roadmap to Compliance• Moving the Industry to Adoption and Utilization• The PayerID of the Future - HPID• Future Considerations to drive Adoption and Utilization

UnitedHealthcare – Operating Rules and the Payer Experience

AGENDA


We Have Passed the Deadline – January 2013

THE JOURNEY TO COMPLIANCE

• Administrative Simplification: Affordable Care Act (ACA) Section 1104

• ACA adds the requirement that Payers Certify Compliance by December 31, 2013 (Expected Rule Early 2013)

• Potential Penalties to be Assessed beginning April 2014• Fines up to $20/per member per year


Administrative Simplification Milestones through Nov 2016

Administrative Simplification provisions of ACA

2013 2014 2015 2016

12/31/2013 HHS Certification Filing Submission (1)

1/1/2014EFT/ERA Transactions

(CAQH Phase III)

1/1/2016 Claims Attachments, Premium Payments, Enrollment,

Auths and Ref.

12/31/2015 HHS Certification Filing

Submission (2)

11/5/2014HPIDs Assigned

11/7/2016HPID Implementation

2012

Compliance Dates

1/1/2013Eligibility and Claims Status

Transactions(CAQH Phase I & II)

• Admin. Simplification Wave 1: Implementation of operating rules for eligibility and claims status determination

• Admin. Simplification Wave 2: Implementation of operating rules for EFT payments and remittance advice

• Admin. Simplification Wave 3: Implementation and certification of operating rules for claims/ encounters, enrollment/ disenrollment, premium payments, referrals/ authorizations, and claims attachments

• Admin. Simplification Wave 4: Enumeration of a unique Health plan Identifier

• Implementation of HPID in all transactions

• HHS Compliance Certification: Certification of compliance with eligibility inquiry, claims status, EFT payments, and electronic remittance advise operating rules.


UHG Roadmap: Administrative Simplification

5

EFT/ERA A/OEFT/ERA Q3/Q4 Release

EFT/ERA Partner Test

Phase I/II/III HHS Certification

HPID Enumeration Strategy

HPID Q1 Release

HPID Partner Testing

Clm, Prem, Enroll, Auth A/O

Clm, Prem Auth Q3 Release

Claim, Prem, Enroll, Auth/Ref Partner Testing

HHS Ops Rules Compliance Certification

2012 2013 2014 2015 2016

2013 2014 2015 2016

12/31/2013 HHS Certification Filing Submission (1)

1/1/2013Elig & Claims Status

Transactions(CAQH Phase I & II)

1/1/2014EFT/ERA Implementation

(CAQH Phase III)

1/1/2016 Claims Attachments, Prem Pmts,

Enrollment, Auths and Ref.

12/31/2015 HHS Certification Filing

Submission (2)

11/5/2014HPIDs Assigned

11/7/2016HPID Implementation

2012

Clm, Prem Auth Q4 Release

HPID Q2 Release

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ELIGIBILITY INQUIRY AND CLAIMS STATUS

• CMS Announces 90-Day Period of Enforcement Discretion for Compliance with Eligibility and Claim Status Operating Rules.

• CMS will not initiate enforcement action until March 31, 2013 for health plans that are not in compliance with the operating rules adopted for Eligibility Inquiry (270/271) and Claim Status (276/277) transactions.

• The compliance date for using the operating rules remains January 1, 2013.• UHG systems were upgraded to be in compliance with these operating rules

as part of the scope of HIPAA 5010 (CORE Phase I & II Certification) but we are anxious for the industry to be aligned on these transactions.

CMS Enforcement Date Change


UnitedHealthcare

CAQH CORE Phase I and Phase II Operating Rulesand

CORE Certification Testing


UnitedHealth Group: Corporate Profile

OUR HEALTH BENEFITS BUSINESS: UNITEDHEALTHCARE OUR HEALTH SERVICES BUSINESS: OPTUM

Helping People Live Healthier Lives

UnitedHealthcare Community & State

UnitedHealthcare Employer & Individual

UnitedHealthcare Medicare & Retirement

UnitedHealthcare Military & Veterans

Making the Health Care System Work Better for Everyone

OptumInsight

OptumHealth

OptumRx

“Health in Numbers”• Serving 35 million Americans at every stage of life• Innovation-driven growth• Exceptionally well positioned to evolve and grow through

health care reform

“Good for the System”A dedicated and independent business providing services to:

6,000 hospital facilities, 250,000 health care professionals, 60 million consumers

• Health care information technology• Consumer engagement and support• Integrated care delivery• Pharmacy • Health financial services

FOUNDATIONAL COMPETENCIES

• Domain knowledge around care management and care resources • Actionable health care information and intelligence• Advanced, enabling technology


