Eligibility and Claim Status Operating Rules Update

January 1, 2013 is rapidly approaching. This is the date by which HIPAA covered entities must implement the Department of Health and Human Services (HHS) Eligibility and Claim Status Operating Rules mandated under the Affordable Care Act. The Eligibility and Claim Status Operating Rules that HHS adopted by regulation in 2011 comprise the majority of those required for CAQH CORE’s voluntary Phase I and II certification. Emdeon became CORE Phase II certified in 2010, so Emdeon was in a strong position of readiness when HHS adopted these operating rules.

Emdeon has completed a thorough gap analysis in order to be ready by the compliance date. We are now concluding our remediation of any identified gaps.

Trading Partner Support
Emdeon is dedicated to help our clients complete this important transition successfully. We have already initiated testing with health plans that are ready to test their operating rule conformance.

In addition, we are actively engaging health plans who utilize our Eligibility and Claim Status Hosted Data Services (HDS). These health plans must:
• Migrate to version 3 of HDS if they are not on that version already; migration efforts for clients on prior versions are actively underway.
• Provide the proper data content in their eligibility files. (There are no data content requirements for the Claim Status transaction)

HIPAA Simplified
Our HIPAA Simplified website, www.hipaasimplified.com, remains the primary resource for information regarding the operating rules and other HIPAA and ACA regulations.

On the Operating Rules pages, you will find the newly updated Operating Rules Playbook. This publication is full of valuable information, including our operating rule program management structure, roles and responsibilities, educational material on the rules themselves and a new section specific to the upcoming ERA/EFT Operating Rules.

HIPAA Simplified is updated regularly, so check back often!

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From the Desk of Chris Meffe

Welcome and thank you for taking time to read the Emdeon Current newsletter!

First, I would like to introduce myself. I’m Chris Meffe, Senior VP of Emdeon’s Strategic Partner Group. Though I’ve been with Emdeon for nearly 13 years, I have just recently taken the helm of this segment of our company. In my new role, I am focused solely on leading our group to meet the needs of you, our channel partners. It is my job to make certain that we are about the business of making your business run smoother, offering greater value to your customers and helping you be more profitable than ever before.

We have restructured our approach to create absolute and critical focus on your business priorities, all with the goal of responding in the most customized, holistic manner possible. I am leading our team to connect with you one-to-one—more personally and directly—to get a greater understanding of what’s really going on with your business. That is what it is going to take for us to continuously develop better solutions and support to drive results all around.

To help launch this pinpoint approach, we recently conducted a study in partnership with a third party research firm to learn what you and your colleagues are most concerned about in the market today. We collected measurable insights about the hot button issues and business needs you are prioritizing now and in the coming year, and we are already putting that knowledge to work in the form of tailored solutions you can offer to your client base (read all about it by clicking here).

Knowing you as well as we already do, we understand that you also strive to take a personalized, client-centric approach with your customers. Now as we get to know you even better, we are excited about the possibilities to help you become an even greater resource for your clients—to take your business further.

This newsletter has always been about providing a useful source of information and ideas and we will continue to make sure it provides that insight. Please share your questions and suggestions so we can tailor our content to be more helpful and meaningful for you.

Thanks again for reading! We’re grateful for your partnership.

From the desk of...
Chris Meffe

About Chris Meffe
Chris Meffe is Senior Vice President, Strategic Partnerships for Emdeon, overseeing strategy, operations, service, support and sales for channel partner customers. Meffe has been with Emdeon since 2000 when he joined as Vice President of Operations for the company. He is a graduate of Elon University with a BA in Economics.

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The "Complete" Answer to the Question of Growing Your Business

A look at your business priorities & Emdeon Provider Complete

Emdeon recently conducted a research study in partnership with a third party research firm to determine the priorities that our channel partners are most focused on in the next 12 to 18 months. The results were telling.

