hipaa transaction testing [email protected] october, 2002 julie a. thompson alliance partners
TRANSCRIPT
Agenda• HIPAA Transaction Overview – A whole new world
• Transaction Analysis – The steps in the process
• Transaction Issues and solutions
• Test Planning
• Testing Methodologies
• Example Test Scenarios
• Other considerations– Building Client Specific Test Data– Certification/Testing Vendors– Companion Documents
• The Implementation Process– Contingency Plans– Vendor Assessments– Transaction Implementation
A True Paradigm Shift• In Plato’s famous analogy of the
cave, describing a tribe of people have lived in a cave from their childhood. Their legs and necks chained so that they cannot move, and can only see before them. They cannot see above, or behind them.
• Yet, if only they would stand up, turn around and face the mouth of the cave. A whole NEW world was waiting!
• Plato challenges all people to recognize that their perception of the world is limited and a simple stretch will open opportunities to visit new worlds.
View from within the cave –
A whole new world
Changing Technology-Where are we going?
1975
1982
1985
1996
2004
HCFA 1500 Professional ClaimPoint to Point
UB-82 First Uniform Institutional Paper Form
NSF electronic StandardInternet – First EDI
Standard
HIPAAX12 Standard adopted by Healthcare
EDI Outsourcing X12N-XML-eCommerce
Healthcare Claims History
The new transaction worldTypes of Covered Transactions
Cla
ims
Pa
ym
en
t/R
em
it
Pro
ce
ss
ing
Providers
Payors
Employers
Claim 837 Remittance Advice 835
Su
bs
cri
be
r/P
ati
en
t In
fo.
Re
ferr
al/
Au
th/
Ce
rtif
ica
tio
n
27
7 C
laim
Sta
tus
Eligibility Inquiry
270
Eligibility Response 271
Request for
Review 278
Review Response 278
Status Inquiry
276
Enrollment 834
Premium Payment 820
Su
bs
cri
be
r In
fo.
Pre
miu
m P
ay
me
nt
Attachments 275
Where do we begin?
• What are the steps?
• What problems can we anticipate?
• How do we solve those problems?
• How do we test the solutions?
• How do implement the solutions?
HIPAA Transaction Testing
What are the steps?
Steps in Transaction Analysis1. Define Transaction Strategy
2. Build System, Application Inventory
3. Build Maps based on the inventory
4. Define Transaction Issues and Solutions
5. Build a Document Library Trading Partner
Business Rules
Code Set Crosswalk
6. Reports – Gaps, Solutions, Plans, Budget
CAP MAP Cohesion TpXManager
How do we implement the transactions?
Tools
Phases
Resources
Activities
Concio’s Transaction SolutionsTransaction
Specifications
Transaction
Analysis
Transaction
Analysis
Budgeting
Budgeting
Progress Monitori
ng
Progress Monitori
ng
ProjectPlanningProject
Planning
MAP
Project Manager/ Transaction Testing Consultants/ Subject Matter ExpertsProject Manager/ Transaction Testing Consultants/ Subject Matter Experts
Trading Partner Mgmt.
Trading Partner Testing
Management
Trading Partner Testing
Management
Trading Partner Specific Testing
Trading Partner Specific Testing
TpX Manager
Test Planning
Internal Testing
IntegrationAnd
Certification
HIPAA Compliant System HIPAA Compliant System
TestScenario
s
TestScenario
s
TestCasesTest
Cases
TestData/ Files
TestData/ Files
Unit/ System Testing
Unit/ System Testing
Level 1-6
Testing
Level 1-6
Testing
Testing/ Certificatio
n
Testing/ Certificatio
n
Integration
Testing
Integration
Testing
Cohesion
HIPAA Transaction Testing
What are the issues and solutions?
Remediation Solutions – What is the impact?
Both Payers and providers must communicate how repeating loops, segments, and element will be created, processed, and accepted.
Providers may submit all valid Provider Ids to assure payment
Payers tend to focus on only the require elements and the elements used in previous standards like NSF, HCFA 1500, and the UB92.
Providers must utilize the situational and optional elements for proper reimbursement.
The Issue The Impact Repeating Loops,
Segments, Elements
• Up to 999 claim lines• Unlimited Pay to
Providers Up to 8 Secondary
Provider IDs
Situational and Optional Elements
Remediation Solutions – What is the impact?
Repeating Loops and Segments
1. Claims up to 999 lines
2. Unlimited Pay to Provider Loop
Code Set Cross walks
Maintaining the original line number order. Payers, Clearinghouses, and/or Repricers may change original line order.
