Business Analyst

Claim Processing

noreply@blogger.com (Sam) — Fri, 02 Apr 2010 18:04:00 +0000

Claim Processing is a multi-step process of processing the claim submitted by the Provider or the Beneficiary. Two ways to submit a claim:

a) Hard copy format (entered manually into system)

b) Electronically (EDI or DDE)

For Hard Copy format: Image of hard copy format is captured for audit and archival purpose using imaging, micro-filming or intelligent character recognition (ICR/OCR); assigns a control number to each claim; claim information is manually entered or using ICR technology; then claims is submitted to the shared system.

A. Validation and Sorting

i.Stamps the date of receipt on paper claims

ii.Image paper claims and attachments (stores the copy)

iii.EDI translation is performed on electronic submission. Translates into flat file.

iv.Automated process is performed for initial format validation check.

v.HIPAA compliance edits are performed.

vi.A back up copy of electronic files is created for audit and archival purpose.

vii.Sorting of claim is done.

viii.A control number (unique) is assigned to each claim.

ix.Claims are sent into shared system into batches.

x.Any claim that doesn’t pass the edit is rejected back to the Provider.

xi.Beneficiary and Provider data is checked on the claim against the data in the corresponding beneficiary and provider data in files. If the Provider or Beneficiary data is not matched with the data on the file, the claim is rejected.

xii.Incomplete claims are returned to submitter for correction and resubmission.

xiii.Complete claims are ready for batch processing and moved to next processing stage.

xiv.Claims with invalid data are denied.
B. Adjudication
Automated batch processing
i. Completeness

ii. Valid submittals

iii. Valid values and

iv. Data consistency

v. Apply rules and guidelines to check for duplicate and suspensions and valid Provider and Beneficiary eligibility.

vi. If suspensions are generated or further investigation is required, the claims/adjustment undergo further manual processing

vii. Rejection may be generated by line or by claim; if some parts of claim are acceptable, that part of the claim may be paid.
C.
Pricing and Remittance Advice:
· Once the claim/adjustment is complete, it goes through pricing and is then sent for verification.

HL7 Format

noreply@blogger.com (Sam) — Fri, 02 Apr 2010 18:02:00 +0000

HL7 is a standard developing organization operating in healthcare domain and develop standards to permit exchange of healthcare information between computer applications in encoded format.

HL7 format uses Arden syntax for encoding medical information.

While interfacing two machines or applications which exchange medical information, some specifications need to be specified like:

· Defining the communication protocol it will use.

· HL7 version to be used (currently 3.0).

· Define HL7 messages to be sent or received between the applications.

· Defining the message format for each message that the two applications or machines will exchange.

As we know every healthcare organization bills for services provided, the moment medical information is exchange for billing purpose; the HL7 standard comes into picture.

· Whether it’s transferring the clinical data to different departments throughout the hospital, or

· Exchanging data with reference labs.

So, overall HL7 provides standards to make process of clinical data exchange to be standardized, secured and consistent.

HIPAA 5010: Changes in Individual Transaction

noreply@blogger.com (Sam) — Fri, 02 Apr 2010 17:58:00 +0000

270- Eligibility Request

· Added search option wit Member ID, last name and date of birth.

· Added support for additional 38 Patient Service Type codes.

· Added benefit search based on Diagnosis Codes.

271- Eligibility Response

· Changes are made to clarify that when a patient has active benefit coverage, the health plan must report: Beginning effective date, Plan Name and the benefit effective date if different from overall coverage.

· New Health Plan requirements are added to the 271 Eligibility response.

· New requirements are added to specify nine category of benefits to be reported if available the patient.

· When reporting on co-insurance, co-payment and deductible, it’s now explicitly required that patient portion of payment is to be reflected in either monetary or percentage amount.

276/277- Claim Status Request and Response

· Sensitive Private Health information is removed for status check purpose.

· REF segment can now be used to identify prescription number for pharmacy information.

· Specific tracing number can be recorded (modified TRM segment).

· New requirements allow Payer to report more status code (STC) and greater details about the claim status.