In some instances, the responses of channel partners mirrored those that would be expected of their customers. Electronic Medical Records (EMRs) and Meaningful Use, as well as ICD-10 changes were on the list. However, channel partners’ priorities went deeper, specifically calling out the key ways that they as solutions providers must be able to lead providers through the industry’s unfolding regulations and beyond. These priorities include:

• Customer retention
• Growth
• Increased ROI
• Maintaining excellent support through ICD-10 changes
• Upgrading of software to an EHR compatible system
• Overcoming implementation obstacles
• Integrating hospitals and physicians
• Finding innovative billing/payment software.

Some of these goals, like customer retention, growth and increased revenue, are likely to remain constant through any season. Others are ways of getting to what your customers are asking for.

Here is a question for you.

How do you establish a 24/7 excellent customer service department, grow your sales and expand services mentioned above, all without adding any new staff members, facilities or operations?

The answer is simple. Utilize Emdeon’s resources to make it happen.

That’s right. The full-service Emdeon Provider Complete model is a robust offering that can help you get to that goal of bringing more services, support—and value—to your providers, without having to add people, expand internal capabilities or acquire costly office space or expand operations. We have tailored this solution with a deep understanding of what you and your providers need to succeed in the healthcare landscape.

And if there is still a question in your mind why Emdeon Provider Complete should be your choice, we have a very straightforward answer for that also. Through your one connection to Emdeon, your providers have access to the most labs, pharmacies and payers in the industry enabling health information exchange, Meaningful Use, lab results & orders, ePrescribing, a full suite of EDI solutions and industry leading patient payment solutions. No one else can offer all of this to your providers. With a business partner like Emdeon, this can become your strength also.

Here’s a quick look at the Emdeon Provider Complete Solution offering:
• Say goodbye to months of backlogged payer enrollments because Emdeon will take care of all that. We closely monitor providers as they are going live to minimize rejections

• We also provide front line support for all EDI related issues so that you don’t have to. There will no longer be a need for you to be the intermediary point as your providers will be able to submit and track all support issues directly with Emdeon.

• Proactive claim rejection monitoring is also provided so providers can rest easy knowing that their cash flow is being closely monitored by Emdeon.

• Emdeon can be an extension of your sales team, reaching out to your providers and helping cross-sell solutions that benefit both you and your providers.

• Emdeon’s revenue cycle management capabilities can be tightly integrated into any practice management software.

The Emdeon Provider Complete Solution helps you not only compete, but win as well. Emdeon processes billions of health information exchanges annually within our expansive network of hospitals, pharmacies, doctors, dentists and laboratories. We have developed innovative technology solutions for claim rejection monitoring, payer enrollment for providers, 24/7 customer support and more. Our solutions are engineered for compliance and can be easily implemented and integrated while being easy to use.

Emdeon Provider Complete Solution is designed to help make you and your providers successful. With Emdeon Provider Complete, your business won’t miss opportunities or leave providers with fragmented services. You can offer a total package to your providers while being able to focus on customer retention and growth.

To learn more or get started, please call 855.559.8654 or email ProviderSolutions@emdeon.com.

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From Politics to Practice

What we learned at MGMA. By Gene Boerger, V.P. of Professional Product Management at Emdeon

On the surface, the agenda for the 2012 MGMA annual conference (San Antonio, Oct. 21-24) contained few surprises: Education sessions focusing on ICD-10, ARRA, administrative simplification, Meaningful Use and ACOs.

What was unexpected, however, was the energy invested by more than 3,000 people in attendance in transforming the politics of these issues into actionable strategies. Attendees and vendors alike were eager to convert the principles of reform into practice. We strategized with numerous provider groups to share how our expertise in care management, clinical information exchange and revenue optimization can transform industry concepts into real, workable scenarios. From our viewpoint, attendee interests fell into four major categories:

1. Solution engineering. We spoke with leaders at medical groups who recognize they need new solutions and new processes to achieve their objectives. Educational sessions, hallway discussions and vendor meetings centered on best practices and lessons learned. Attendees seemed to have a grasp of what they need and were tuned in to asking questions about how to get from here to there. Vendors were on the same wavelength. Countless meetings were held outside of exhibitor hours, where discussions about how to collaborate and integrate technologies to provide a more comprehensive whole abounded.

