Outcomes and Lessons Learned From5010 Testing Project Collaboration

Elliot Sloane, PhD, CCEVillanova UniversityCo-Chair, IHE InternationalCo-Chair, IHE International

Bob BowmanCORE ManagerCAQH

Paul DecrostaManager, IPP RegulatoryBCBSA

April 5, 20099:45 – 10:45 am

Agenda– IHE

• Proven Standards Adoption Process– Encourage adoption of existing standards/private-public collaboration

• Complementary Paths: Streamlining Data Exchange– Clinical (IHE’s focus) and Administrative (CORE’s focus)

– CORE• Overview: Mission, Vision and Rules• Goal of HIMSS/IHE-CORE-BCBSA Demonstration• Goal of HIMSS/IHE-CORE-BCBSA Demonstration

– Support for existing standards: 5010 testing crossover– Public-private involvement

• HITSP cross-over• Outcomes and Lessons Learned

– BCBSA• BCBSA Overview• CAQH / CORE Coordination

– Role in public private collaboration in national and local HIT efforts

• Blues 5010 work to date– HIPAA 005010 Mandates and HIT Implementation 2

A Synergistic Collaborationfor the 5010 Testing Project

The Players

Centers for Medicare & Medicaid Services (CMS)provided (non-financial) support

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Integrating the Healthcare Enterprise

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What is “Integrating the Healthcare Enterprise”?

• A 11-year public-private initiative• Driven by end-users, IHE improves patient care by

harmonizing electronic health information exchange• Enables approved standards to seamlessly pass

health information among care providers on a local,regional and national level

• IHE products are freely available to all

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Who’s involved in IHE?

• Users– Clinicians, Staff, Administrators, CIOs, Gov’t agencies (e.g. NIST,

VA, DoD, CDC, CMS)

• Professional Societies– representing 270,000 individual members– representing 270,000 individual members– HIMSS, RSNA, ACC, ACP, AAO, ACCE, ASTRO, etc

• Standards Development Orgs (SDOs)– HL7, DICOM, ISO, CDISC, ASTM, W3C, IEEE,

IETF, etc

• Vendors & Consultants– e.g., imaging, EHRs, cardiology, medical devices

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Proven Standards Adoption Process

Develop technicalspecifications

Develop technicalspecifications

Testing atConnectathonsTesting atConnectathons

IHEDemonstrationsIHEDemonstrations

Identify availableIdentify availablestandards (standards (e.g. HL7,e.g. HL7,DICOM, IETF, OASIS)DICOM, IETF, OASIS)

Identify availableIdentify availablestandards (standards (e.g. HL7,e.g. HL7,DICOM, IETF, OASIS)DICOM, IETF, OASIS)

Productswith IHEProductswith IHE

Timely access toinformationTimely access toinformation

Easy to integrateproductsEasy to integrateproducts

Document Use CaseRequirementsDocument Use CaseRequirements

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11 Years of Steady Evolution 1998 – 2009The IHE Development Domains

PharmacyNEW 2009 Pathology

since 2006

Radiologysince 1998

Cardiologysince 2004

Laying the Groundwork1998

Radiation Oncologysince 2004

Patient Care Devicessince 2005

Patient Care Coordinationsince 2004

Eye Caresince 2006

QualityResearch & Public Health

since 2006

Laboratorysince 2004

(Healthcare)IT Infrastructure

since 2003

International Adoption

The IHE Deployment InitiativeWorldwide

NorthAmerica

Europe

Asia–

Oceania

CORE and IHE: Complementary Paths• Both IHE and CORE serve as a process and a forum for encouraging

uniform implementations of existing standards, respectively achievingclinical and administrative information exchange goals

• Each has a testing process to demonstrate entity-specificimplementations of milestone-driven requirements key to achieving thegoal of interoperabilitygoal of interoperability

• IHE and CORE also share the common HITSP thread: CORE rules and IHEprofiles are both incorporated in HITSP’s efforts, thereby allowing HITSPto more quickly achieve its goals and ensure industry efforts arecomplementary, and not duplicative

• Collectively, CORE and IHE testing demonstrates existing industry testingtools are guiding stakeholders towards standards-based “real world”implementations

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Committee on Operating Rules forInformation Exchange (CORE)

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CORE• CORE is composed of more than 100 industry

stakeholders – health plans, providers, vendors,government agencies, associations, regional entities,standard-setting organizations and other healthcareentities

• Working in collaboration, CORE is building consensus• Working in collaboration, CORE is building consensuson a set of operating rules that will:– Enhance interoperability between providers and payers– Streamline the exchange of administrative data transactions

(e.g., eligibility, claim status)– Reduce the amount of time and resources providers, payers, and

other stakeholders spend on administrative functions– Allow for administrative-clinical compatibility

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Administrative and Clinical Integration