• A Phase I and Phase II v5010 CORE-certified health plan

• CAQH Board Member and CORE Transition Committee Member

• Co-Chair of the CAQH Committee on Operating Rules for Information Exchange (CORE) CORE Code Combinations Task Group

• Current CAQH Board Chair: David S. Wichmann, Executive VP, UnitedHealth Group and President, UnitedHealth Group Operations and Technology

• UnitedHealth Group is an active collaborator on industry initiatives that simplify healthcare administration for health plans and providers, resulting in better care experiences for patients and caregivers

United Healthcare: CAQH/CORE Involvement


• Health Plan Operations

– > 20 million Benefit/Eligibility and Claim Status calls in 2012

– > 411 million claims were processed in 2012

• Eligibility and Benefits

– Supports eligibility transactions both in real-time and batch

– >264 million EDI transactions annually

– 95% of these eligibility transactions are handled in real-time

• Claim Status

– Supports claim status transactions both in real-time and batch

– 54 million EDI transactions annually

UnitedHealthcare: Transaction Services Profile

Operational Objective: Collaborate with our provider network to transition phone calls and paper to electronic transactions, and transition batch to real-time.


Scope of CAQH CORE Operating Rules: Phase I and Phase II

*Please Note: The Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, CORE 150 and CORE 151 are not included for adoption. Although HHS is not requiring compliance with any operating rules related to acknowledgement, the Final Rule does say “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.”


UnitedHealthcare: Transaction Flow and Channels

ConnectivityDirector

64%

1%

35%

CHANNEL*TRADING PARTNERS

SYSTEMS INFRASTRUCTURE

Electronic channels support the following HIPAA ASC X12 transactions: • Real-Time eligibility (270/271), claim status (276/277) – using v5010 • Batch eligibility, claim status, referrals (278), payment advice (835), and claim

(837)

Note: UnitedHealthcare (UHC) also supports web portal inquiries but is encouraging the adoption of electronic transaction processing

LabCorpQuest

Large Facilities

Providers

Providers

ClearingHouses

OptumInsightClearinghouse

DirectConnects

ConnectivityDirector External

CustomerGateway

B2B UFE ClaimsEngines


• Results from an internal research analysis indicated as many as 30% (6.6 million) of call center service requests could be resolved by adopting the CORE Operating Rules for eligibility response transactions.

• Management had a strong interest in leveraging voluntary CORE Operating Rules and the CORE Certification process to gain valuable experience and insight about the benefits associated with implementing industry operating rules prior to federal and state mandates.

CORE Certification: Project Rational


Next Phase of Operating Rules – Can we get the next 30%

Cumulative IsolatedCurrent 32.21%Benefits ‐ Vendor #'s 35.21% 3.00%Benefits ‐ Notifications Req'd? 38.95% 2.62%Benefits ‐ Not Covered 41.20% 2.25%Benefits ‐ Spec Proc Code 58.05% 1.87%Benefits ‐ Pre‐X Timeframes 59.55% 1.50%Benefits ‐ Lifetime Max 62.17% 0.75%Benefits ‐ Referral Req'd 64.42% 0.75%

Current 23.97%All Additional Information Requests 35.62% 11.56%All Processing Details 52.05% 9.96%Check Information 58.90% 5.82%TAT 65.75% 3.08%Requested EOB 70.55% 1.37%

Call Obviation Potential

Benefits and Eligibility

Claim Status


• United Healthcare Executive Management supported CORE certification as a critical organizational priority

• Enterprise-wide requirements were created for the HIPAA v5010 compliance project as well as for the implementation of Phase I and II CORE Operating Rules

• CORE Operating Rules implementation was managed as its own project. The timeframe for implementing CORE Operating Rules ran concurrently with the organization’s HIPAA v5010 implementation.

• Pursued Phase I and II CORE Certification concurrently

CORE Certification: Project Approach


Lessons Learned

• A full understanding of CORE Operating Rules requirements and how they impact your organization’s IT systems is essential

• Upfront business/systems planning and analysis is a major component of the project

• Technical and business analyst resources must be available and work closely together throughout the full lifecycle of the project

• If you rely on vendors, make sure they are involved early-on in the planning process

• Consider early on how CORE Master Test Bed Data (for testing eligibility rule) will be loaded and used within the context of your system environment. It took approximately 8 weeks to setup the data due to complexity of the UnitedHealthcare claim platforms

• Execute the test scripts first that you have concerns with as you can run the test scripts as many times as you want and this will give you more lead time to fix any problem areas


UnitedHealthcare Eligibility and Claim Status 4 Year Trends


Deployment: CAQH CORE Operating Rules UnitedHealthcare Eligibility and Claim Status Implementation