287- Health Care Service Certification

· Structural changes are made which enables to group information about patient events such as diagnosis, category of service hierarchically.

· Procedures are moved to from Healthcare information code segment (HI) to professional (SV1), institutional (SV2) and dental (SV3).

· The 278 TR3 also clarified the use of the patient condition segment, by adding separate implementation segments and rules.

· Reject reason code data elements was changed, now to be a repeating data element to allow multiple reject codes to be reported.

837- Healthcare Claims (I, P and D)

· Subscriber information is not reported if Patient information uniquely identifies the patient.

· Clearly defined as to how NPI subparts are to be reported structurally.

· A separate element is added to report tax number.

· ICD-10 is supported.

835- Claim Payment/Remittance

· A remittance delivery method segment is added.

· A new Healthcare Medicare Policy segment is added.

· Segment is added to supply the Payer URL.

Major Changes in HIPAA 5010

noreply@blogger.com (Sam) — Fri, 02 Apr 2010 17:56:00 +0000

1. This new rule adopts the use of ANSI X12 version 5010 of EDI transactions in healthcare, replacing the older version 4010A1.

2. This new rule also addresses to adopt ICD-10, which is a modification of Medical Code Set Data.

3. It clarifies the NPI instructions and it’s use.

4. In HIPAA 5010 additional attention is paid to Privacy Issue around “Minimum Necessary” rule.

5. This new rule also eliminates the dependency on Companion Guide.

6. Additional attention is paid on Acknowledgement Transactions.

7. New rule will eliminate the PHI theft, fraud and abuse cases in healthcare industry.

HIPAA

noreply@blogger.com (Sam) — Fri, 02 Apr 2010 17:54:00 +0000

HIPAA stands for ‘Health Insurance Portability and Accountability Act’. HIPAA was started by Congress in 1996 and was produced in two Titles:

· Title I: Title I protects the health insurance coverage of workers and their families when they change or loose job.

· Title II: Title II, also known as ‘Administrative Simplification Provision’. It requires the establishment of national standards for electronic healthcare transactions and national identifiers for Providers, Health Insurance Plans and Employers. Basically it addresses the security and privacy of Health Data.

HIPAA mandates healthcare organizations to implement privacy and security standards when electronically storing and sending healthcare information.

Under Title II, comes the five different rules to protect the healthcare information of an individual:

1. Privacy Rule

2. Transaction Code Set Rule

3. Security Rule (Administration, Physical and Technical)

4. Unique Identifier Rule

5. Enforcement Rule

SWOT Analysis

noreply@blogger.com (Sam) — Wed, 31 Mar 2010 02:41:00 +0000

SWOT analysis is done in strategic planning before the phases of SDLC. SWOT stand for Strength, Weakness, Opportunity, Threats. Basically we analyze our company, project under these four headings

I suppose its nothing more than a structured form of brain storming, but because it is simple, it a great way at the start of the project to encourage people to think 'out of the box'.
That means, it is better to look into the industry where we are and then identify the threats and opportunity of the industry, not of our company but of the whole industry that we are in. We need to consider the competition right away, then we can identify company's strength and weakness.
The logic behind the SWOT analysis is to align company's strength and/or weakness to the opportunities of industry. This way we can attack the industry with the current company's strengths or we may remove the company's weakness to confront the threats of industry.
There are lots of tools in market to get templates for SWOT analysis like smartdraw, mindjet, etc.

noreply@blogger.com (Sam) — Wed, 31 Mar 2010 02:35:00 +0000

Healthcare Terms

HIPAA: HIPAA stands for Healthcare Insurance Accountability And Portability Act.

HMO: HMO Stands for Health Maintenance Organization. It offers prepaid comprehensive coverage for both hospital and physician services.

Medicare: It’s a Federal health insurance program for people of age 65 or older and for individuals with disabilities.

Medicaid: It is a program sponsored by the federal government and administered by states and is intended to provide health care and health related services to low income individuals.