• IHE, CORE, HITSP efforts– Industry initiatives through phased approaches– Interoperable solutions– Administrative and clinical data integration

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– Administrative and clinical data integration

Admin/Clinical Integration

CORE IHE

HITSP

CORE Rules – Phased Approach• Phase I

– Infrastructure rules• Acknowledgements• Connectivity: HTTPS and

authentication• Companion Guide format• Response Time• System availability

• Phase II– Infrastructure rules

• Connectivity: HTTPS withSOAP WSDL andauthentication

• Last Name Normalization• AAA Error Code Reporting

for patient identification• System availability– Data Content

• 270/271 Eligibility, e.g.– Patient financials, e.g.

co-pay, deductibles– In/out of network

variances– Service type

coverage

for patient identification– Data Content

• Additional 270/271Eligibility

– Additional servicetypes

– More financials, e.g.YTD deductibles

• 276/277 Claim Status– Application of Phase I

infrastructure rules

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• Latest iteration of implementation guide for administrative transactionsmandated by HIPAA – federally mandated compliance by January 2012

• Replaces current version 004010• Examples of X12 standard transactions under HIPAA - used by

providers and health plans:

HIPAA Mandated Version 005010

270-271: Eligibility inquiry and response• An inquiry from a provider and the response from a health plan regarding a

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• An inquiry from a provider and the response from a health plan regarding apatient’s eligibility for coverage, or the benefits for which a patient may be eligible

276-277: Claim status inquiry and response• An inquiry from a provider and the response from a health plan about the

processing status of a submitted claim or encounter

278: Prior authorization and referral• An inquiry from a provider and the response from the health plan about a

patient’s prior authorization or referral for services

837: Claims or equivalent encounter information• Healthcare service information provided to a health plan for reimbursement

Note: For each transaction, only part of the standard is required

Goals of HIMSS/IHE-CORE-BCBSADemonstration

• Goals– Learn about the proactive approaches and work

among the healthcare stakeholders that is buildingmomentum for the implementation of the 5010 HIPAAtransaction requirementstransaction requirements

• CORE rules and testing - key input by Blues• HITSP and CORE convergence• Annual CORE participation at IHE

– See how trading partners are demonstrating industrycapabilities for HIPAA-compliant administrative dataexchange testing via CORE

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Proactive, Voluntary, Implementationof Standards and Business Rules

• CORE demonstrates that:– Public and private healthcare stakeholders can work to implement

change• Building on HIPAA and other standards, CORE rules are written

through a consensus-based process, agreed upon by itsparticipants and implemented by stakeholders; Medicare and CMSOffice of e-Health Standards and Services are at the table as are

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Office of e-Health Standards and Services are at the table as areother parts of government like Department of Veterans Affairs

– A voluntary industry effort can be used to quickly achieve milestones• CORE uses an incremental approach in order to achieve maximum

adoption• Take advantage of early adopters and industry leaders

– Stakeholders can implement and test new standards/specifications “inthe real world” before a federal mandate or directive is sought

• The CORE rules were defined with 5010 in mind• HITSP includes the CORE Rules – connectivity and content rules

CORE/5010 Crossover: Response toGeneric Eligibility Inquiry from Provider

5010: Federal Mandate for Jan. 2012Name of health plan (if available)Health plan coverage begin dateStatus of coverage (active, inactive)Status of following service types:

1 Medical Care

CORE: Required by Phase I effective 4/06Name of health plan (if available)Health plan coverage begin dateIn/out of network coverage varianceStatus of coverage (active, inactive)Status of following service types such as*:

1 Medical Care

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NOTE: Red italicized font indicates service type variance between CORE Phase I and 5010

1 Medical Care33 Chiropractic35 Dental Care86 Emergency Services88 Pharmacy98 Prof. Office VisitAL Vision47 HospitalMH Mental HealthUC Urgent Care

1 Medical Care33 Chiropractic35 Dental Care86 Emergency Services88 Pharmacy98 Prof. Office VisitAL Vision

* 41 other service types required in CORE Phase II

• CORE certification for Health Plans responding to an eligibility query fromProvider includes testing for the return of patient financials

• The return of patient financials has been included in CORE requirements –using the HIPAA standards - since Apr 06 well ahead of therecommendations in 5010 to return such information

CORE/5010 Crossover: EligibilityInquiry- Patient Financials

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Patient Financial Required by CORE Phase I 4/06 orCORE Phase II since 7/08

(either 6 or 4 yrs prior to 5010)

Recommended by 5010(not mandated)