2. Care Management. Discussions about new care and reimbursement models, such as accountable care organizations (ACOs) and other pay-for-performance arrangements, have progressed from the abstract (“these approaches will help us control costs and improve care”) to the concrete (“who needs to be involved and what precisely will they be doing?”). Attendees explored the structures needed for greater focus on care management and heightened levels of coordination among providers. These conversations also dug deep into alignments—particularly as they affect community physicians—with hospitals.

3. Data drivers. As quality measures become engrained in emerging reimbursement models, medical groups increasingly need advanced data collection, analysis and reporting capabilities to successfully participate in a pay-for-performance or ACO-type model. Attendees recognized that their EHRs must work harder and that health information exchange (lowercase) is crucial. With a traditional focus only on delivering care—and not necessarily measuring it—providers are now taking a crash course in what tools are available, how they need to be configured and what they can do with the data that’s produced.

4. Business success. Billing professional fees. Proper coding and revenue optimization. Preparing for (and passing) audits. Contract negotiations. Use of outsourcing and technology. Patient collections. All activities that impact the bottom line—with a plethora of “practice proven and time tested” solutions for the challenges many medical groups face—were widely discussed. To arm our providers with information to improve business success, Emdeon held several educational presentations aimed at increasing revenue while effectively managing operations. Attendees agreed these considerations were more important in 2012 than ever before because of the incentive and payment reduction programs payers have adopted.

Emdeon made its presence felt throughout the conference, joining more than 350 other companies on the trade show floor with a dynamic booth that hosted long-time customers and new prospects. Emdeon was joined by the American Academy of Family Physicians for a speaking engagement in the MGMA Innovation Center on Care Management, and Emdeon representatives also delivered a number of in-booth educational sessions on topics ranging from how to remove barriers to submitting clean electronic orders to revving up cash flow by accepting online payments.

Overall, the mood of MGMA seemed to be of anticipation, partly fueled by the impending presidential election. Many attendees seemed to be of the opinion that the trends spurred by healthcare reform legislation would continue—and that they are embracing and preparing for new directions.

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Setting the Stage for Stage 2. Where We Are Now & What You Need to Know.

(Part 1 of 4)

Stage 2 of the Meaningful Use (MU) incentive program is being billed by some as “a giant leap in data exchange1.” The overriding goal of the program is to advance the secure exchange of information within our health system between all of a patient’s providers as well as the patients themselves —and that is a giant leap from where the system is currently, indeed. Of course, with every giant leap comes the chance for big missteps. That’s why the time is now to prepare for Stage 2 objectives and requirements.

The Biggest Challenges Revealed in Stage 1
According to a recent study published in the Journal of the American Informatics Association, the biggest challenge for hospitals participating in the MU program is Computerized Provider Order Entry (CPOE). Out of 2,475 hospitals in the study that intended to participate in MU, only 313 received incentive payments in 2011 during Stage 1. Half of those hospitals that didn’t meet Stage 1 requirements cited CPOE criteria as a top challenge. As we move to Stage 2, issues related to CPOE will remain as many hospitals are only beginning to adopt EHRs and build infrastructure to meet MU criteria.

For hospitals that were awarded incentive payments, giving patients access to their data in electronic form and generating numerator and denominator data for quality reporting directly from the Electronic Health Record (EHR) were reported to be the most significant challenges. The difficulty of providing electronic data to patients is very important to note and prepare for, as Stage 2 focuses on electronic patient communications and assigns heightened requirements to achieve program incentives.

According to Stage 2 Meaningful Use requirements final rule by Centers for Medicare & Medicaid Services (CMS), providers must achieve meaningful use under Stage 1 criteria before advancing to Stage 2. CMS has announced certain changes to Stage 1 CPOE; details may be found by clicking here.

What is different in Stage 2 as compared to Stage 1
In Stage 2, there are more core objectives for Eligible Professionals, Eligible Hospitals and Critical Access Hospitals (CAHs). Many Stage 1 core objectives have been merged or folded into other requirements. Eligible Professionals have 20 total objectives, including 17 core objectives and 3 (of 6) menu objectives. For Eligible Hospitals and Critical Access Hospitals (CAHs), there are 19 total objectives comprised of 16 core objectives and 3 (of 6) menu objectives.