CMS: CMS is the Centers for Medicare & Medicaid Services.It is the federal agency responsible for administering the Medicare, Medicaid, SCHIP (State Children's Health Insurance), HIPAA(Health Insurance Portability and Accountability Act), CLIA (Clinical Laboratory Improvement Amendments), and several other health-related programs.

EDI: It stands for Electronic Data Interchange. It’s the mutual exchange of healthcare data between the providers and insurance company.

EOB: EOB stands for Explanation Of Benefits. It details the results of processing a claim. Provider receives a remittance advice or remit, which is a notice sent by the insurance company that contains payment information about a claim.

Coding: It’s the process of assigning diagnoses, procedures, and services using numeric and alphanumeric characters. Two coding systems are used in healthcare: ICD-9-CM (International classification of disease) and HCPCS (Healthcare Common Procedure Coding System).

HIPDB: Its Healthcare Integrity and Protection Data Bank which combats fraud and abuse in health insurance and health care delivery.

HCRA: HealthCare Reimbursement Account, a tax exempt account used to pay for healthcare expenses.

MEVS: Medicaid Eligibility Verification System. It allows provider’s to electronically access the state’s eligibility file.

NPI: Stands for National Provide Identifier. Its purpose is to uniquely identify a healthcare provider in standard transactions, such as healthcare claims.

HHS: The Department of Health and Human Services (HHS) has determined that CMS will have responsibility for enforcing the transactions and code set standards, as well as security and identifiers standards when those are published. CMS will also continue to enforce the insurance portability requirements under Title I of HIPAA. The Office for Civil Rights in HHS will enforce the privacy standards.

COB: Coordination of Benefits.

EFT: Electronic Fund Transfer

LR: Legislative request

EDI Transaction Flow in Healthcare

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 20:20:00 +0000

EDI Testing

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 20:00:00 +0000

Recommended Types of Testing:

Type 1: EDI syntax integrity testing – Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. This will validate the basic syntactical integrity of the EDI submission.

Type 2: HIPAA syntactical requirement testing – Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. Also included in this type is testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table.

Type 3: Balancing – Testing the transaction for balanced field totals, financial balancing of claims or remittance advice, and balancing of summary fields, if appropriate. An example of this includes items such as all claim line item amounts equal the total claim amount. (See pages 19-22, Healthcare Claim Payment/Advice – 835 Implementation Guide for balancing requirements of the 835 transaction.)

The Coupler Mapper Maporators provides extensive set of functions to achieve this type of testing.

Type 4: Situation testing – The testing of specific inter-segment situations described in the HIPAA Implementation Guides, such that: If A occurs then B must be populated. This is considered to include the validation of situational fields given values or situations present elsewhere in the file. Example: if the claim is for an accident, the accident date must be present.

Type 5: External code set testing – Testing for valid Implementation Guide-specific code set values and other code sets adopted as HIPAA standards. This level of testing will not only validate the code sets but also make sure the usage is appropriate for any particular transaction and appropriate with the coding guidelines that apply to the specific code set. Validates external code sets and tables such as CPT, ICD9, CDT, NDC, status codes, adjustment reason codes, and their appropriate use for the transaction. NOT SUPPORTED by Coupler.

Type 6: Product types or line of services: This testing type is required to ensure that the segments/records of data that differ based on certain healthcare services are properly created and processed into claims data formats. These specific requirements are described in the Implementation Guides for the different product types or lines of service. For example, ambulance, chiropractic, podiatry, home health, parenteral and enteral nutrition, durable medical equipment, psychiatry, and other specialized services have specific requirements in the Implementation Guide that must be tested before putting the transaction in production. This type of testing only applies to a trading partner candidate that conducts transactions for the specific line of business or product type.