Payers may choose to split claims to resolve this kind of issue. Providers should consider the impact on reimbursement and 835 remittance.
Trading Partners may want to share all code set crosswalks.
Providers require all original lines to be returned on the 835 in the original order.
The Issue The Impact
Remediation Solutions – What is the impact?
Payers and providers will need to consider adding new fields to their systems.
A Transaction Repository is a valid solution and is used by other industries such as banking.
Trading Partners need to communicate the usage of each of the 10 different types of Providers. Both on the claim level and the line level.
The Issue The Impact Handling fields not in core
system
1. Add field to core system. For example: Provider’s Claim ID (CLM01) is required on the 835 payment remittance
10 types of providers on both the claim header and each line time: Billing, Rendering, Pay-to, Referring, Purchased, Supervising, Ordering, Attending, Operating, Other
Remediation Solutions – What is the impact?
All original lines must be returned to the provider in the original line number order on the 835 payment remittance.
Companion documents may be necessary but they must adhere to the HIPAA Transaction Implementation Guides.
The Issue The Impact
Multiple references to line numbers
1. Provider line number
2. Payer line number
Providers may receive multiple trading partner companion documents for health plans.
HIPAA Transaction Testing
How do we test the solutions?
Facing the Testing Challenges…• How will your organization determine a Trading Partner has
passed acceptance testing?
• High potential impact on corporate financials and market share
• Complex testing criteria – multiple levels, systems
• Software changes in multiple systems and vendors
• High volume testing and numerous testing scenarios
• Multiplied by Large number of trading partners
• Potential delays in claim and eligibility processing
• Tight testing schedule – begin by April 16, 2003
• Severe penalties for non-compliance
Education Assessment Remediation Testing Monitoring
Understanding the Basics
Standard testing methodology terms:
• Unit – Is a date in the right format?
• System – Does a single system pass information correctly to another system?
• Integration – Does both system process both the request and the response correctly?
Unit, System, and Integration
Trading Partner Business to
Business testing
Integration
Transaction Certification
System
Compliance testing
Types 1-7
Unit
Test Plan Design
• Easy Isolation of error source using test phases
• Gradually increasing complexity
• Clear identification of issue solutions
• Comprehensive evaluation of all potential situations
• Expect the unexpected
• Work Load Testing for high volume
Test Phases – Identifying source of errorsPhase 1 – Translator Only Phase 2 – Single Pass System Testing
Phase 3 – Full System Integration Testing
Payer ProviderProvider Payer
Core System
Core System
Payer Provider
Core System
Core System
clea
ringh
ouse
Integration Testing includes:
• Testing System Components and Component Integration
• API and Middleware Testing
• Testing System Interfaces
• Testing the Integration of Front-Ends with Legacy Systems
HIPAA Transaction Testing
Testing Consideration for Claims and Claim Payments
Integration Testing – What is it?
837
Resu
lts
835
X12N CoveredBusiness Processes
Cohesion
• Match original claim to payment
• Validate bundling and unbundling
• Validate claim/payment corrections
• Validate repriced claims
• Validate split claim payments
• Verify Reissued claim handling
• 837 – 277 comparison
• Monitor Statistical/Encounter or Capitated claims
• Validate Patient Payments
• Estimate Prompt Payment liabilities
• Validate COB Primary processing
• Validate COB Secondary processing
• Validate Dental Predetermination claims (estimated claims)
835 Test Scenario OverviewThe HIPAA Perspective – Covered Business Processes
• Claim adjustments Original Claim Payments 837 Claim Corrections
(Demographic/Line Item Adjustments) Payment Reversals and Corrections Incoming Provider Adjustments COB claims (Primary Payer Adjustments)
• Claim Splits• Line Bundling and Line Deletion• Claim Predetermination/Estimates• Patient Payments• Repriced Claims• Statistical Encounters
Original Claim Payments
Payer System
HIPAA Transaction Relationships
Provider System
837 835
835 Processing
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1 Paid
Service Line 2 Paid
Service Line 3 Paid
Service Line 4 Not Paid
Service Line 5 Not Paid
PaymentService Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Paid Line 1
Paid Line 2
Paid Line 3
All original lines returned with Payments
Gateway
Gateway
837 Claim (Demographic/Line Item Adjustments)
Corrections should be processed electronically by both payer and provider to assure 835 payment remittance can be processed by the provider.