Here’s a quick look at core objectives that Eligible Professionals must report on, as well as the six menu objectives they may choose from.

Core Objectives
1. Computerized Provider Order Entry (CPOE)
a. Use CPOE for more than 60 percent of medication, 30 percent of laboratory, and 30 percent of radiology.

2. ePrescribing (eRx)
a. Use eRx for more than 50 percent.

3. Demographics
a. Record demographics for more than 80 percent.

4. Vital Signs
a. Record vital signs for more than 80 percent.

5. Smoking Status
a. Record smoking status for more than 80 percent.

6. Interventions
a. Implement 5 clinical decision support interventions + drug/drug and drug/allergy.

7. Labs
a. Incorporate lab results for more than 55 percent.

8. Patient List
a. Generate patient list by specific condition.

9. Preventive Reminders

10. Use Electronic Health Record (EHR) to identify and provide reminders for preventive/follow-up care for more than 10 percent of patients with two or more office visits in the last 2 years.

11. Patient Access
a. Provide online access to health information for more than 50 percent with more than five percent actually accessing.

12. Visit Summaries
a. Provide office visit summaries for more than 50 percent of office visits.

13. Education Resources
a. Use EHR to identify and provide education resources more than 10 percent.

14. Secure Messages
a. More than five percent of patients send secure messages to their Eligible Professionals (EP).

15. Prescription Reconciliation
a. Medication reconciliation at more than 50 percent of transitions of care.

16. Summary of Care
a. Provide summary of care document for more than 50 percent of transitions of care and referrals with 10 percent sent electronically and at least one sent to a recipient with a different EHR vendor or successfully testing with CMS test EHR.

17. Immunizations
a. Successful ongoing transmission of immunization data.

18. Security Analysis
a. Conduct or review security analysis and incorporate in risk management process.

Menu Objectives (select 3 of 6)
1. Imaging Results
a. More than 10 percent of imaging results are accessible through Certified EHR Technology.

2. Family History
a. Record family health history for more than 20 percent.

3. Syndromic Surveillance
a. Maintain successful ongoing transmission of syndromic surveillance data.

4. Cancer
a. Maintain successful ongoing transmission of cancer case information.

5. Specialized Registry
a. Maintain successful ongoing transmission of data to a specialized registry.

6. Progress Notes
a. Enter an electronic progress note for more than 30 percent of unique patients.

For even more details, view the CMS’ Stage 2 Tipsheet by clicking here.

The Five Percent+ Factor: Focusing on Patient Engagement in Stage 2
Patient engagement—reciprocal communication between patients and providers—is a significant focus that everyone must be prepared for in Stage 2. To be eligible for incentives, providers must achieve the following patient action.

- More than five percent of patients must send secure messages to their eligible providers.

- More than five percent of patients must access their health information online.

For many Eligible Professionals, it may be quite daunting to evoke such engagement from over five percent of patients, as so many factors affect the transition to electronic information sharing. Technological, cultural and organizational barriers exist across communities nationwide. For example, CMS is introducing exclusions based on broadband availability by county, as some areas simply don’t have the Internet access necessary for five percent to take action even if they are willing to do so.

Timing for Stage 2
The final rule has been out since August 2012 and though there is an urgency for Stage 2, there is not the mad rush that surrounded Stage 1. Stage 2 test scripts have not yet been released in full from certification bodies and at this writing only three are out. Test scripts from vendors will be released in phases, with the launch of testing anticipated for December 2012 or January 2013.

For a complete look at Stage 2, visit CMS’ website by clicking here. There you’ll find tables, tipsheets and updates directly from CMS. In addition, continue to follow Emdeon for targeted announcements and interpretation of latest updates as it relates to your business. Emdeon will continuously guide you through Stage 2 so that you are prepared to offer expertise to your customers every step of the way.

Stay tuned for our next article in series, Planning for Certification and Strategies in Testing.