Type 7: Implementation Guide-Specific Trading Partners: The Implementation Guides contain some HIPAA requirements that are specific to Medicare, Medicaid, and Indian Health. Compliance or testing with these payer specific requirements is not required from all trading partners. If the trading partner candidate intends to exchange transactions with one of these Implementation Guide special payers, this type of testing is required. When a certification service certifies a trading partner for compliance, the certification service must indicate whether these payer specific requirements were met during the certification process. Other payers and trading partners may have their own specific business requirements; but, unless they are listed in the HIPAA Implementation Guides, they are not HIPAA requirements. These non-HIPAA trading partner specific requirements must be tested as part of the business-to-business testing. For further information on business-to-business testing and for further information on testing trading partner rules that are not contained in the Implementation Guides, please see the Business-To-Business Testing White Paper developed by this sub-workgroup.

HIPAA Modification Rule

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:20:00 +0000

1. What was adopted under the HIPAA Modifications

Rule Version 5010 of the X12 standards suite of administrative transactions
Version D.0 of the NCPDP suite for retail pharmacy
Version 3.0 of the NCPDP Suite for Medicaid pharmacy subrogation
Version D.0 orVersion 5010 for retail pharmacy supplies and services, based on trading partner agreements

2. Why Version 5010?

Version 4010 is outdated:

More than 5 years since initial implementation, but 8 years since balloting of the current version
Many situational and required rules did not fit business practices of the industry
Industry relied extensively on companion guides, limiting value of standards
Many transactions were not implemented at all because of limited utility and value

Version 5010 is an improvement because it…

Includes structural and content oriented changes
Incorporates more than 500 change requests
Resolves ambiguities in situational rules
Provides more consistency across transactions –most rules are the same throughout the suite
Shortcomings have been addressed to increase value of transactions such as referrals and authorizations.

3. Why Version D.0?

Version 5.1 is outdated:

More than 5 years since initial implementation, but 8 years since balloting of the current version

Version D.0 is an improvement because it:

Incorporates change requests submitted by the industry to accommodate changing business needs
Incorporates changes necessitated by the requirements of the Medicare Prescription Drug Improvement and Modernization Act (MMA)

4. Policy features of HIPAA modifications rule

Compliance date for 5010 and D.0
Mandatory compliance on January 1, 2012 –all covered entities
Internal Testing to begin on or after January 1, 2010
External testing to begin on or after January 1, 2011

No entity may require another entity to use the new version of the standard without agreement between the two parties for testing and implementation

Ability to use X12 or NCPDP for retail pharmacy supplies and services
Supports existing industry practice
Requires agreement between trading partners

Compliance date for Version 3.0
Mandatory compliance on January 1, 2012 –all covered entities except small health plans
Small health plans have until January 1, 2013

5. Benefits of Conversion: 5010/D.0/3.0

Less ambiguity in the TR3 (guides)
Enhanced usability and usefulness of certain transactions such as referrals and authorizations (X12 and NCPDP)
Improved utility of the NCPDP standards, compliance with Part D requirements
Reduces reliance on companion guides
Supports increased use of EDI between covered entities
Supports E-Health initiatives now and in the future
Version 3.0 provides standard method of recouping State Medicaid funds paid inappropriately

6. Who is Affected?

All HIPAA Covered Entities

–Providers
–Health Plans
–Clearinghouses

Business Associates of Covered Entities that use the affected transactions

Billing/Service Agents

7. What must be changed?

•The formats currently used must be upgraded from X12 Version 4010A1 to 5010 and from NCPDP 5.1 to D.0

•Systems that submit claims, receive remittances, exchange claim status or eligibility inquiry and responses must be analyzed to identify software and business process changes

•The new versions have different data element requirements

•Software must be modified to produce and exchange the new formats

•Business processes may need to be changed to capture additional data elements now required

•Transition to the new formats must be coordinated:

–continue to use the current formats for some Trading Partners’ exchange
–start to use the new formats with other Trading Partners

8. HIPAA 5010 Scope

•New ASC X12 standard acknowledgement and rejection transactions

–The Functional Acknowledgement 997 is being replaced by the 999 transaction
–The Claims Acknowledgement (277-CA) will be used to replace proprietary error reporting

9. Enhancements included with 5010

•Enhancements are focused on functional areas requiring 5010 changes and are limited to:

–Improving claims receipt, control, and balancingprocedures
–Increasing consistency of claims editingand error handling