Payer System
Provider System
837835
835 Processing
Demographic 1
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Demographic 2 Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Gateway
Original and/or Corrected Payments
Demographic 2
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
837Claim Frequency Type Code (CLM05-3)1 - ORIGINAL (Admit thru Discharge Claim)6 - CORRECTED (Adjustment of Prior Claim)7 - REPLACEMENT (Replacement of Prior Claim)8 - VOID (Void/Cancel of Prior Claim)
Duplicate Claim Logic must
consider resubmission as updated claims
Original Claim
Corrected 837
Original Claim
XPhone corrections may not allow for proper posting of
the 835 by the provider
Corrected Claim
Payer System
Provider System
837 835
835 Processing
Service Line 1
Service Line 2
Service Line 3
Original Payment
Payment Corrections and Reversals
Line 1 paid 10.00
Line 2 paid 20.00
Line 3 paid 0.00
Payment Correction
Line 1 paid 10.00
Line 2 paid 20.00
Line 3 paid 15.00
835
Correction (CAS01 = CR)
OriginalLine 1 paid 10.00
Line 2 paid 20.00
Line 3 paid 0.00
Line 1 paid 10.00
Line 2 paid 20.00
Line 3 paid 15.00
UPSUniversal
Payment System
HIPAA Transaction Relationships
Gateway
Gateway
Incoming Provider Adjustments
Payer System
Provider System
837 835
835 Processing
PaymentService Line 1
Service Line 2
Service Line 3
Service Line 4
Provider Contractual Adjustment (CAS)
Original Lines with Payments
UPS GatewayService Line 1 Paid
Service Line 2 Paid
Service Line 3 Paid
Service Line 4 Paid
Provider Contractual Adjustment (CAS)
Service Line 1 Paid
Service Line 2 Paid
Service Line 3 Paid
Service Line 4 Paid
Provider Contractual Adjustment (CAS)
Service Line 1 Paid
Service Line 2 Paid
Service Line 3 Paid
Service Line 4 Paid
Provider Contractual Adjustment (CAS)
HIPAA Transaction Relationships
Gateway
COB Claim(One Scenario - Awaiting HHS NPRM )
Payer System
Provider System
837 835
835 Processing
ORIGINAL Provider Submitted Lines
Original Charge 25.00
Original Procedure
Original Units
PRIMARY Payer Adjudicated ServicesPRIMARY Incoming Adjustments
UPS PaymentAll Original Lines
ORIGINAL Provider Submitted Lines (Secondary Responsibility)
Original Charge 25.00 Original Procedure Original Units Adjudicated Charge 20.00 Adjudicated Procedure Adjudicated Units
SECONDARY PaymentsSECONDARY Adjustments
ORIGINAL Provider Submitted Lines
Original Charge 25.00
Original Procedure
Original Units
Adjudicated Charge 20.00
Adjudicated Procedure
Adjudicated Units
SECONDARY PaymentsSECONDARY Adjustments
PRIMARY Payer Adjudicated ServicesPRIMARY Incoming Adjustments
Medicare Secondary COB
Transaction Repository PRIMARY Payer Adjudicated ServicesPRIMARY Incoming Adjustments
HIPAA Transaction Relationships
Split Claims and the associated payments
Payer System
Provider System
837 835835
835 Processing
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3Week 1
Week 2Service Line 4
Service Line 5
Week 1 Payment
Week 2 Payment
Claim 2
Claim 1
HIPAA Transaction Relationships
Total Charges will differ from the
original claim, first 835 and second 835.
Line Bundling and Line Deletion
Payer System
Provider System
837 835
835 Processing
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Line Bundling
- or -
Lines Deleted
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Transaction Repository
or Remediated Core System
Gateway
Original Lines with Payments
HIPAA Transaction Relationships
False aging may occur without all the original lines on the 835 claim
payment
Predetermination Claim Estimates (Dental)
Payer System
Provider System
837D 835
835 Processing
Date of Service = Blank
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
GatewayDate of Service filled
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Services Rendered
837D
Predetermination Claim(CLM19 = PB)
Dental Predetermination Claim Processing,
No Payment for Predetermination
Completed Service Lines with Payments
HIPAA Transaction Relationships
Repriced 837 Claim
Payer System
Provider System
837 835
835 Processing
Service Line 1
Service Line 2
Service Line 3
Service Line 4 Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Gateway
Return all Original lines in the original
order
Service Line 3
Service Line 4
Service Line 5
Service Line 2 Service Line 1
Repriced References (REF01=9A,9C)
Original Claim
Claim Repricing
HIPAA Transaction Relationships
Statistical Encounter(Managed Care)
Payer System
Provider System
837
278 Claim Status Processing
No Payment to be madeService Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
Related transaction 276/277 Claim Status
276 277
Service Line 1 0.00 Paid
Service Line 2 0.00 Paid
Service Line 3 0.00 Paid
Service Line 4 0.00 Paid
Service Line 5 0.00 Paid
Claim Status Processing
HIPAA Transaction Relationships
Claim Status = 105, Claim captiated.