1. http://www.healthit.gov/buzz-blog/meaningful-use/meaningful-use-stage-2/
2. http://www.fierceemr.com/story/cpoe-huge-stumbling-block-meaningful-use/2012-10-02?utm_source=rss&utm_medium=rss
3. http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage1vsStage2CompTablesforEP.pdf

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New Payer Transactions Added Recently

Association de Maestros (PR), Payer ID: L0150
Assurant Health (Repricing for HealthSpan Network Only), Payer ID: ASNTH
CenterLight Healthcare, Payer ID: 13360
CenterPoint Human Services, Payer ID: 56122
ClubMD, Payer ID: 37272
Employee Benefit Systems, Payer ID: 42149
Good Samaritan Medical Practice Association, Payer ID: IP086
HealthPlan Services, Payer ID: 59140
Innovative Healthware Services, Inc., Payer ID: Call
J. Smith Lanier & Co. Administrators, Payer ID: 37272
JMH - SFCCN PHT (PSN, CMSN), Payer ID: 09822
JSL Administrators, Payer ID: 37272
Klais & Company (Repricing for HealthSpan Network Only), Payer ID: 3414A
MAPFRE LIFE, Payer ID: L0160
Mapfre Excel, Payer ID: L0100
Max Specialty Benefits, Payer ID: 27320
Medical Card System Inc (PR), Payer ID: L0170
Mutual Group (The) (US), Payer ID: 59140
NALC/Affordable, Payer ID: 53011
National Association of Letter Carriers, Payer ID: 53011
National Association of Letter Carriers/NALC, Payer ID: 53011
Pan American Life Insurance Company, Payer ID: L0180
Physicians Alliance/Stones River Regional IPA, Payer ID: 15749
Pittman & Associates, Payer ID: 37224
Plan de Salud Menonita (PR), Payer ID: L0190
RMSCO, INC., Payer ID: 16117
Smokey Mountain Center, Payer ID: 13010
UMC HEALTH PLAN, Payer ID: 75130
UMR/Cincinnati (Repricing for HealthSpan Network Only), Payer ID: UMRC1
United Healthcare Ovations Insurance Solutions (AARP), Payer ID: 36273
Wells Fargo Third Party Administrators, Inc. (Formerly JSL Administrators), Payer ID: 37272
Western Mutual Insurance, Payer ID: 37247
California Medicaid (Medi-Cal), Payer ID: SKCA0
Care Access PSN, Payer ID: 65063

Eligibility Inquiry and Response
CareSource, Payer ID: 00325
Illinois Medicaid - SCHALLER ANDERSON, Payer ID: ILMSA
Integral Quality Care FL - SCHALLER ANDERSON, Payer ID: IQCFL
Schaller Anderson MajestaCare VA, Payer ID: MACVA
United Healthcare Shared Services, Payer ID: UHIS
Blue Cross Blue Shield of Mississippi, Payer ID: 00075
Blue Cross Blue Shield of Mississippi, Payer ID: BCMS
Puerto Rico Medicaid, Payer ID: AID60

Claim Status Inquiry And Response:
AmeriHealth Mercy Health Plan, Payer ID: AHMHP
Horizon New Jersey Health, Payer ID: HNJH
Illinois Medicaid - SCHALLER ANDERSON, Payer ID: ILMSA
Integral Quality Care FL - SCHALLER ANDERSON, Payer ID: IQCFL
Keystone Mercy Health Plan, Payer ID: KYMHP
MDWise Hoosier Alliance, Payer ID: MDWHA
Passport Health Plan, Payer ID: PPHPC
Schaller Anderson MajestaCare VA, Payer ID: MACVA
Select Health of South Carolina, Payer ID: SHSC
Blue Cross Blue Shield of Kansas, Payer ID: BCKSC
Blue Cross Blue Shield of Kansas City, Payer ID: BCKCC
Blue Cross Blue Shield of Mississippi, Payer ID: 00075
Blue Cross Blue Shield of Mississippi, Payer ID: BCMS
Missouri Medicaid, Payer ID: AID03
Missouri Medicaid, Payer ID: MO

For all payers, visit https://access.emdeon.com/PayerLists/

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