Co-pay X X

Coinsurance X X

Deductible (static) X X

YTD Deductible (remaining) X (Phase II) No

In/out of network variances X No

HITSP Standards Harmonization

• HITSP process for Standard Development:– Identify a pool of standards for a general breakthrough area– Identify gaps and overlaps for specific context– Make recommendations for resolution of gaps and overlaps– Develop Interoperability Specifications for using the selected– Develop Interoperability Specifications for using the selected

standard(s) for a specific context– Test the instruction for using the standard

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HITSP and CORE

HITSPNumber

HITSP Name CORE Rules Inclusion

IS03 Consumer Empowerment C32 – Summary Document Using HL7 CCD -includes CORE Phase I Data Content Rule asinformative text in insurance module

IS05 Consumer Empowerment and Accessto Clinical Information via Media

IS07 Medication Management T40 – Patient Generic Health Plan EligibilityVerification Transaction -includes complete

HITSP includes CORE Rules within its constructs

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Verification Transaction -includes completeCORE Phase I Rule Set

T85 – Administrative Transport to Health Plan– includes CORE Phase II Connectivity Rule,e.g. SOAP with WSDL and digital certificatesor user/passwords

IS08 Personalized Healthcare T40 and T85 is included in all of these.

IS09 Consultations and Transfers of Care

IS77 Remote Monitoring

CORE-Certified Trading Partners• CORE-certified trading partners are exchanging

eligibility 5010-level HIPAA administrative datatoday– Edifecs is the Phase II CORE Testing and

Certification VendorCertification Vendor– Over 40 CORE-certified organizations/products

• Clearinghouses, health plans, providers and vendorshave all gone through the testing process

• Complete list can be found at www.caqh.org

– CORE-certified trading partners attest tocompliance with HIPAA (currently mandated versions)

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Lessons Learned• Implementing change is not easy

– Eligibility/data content is a challenge• Multiple databases, legacy systems

– Multiple systems may need enhancement

• Gap analysis is important• Test environment set up for CORE can also

assist with trading partner testing• Infrastructure established be CORE also matters

– it helps data flow (e.g., response time, connectivity)

• CAQH submitted comments to HHS on 5010based on implementation experience from CORE

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Outcomes• CORE rules are having an impact

– Reducing administrative costs– Increasing real-time eligibility verification (e.g., BCBSNC)– More efficient process for providing eligibility and benefits information

to providers– Have begun goal to improve other transactions/processes (e.g., claim

status in Phase II)status in Phase II)

• Momentum toward a national approach that can beimplemented on a state/regional level

• Merging clinical/admin (e.g., CORE ConnectivityRule is payload agnostic – can use X12 or HL7)

• Better communication among industry stakeholders

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Blue Cross Blue Shield Association

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BlueCross BlueShield Association

Who we are:

• Mission Statement:– We are an association of BlueCross® and BlueShield® Plans

dedicated to protecting and strengthening the BlueCross and Blue

Shield Brands, supporting the Plans individually and collectively in

their pursuit of Blue business and preserving the private healthcare

market

– BCBSA is made up of 39 individual community based Plans

– We represent more than 101 million members throughout the country

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BCBSA Statement of Support

• “BCBSA is pleased to participate in CAQHCORE's efforts to streamline electroniceligibility. Simplifying provider access to patientinsurance coverage information is critical andinsurance coverage information is critical andthe Blues believe that CORE is a key initiativeto bring the industry together for collaborationand consensus building.”

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HIPAA Mandated Version 005010• BCBSA work effort to date

– We have partnered with a vendor to conduct a gap analysis ofexisting 004010 formats

– We are working with BCBS Plans to establish implementationtimelines and an education strategy

• BCBS Plan calls – best practices sharing and issues• BCBS Plan calls – best practices sharing and issuesresolution

• Create Provider outreach toolkits and education sessions• Partnering with CMS and other industry groups on national

education and outreach efforts– We will continue to work with our Plans and the industry to look

at best practices on implementation strategies

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• Currently have active, leadership roles in numerous industry organizationsthat work to advance HIPAA and HIT

Blue Industry Engagement

• X12• HL7• WEDI• HITSP

• CCHIT• NCVHS• NeHC• CAQH CORE

• Local BCBS Plans engaged with implementing local HIE’s• Local BCBS Plans engaged with implementing local HIE’s(e.g., AHIN)

• Partnered with AHIP to establish Payer-to-Payer transfer of PHR dataOperating Rules

• Partnered with ASC X12 and HL7 to develop Payer-to-Payer transfer ofPHR data technical standards

• Local BCBS Plans (e.g., BCBS of MA) are conducting pilots or providingincentives or hardware to advance provider HIT adoption

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5010 Industry Collaboration:Leveraging Coordinated Testing Efforts to Help Prepare

for Uptake and Adoption of National IT Standards

CAQH/CORE PresentationApril 7, 2009April 7, 2009

11:15 - 11:45 am

IHE Theater B

Exhibit Floor – Booth # 7750

http://www.ihe.net/

Q and A

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http://www.caqh.org/

http://www.bcbs.com/