BHT06 = RP
Entire batch is capitated
HIPAA Transaction Testing
Testing Consideration for Eligibility
Eligibility (270/271) Batch .vs. Real Time
HHS FAQ: What level of service is required to be provided under HIPAA when an entity implements batch and/or real time submission of a standard transaction?
45 CFR 162.925 states "a health plan may not delay or reject a transaction, or attempt to adversely affect the other entity or the transaction, because the transaction is a standard transaction."
If the standard transaction (e.g., ASC X12N 270/271) is offered in a batch (non-interactive) mode, the health plan has to offer the same or higher level of service as it did for a batch mode of transaction before the standards were implemented by the plan.
If a health plan offers the transaction in a real time (interactive) mode, the level of service has to be at least equal to the previously offered level for a real time mode of transaction.
If a transaction is offered through Direct Data Entry (DDE), the level of service, again, has to be at least equal to the level offered for the DDE transaction before implementation of the HIPAA standard.
Patient Eligibility – Real Time .vs. Batch Current response time must be maintained
Payer System
Provider System
270 271
835 Processing
Service Line 1
Service Line 2
Service Line 3
Service Line 4
Service Line 5
GS03 (real time/batch)Real Time Linkage:BHT03TRN 2000C, 2000D
Gateway
Information Source, a provider
or payer, not a clearinghouse or van (2100A loop NM1)
Information Receiver
a provider, payer, employer,
not a clearinghouse or van (2100B loop NM1)
Currently providing real time, 271 must provided real time
Real Time (GS02)
Batch (GS02)
See clearinghouse
discussion page 19
Eligibility (270/271) Levels
The 270/271 may convey the following information regarding a patient’s eligibility:
1. Eligibility to receive health care under the health plan.
2. Coverage of health care under the health plan.
3. Specific benefits associated with the benefit plan.
Eligibility - Types of Requests
1. General Request - All Providers, all benefits
2. Categorical Request – All Benefits for a provider type
3. Specific Request – Detailed Benefits for a specific submitter
Eligibility - General Request Request: For All Provider Types and All
Medical/Surgical Benefits and Coverage
Segment: EQ01 = 60 General Benefits
Response:eligibility status (i.e., active or not active in the plan)
maximum benefits (policy limits)
exclusions
in-plan/out-of-plan benefits
C.O.B information
deductible
co-pays
Eligibility - Categorical Request Request: For a Specific Provider type All Benefits Pertinent to
Provider Type
Segment: PRV01 Type of Provider Code EQ01 = 60 General Benefits
Response: eligibility status (i.e., active or not active in the plan)
maximum benefits (policy limits)
exclusions
in-plan/out-of-plan benefits
C.O.B information
deductible
co-pays
Eligibility - Specific Request
• Ambulatory Surgery Center Hernia Repair
• D.M.E Wheelchair Rental
• Dentist Bonding
• Free Standing Lab Diagnostic Lab Service
• Home Health Nursing Visits
• Hospital Pre-Admission Testing
• Hospital Detoxification Services
• Hospital Psychiatric Treatment
• Hospital O.P. Surgery
• Nursing Home Physical Therapy Services
• Other Allied Health Providers Occupational Therapy
• Pharmacy Prescription Drugs
• Physician Well Baby Coverage
• Physician Hospital Visits
Segment : EQ01 not equal to 60 – General
Eligibility - Specific Response
• procedure coverage dates• procedure coverage maximum amount(s)
allowed• deductible amount(s)• remaining deductible amount(s)• co-insurance amount(s)• co-pay amount(s)• coverage limitation percentage• patient responsibility amount(s)• non-covered amount(s)
Segment : EB
HIPAA Transaction Testing
Additional Considerations:Test Data, Certification, Companion Documents
Creating Client Specific Test Data
HCFA 1500
NSF
UB92
Valid Partner Specific
837
Certification Options
• Claredi – Certification Portal
• Concio Cohesion – In Line, All the time
• Hipaatesting.com
• Foresightcorp.com
• HCCO – HIPAA Conformance and Certification organization
http://www.hcco.us/leadership.htm
HCCO At-a-Glance
• Launched July 2002
• Over 100 Members and Covered Entities
• Aligned with NIST, SQE, ISO, UCC
• Transactions, Privacy and Security
• “Best practices” organization
• Accreditation and Certification
HCCO Certification
• Interoperability Testing
• Covered Entity Certification
• IT Products Certification
• IT Services Certification
Transaction certification observations
• Further educational awareness on transactions
• Upgrade the use of proper testing processes
• Upgrade quality assurance methodologies
• 3rd party testing efforts must be portable
• Clear definitive interpretation of the guides are needed
• IG ambiguities must be identified and resolved
• Software interoperability concerns must be solved
• Clear certification guidelines must be published
• Time and money saving initiatives must be implemented
Companion Documents
• Some trading partner relationships may require specific content
• Some Health Plans have prepared companion documents for their trading partners
• HHS requires that companion documents adhere to the HIPAA Implementation Guidelines without exceptions, limitations, or other restrictions.