Final 5010 Implementation


Deployment: CAQH CORE Operating Rules UnitedHealthcare Eligibility Implementation Results


Deployment: CAQH CORE Operating Rules UnitedHealthcare Claim Status Implementation Results


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UCL=32045350

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4010 5010

I-Chart of B&E 270/271 EDI Transaction by Month

12-Nov

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I-Chart of Claim Status 276/277 EDI Transaction by Month

Statistically Significant Increases for both Eligibility and Claim Status post 5010/CORE Deployment

Benefits and Eligibility Monthly Average:Jan ‘11 – June ‘12 16.4MJuly ‘12 – Dec ’12 27.8M

Represents a statistically significant increase in Benefits and Eligibility transactions from 4010 to 5010/CORE

Claim Status Monthly Average:Jan ‘11 – June ‘12 3.8MJuly ‘12 – Dec ’12 5.1M

Represents a statistically significant increase in Claim Status transactions from 4010 to 5010/CORE


Moving from PayerID to Health Plan ID (HPID)


Health Plan ID (HPID)• Why Health Plan ID?

“Adoption will allow for a higher level of automation for health care provider offices, particularly for provider processing of billing and insurance related tasks, eligibility responses from health plans, and remittance advice that describes health care claim payments.”1

• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Secretary to adopt unique identifiers for each of the following:• Individuals(status: Congress delayed indefinitely)• Employers (status: EIN adopted)• Health plans (status: HPID adopted)• Health care providers (status: NPI adopted)

• Structure• 10-digit, all-numeric identifier with a Luhn check-digit as the 10th digit.• Intelligence- free identifier except for 1st digit

1Federal Register / Vol. 77, No. 172 / Wednesday, September 5, 2012 / Rules and Regulations, 54664


Health Plan ID (HPID) – Definitions• Definitions

–

Controlling Health Plan (CHP) means a health plan that (1) Controls its own business activities, actions, or policies; or (2)(i) Is controlled by an entity that is not a health plan; and

(ii) If it has a subhealth plan(s), exercises sufficient control over the subhealth plan(s) to direct its/their business activities, actions, or policies.

–

Subhealth Plan (SHP) means a health plan whose business activities, actions, or policies are directed by a controlling health plan.

–

Other Entity ID (OEID) An entity may obtain an OEID to identify itself if the entity meets all of the following:

– Needs to be identified in a transaction for which the Secretary has adopted a standard

– Is not eligible to obtain an HPID– Is not eligible to obtain an NPI– Is not an individual (defined as “the person who is the subject of

protected health information”)


Health Plan ID (HPID) – Important Dates• Compliance Dates

• Enumeration – November 5, 2014*–

Health plans must enumerate by this date–

A Controlling Health Plan – must obtain an HPID from the Enumeration System for itself– must disclose its HPID when requested– may obtain an HPID from the Enumeration System for Subhealth

plan of the Controlling Health Plan – may direct its Subhealth plans to obtain HPIDs

–

A Subhealth plans may obtain an HPID from the Enumeration System; once enumerated, a Subhealth plan must disclose its HPID when requested

• Full Implementation – November 7, 2016–

All Covered entities must begin using HPID in the HIPAA transactions

* November 5, 2015 for small health plans


Health Plan ID (HPID) – Key Concepts

• HPID Usage – only required when the health plan has an HPID and the Covered Entity (e.g., Provider) is identifying the health plan in standard HIPAA transactions

• We consider a health plan as ‘‘having an HPID’’ if that health plan communicates with its trading partners that it consistently uses a particular HPID, even if the HPID it uses is associated with another health plan, such as its controlling health plan.

• The phased-in approach for HPIDs, where there is lag time between when health plans are required to obtain an HPID and when covered entities are required to begin using HPIDs in the standard transactions, will allow the opportunity for dual use and sufficient time for a successful transition.

• The additional time will allow industry the opportunity to perform extensive testing of the HPID with trading partners prior to full implementation.

• This additional time and phased-in approach to compliance should reduce denied or misrouted claims during the early use of the HPID.


Health Plan ID (HPID) – UHG Considerations• UHG currently utilizes 48 PayerIDs• UHG may have 75 Controlling Health Plans (CHPs) and 5 Sub Health Plans (SHPs)• Additional Considerations:

• UHG has 224 other entities.• Other Entities do not necessarily require enumeration.• If there is a business need to have an Other Entity identified in the standard

transaction the Other Entity will need to obtain an OEID (different than HPID).• 1 PayerID may route to multiple claim platforms.• Currently, some Member ID Cards include a 10 digit PayerID (health plan ID),

this is not the same as the HPID that is being implemented so ID cards may need to be reissued

• Plan moving forward• Develop an Enumeration Strategy• Determine Governance, Implementation and Usage of HPID & OEID• Communicate and educate internal and external partners – especially physician

and hospital partners


Adoption to Utilization

• What is Nirvana?