Provides common edit definitions to be used by all systems and jurisdictions

–Returning claims needing correction earlierin the process
Adds edits for common mistakes to the front end MAC systems, rather than waiting to do these edits in the adjudication systems

–Assigning claim numberscloser to the time of receipt
The front end systems will assign the base claim number (in the format expected by the adjudication system), and have the adjudication system add any suffix necessary for split or adjustment claims

10. HIPAA 5010 Scope vs. ICD-10 Scope

The HIPAA 5010 project is a pre-requisite for the ICD-10 project

•What 5010 DOES do:

–Increases the field size for ICD codes from 5 bytes to 7 bytes
–Adds a one-digit version indicator to the ICD code to indicate version 9 vs.10
–Increases the number of diagnosis codes allowed on a claim
–Includes some of the other data modifications in the standards adopted by Medicare FFS

•What 5010 DOES NOT do:

–Does not add processing needed to use ICD-10 codes
–Does not add a crosswalk of ICD-9 to ICD-10 codes
–Does not require the use of ICD-10 codes

The 5010 format allows ICD-9 and/or ICD-10 CM & PCS code set values in the transaction standard.

The business rules for using ICD-10 code set values will be defined with the ICD-10 project.

Major Changes from ICD-9-CM to ICD-10-CM

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:17:00 +0000

In general, most of the changes were of the following types:

Grouping of codes—Conditions have been grouped in a more logical fashion than in ICD-9-CM. This may have been accomplished by means of movement from one chapter to another or one section to another. Many codes have been added to, deleted from, combined, or moved in ICD-10-CM. ICD-10-CM boasts of some chapters that are entirely unique, although these codes were found in other chapters in ICD-9-CM.
More complete descriptions—In ICD-10-CM, the subcategory titles are usually complete so that the coder does not have to read previous codes to understand the meaning of the code.
Fifth and sixth characters—Fifth and sixth characters are incorporated into the code listing rather than having common fifth digits listed at the beginning of a chapter, section, or category.
Laterality—ICD-10-CM incorporates laterality of conditions or injuries at the fifth or sixth character level.
Increased specificity—ICD-10-CM offers greatly expanded detail for the various conditions. Many categories, which in ICD-9-CM were limited to three or four digits, have fifth, sixth, and even seventh characters/extensions in ICD-10-CM. In some cases, single ICD-9-CM codes were split into several ICD-10-CM codes to provide greater specificity.
Excludes notes—There are three kinds of excludes notes that are used in ICD-10-CM.
Use of extensions—Extensions are used in ICD-10-CM to provide additional information. These extensions are most often found in the injury codes but are found in other chapters. 57
Combination codes—There are numerous codes in ICD-10-CM that group etiology and manifestation. In ICD-9-CM, generally two codes are required to code etiology and manifestation.
Terminology used—Many of the category code or subcategory code titles have been changed to reflect new technology and more recent medical terminology.
Postprocedural conditions—There are many more codes added to ICD-10-CM to describe postoperative or postprocedural conditions.
Trimester specificity—ICD-10-CM codes in the pregnancy, delivery, and puerperium chapter includes codes designating the trimester in which the condition occurs.
New codes—There are many new codes to ICD-10-CM that were not classified in ICD-9-CM. Notably, codes for blood type and alcohol level are included in ICD-10-CM.

Comparison of ICD-9-CM and ICD-10-CM

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:14:00 +0000

ICD-10-CM was designed to offer significant advantages over ICD-9-CM. These changes should result in major improvements in both the quality and uses of data for various healthcare settings.