Trading Partner Companion Documents
Providers
HHS FAQ: Should health plans publish companion documents that augment the information in the standard implementation guides for electronic transactions?
• Additional information may be provided within certain limits.
• Electronic transactions must go through two levels of scrutiny:
1. Compliance with the HIPAA standard. The requirements for compliance must be completely described in the HIPAA implementation guides and may not be modified by the health plans or by the health care providers using the particular transaction.
2. Specific processing or adjudication by the particular system reading or writing the standard transaction. Specific processing systems will vary from health plan to health plan, and additional information regarding the processing or adjudication policies of a particular health plan may be helpful to providers.
Companion Document Guidelines• Such additional information may not be used to modify the
standard and may not include:
– Instructions to modify the definition, condition, or use of a data element or segment in the HIPAA standard implementation guide.
– Requests for data elements or segments that are not stipulated in the HIPAA standard implementation guide.
– Requests for codes or data values that are not valid based on the HIPAA standard implementation guide. Such codes or values could be invalid because they are marked not used in the implementation guide or because they are simply not mentioned in the guide.
– Change the meaning or intent of a HIPAA standard implementation guide.
HIPAA Transaction Testing
How do we implement the solutions?
Providers
Riding the wave….
Payers Small Plans
Oct, 2003
Assure ComplianceEstablish a contingency plan
1) Vendor / clearinghouse compliance assessment
2) Develop a backup plan. Some options are: Choose a new vendor Choose a new clearinghouse Choose a transaction translator
If plans are satisfactory, assure plans can be executed within budget and time frames.
If plans NOT satisfactory, consider implementation of the backup plan.
Decide on a course of actions
October, 2003
Go Live
Define a date
Vendor
Assessment
NewInstallation
Upgrade
Implementation
Unit & System
Testing
April, 2003
Trading Partner
Testing
Integration
Testing
HIPAA Compliant Vendor Assessment
1. Software Compliance Assessment Services
2. HIPAA Tools are available for assessment:
a) Mapping Tools
b) Testing Tools
c) Certification
5. Issues Reporting
6. QA Strategy and Test Planning
7. Supporting Document Library
Vendor Assessment Objectives
• Develop Overall Project Plans for the Assessment
• Develop Contingencies Plans
• Establishment of Process Flows for Standard EDI Transactions
• Electronic Transaction Code Set Remediation
• Convert and Certify Key Trading Partner Electronic Data Exchanges (Unit and System only)
• Review and Validate HIPAA Ready Version
• Develop New Policies/Procedures
• Develop New Training Program
• Evaluate/Design Modifications for Standard Identifiers
• Trading Partner Readiness Survey (in multiple phases)
• Develop a Comprehensive Quality Assurance (QA) Approach and Testing Strategy (Integration Testing)
The Implementation Process
• Legal Agreements
• Trading Partner Specifics
• Security Compliance
• Privacy Compliance
• Testing Process Instructions
• Test Result Reporting
• Implementation and Sign off
Summary• HIPAA Transaction Overview
• Transaction Analysis
• Transaction Issues and solutions
• Test Planning
• Testing Methodologies
• Example Test Scenarios
• Other considerations– Building Client Specific Test Data– Certification/Testing Vendors– Companion Documents
• The Implementation Process– Contingency Plans– Vendor Assessments– Transaction Implementation
Questions?
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