• The Shift - How do we shift the Industry’s move to EDI

“If you build it they will come.”May work in baseball, but not the case here…

Practice Management Systems: Will vendors find value in supporting

Vendors are not HIPAA covered entities; clearinghouses are covered


Industry Context: A Spectrum of Change

ClaimAdjudication

“277” Status Response

“834” Enrollment

“820” Premium PaymentSponsor

Provider

Charge CaptureClinical O/EUtilization Review

“278 “Referral Request

Billing“837” Claim/Encounter

“277” Request for Info

“275” Claim Attachment

A/Rand Treasury

“ 276” Status Inquiry

Health Plan Enrollment

“278” Referral ResponsePre-Adjudication

“270” Eligibility InquiryMembership

“271” Eligibility Response

“835” Remittance A/P

BankCCD+ (EFT)

• During the next several years the entire revenue cycle process will experience significant transformation due to the introduction of operating rules.

• This change can drive interoperability, facilitate greater adoption of standards and generate a responsive, and adaptive, system-wide approach that aligns with other strategic initiatives.


Healthcare Administrative Data Exchange: An End-to-End Perspective

CORE-RequiredData &

Infrastructure

Vendor-Agnostic Operating Rules

ProvidersVendors and

Clearinghouses (includes TPAs)

CORE-RequiredData &

Infrastructure

HealthPlans

• All HIPAA covered entities involved in the electronic exchange of administrative transactions have a role to play in the adoption of CAQH CORE Operating Rules, i.e., providers, health plans, and/or clearinghouses

• HIPAA covered entities work together to exchange transaction data in a variety of ways. The applicability of a given CAQH CORE Operating Rule will depend upon the nature of the trading relationship between HIPAA-covered entities, e.g.,

• Non-covered entities, such as Practice Management System Vendors, also have a significant role in ensuring these processes work – but the driver is not legislation – it is economic.

Health Plans – only group penalized for non-compliance

© 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 31Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.

Electronic vs. Manual Volumes

July – December 2011 July – December 2012

Electronic Eligibility

Inquiry (270) 100.8 M 166.7 M

Electronic Claim Status

Inquiry (276) 21.5 M 30.8 M

Manual Eligibility Calls 3.6 M 3.7 MManual Claim Status

Calls 2.1 M 2.1 M

Significant Increase in Electronic Transactions while Manual Transactions remain stable

Should we offer additional tools to help drive down the manual (and costly) process?


Scheduling / Registration Workflow ~The Art of the Possible~

Patient MakesAppointment

Patient Arrives atAppointment

Objective: Build out an application to streamline the patient scheduling and registration process by matching provider and patient information to confirm eligibility and benefit coverage while ensuring authorizations are obtained prior to patient seeing the physician. The goal is to eliminate any calls a provider has to make prior to service being rendered.

Provider’s PMIS

Confirms Patient Eligibility / COB

Validates Provider Benefit Level

Validates Benefit Coverage

Determines if Auth is Required

Summarizes Product Information

Captures Patient Responsibility

Patient eligibility status and effective datesIdentify secondary coverage (COB) *

Provider’s network status with Patients plan *Determines patient’s out of pocket

Verifies coverage in general or at code levelCaptures patients lifetime / benefit max *

Determine if authorization is required *Auto links next steps to capture auth online

Identifies Patient’s plan / product informationVerifies if referral is required *Provide copy of patient’s ID card

Challenge: Providers work across multiple practice management systems that provide inconsistent tools to leverage EDI transactionspreventing providers to utilize this within their practice workflow.

UHC Systems

Prior authorizationrequests via online

Provider’s PMIS

OptumX Desktop

271

270

Ideal link betweenProvider’s PMISand OptumX Desktop

Workflow Tool

* Not provided through Core 5010 Transactions

Provider referralobtained

Goal: Simplify scheduling and registration process by capturing key information up front prior to patient arriving in the office to validate patient’s eligibility, services are covered, and financial responsibility

Did you know?Provider offices are 20% successful in collecting patient responsibility once a patient leaves the office.

Scheduling / Registration Solutions1. Link provider network status to B&E verification

2. Clarify copay / deductible information

3. Provide clearer member product information on card

4. Simplify what is provided back in a 271 response

5. Link authorization/referrals required to B&E verification

6. View network providers for scheduling purposes

© 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 33© 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.

Timothy Kaja, MBA, [email protected]

Questions???

Eligibility and Claim Status Operating Rules and …UnitedHealth Group: Corporate Profile OUR HEALTH...

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