Significant improvements in both the content and the format of ICD-10-CM include the following:

General Changes and Overall Improvements

ICD-10-CM codes are alphanumeric and include all letters except "U," thus providing a greater pool of code numbers.
ICD-9-CM’s V and E codes are incorporated into the main classification in ICD-10-CM.
The length of codes in ICD-10-CM can be a maximum of seven characters (digits and letters) as opposed to ICD-9-CM’s five digits.
ICD-10-CM offers the addition of information relative to ambulatory and managed care encounters.
Conditions that are new or that were not uniquely identified in ICD-9-CM have been assigned code numbers in ICD-10-CM.
In ICD-10-CM, some three-character categories are not used in order to allow for revisions and future expansion.
Instead of grouping by categories of injury or type of wound, ICD-10-CM groups injuries by site of the injury and then the type.
Excludes notes were expanded in order to provide guidance on the hierarchy of the chapters and to clarify priority of code assignment.
Some conditions with a new treatment protocol or perhaps a recently discovered or new etiology have been listed in a more appropriate chapter.
Combination codes are used for both symptom and diagnosis, and etiology and manifestations—for example K50.03 Crohn’s disease of small intestine with fistula.
Codes for postoperative complications have been expanded. Also a distinction has been made between intraoperative complications and post-procedural disorders—for example, K91 Intraoperative and postprocedural complications and disorders of digestive system, NEC.

Benefits of Implementing ICD-10

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:11:00 +0000

Generally, ICD-10-CM incorporates greater specificity, clinical data, and information relevant to ambulatory and managed care encounters. In addition, the structure of ICD-10-CM allows for the possibility of greater expansion of code numbers. This classification will also extend beyond simply the classification of disease and injuries to include risk factors that are frequently encountered in a primary care setting. The new system also includes those diseases discovered since the most recent revision of ICD-9-CM. General terminology, as well as disease classification, has been updated to be consistent with accepted and current clinical practice. The expanded degree of specificity should provide more detailed information, which would assist providers, payers, and policy makers in establishing appropriate reimbursement rates, improving the delivery of healthcare, improving and evaluating the overall quality of patient care, and effectively monitoring both service and resource utilization.

Problems with ICD-9

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:09:00 +0000

There are several problems with this current classification system (ICD-9) including:

The ICD-9-CM Tabular List is running out of numbers to assign for codes and in some cases, new code proposals could not be adopted because of the limited space.

The current ICD-9-CM diagnosis codes do not provide sufficient clinical specificity to describe the severity or complexity of the various disease conditions. In particular, the codes for healthcare encounters for other than disease (V codes) do not provide enough specificity. Consequently, there are increasing requirements for submission of additional documentation in order to support claims.

The exchange of meaningful healthcare data with healthcare organizations and professionals around the world is hindered by the fact that many countries are presently using ICD-10 or a clinical modification of it (Australia and Canada, for example, have modifications). Even in the US, mortality statistics (information on death certificates) have been collected using ICD-10 since 1999.

The current ICD-9-CM system is ineffective for effectively monitoring utilization of resources, measuring performance, and analyzing healthcare costs and outcomes.

Introduction to ICD-10

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:06:00 +0000

Historically, ICD-9-CM was developed as a classification system for statistical compilation of data in inpatient settings. Unfortunately, it has proven to be inadequate for use in other healthcare settings and even for reimbursement purposes. The cornerstone of DRGs, RUGs, and other prospective payment groups is the ICD-9-CM code. Even non-PPS payment methodologies require complete, accurate, and detailed coding in order to calculate appropriate reimbursement rates, determine coverage, and establish medical necessity.

Keeping all of the problems encountered with ICD-9 in mind, it becomes quite clear that a classification system that provides greater coding accuracy and specificity is greatly needed. Several other organizations have called for Congress to adopt ICD-10-CM, including the American Hospital Association, the Advanced Medical Technology Association, the American Psychiatric Association, and the Federation of American Hospitals.

In 1994, WHO developed the tenth revision of the ICD system. The purpose of the revision was to expand the content, purpose, and scope of the system and to include ambulatory care services, increase clinical detail, capture risk factors in primary care, include emergent diseases, and group diagnoses for epidemiological purposes.

In 1997, the National Center for Health Statistics began the first round of testing following the development of ICD-10-CM. A timetable for the implementation of ICD-10-CM has not been determined. Many of the problems with ICD-9-CM have been addressed in ICD-10-CM. It provides better information for nonacute care or nonhospital encounters, clinical decisionmaking, and outcomes research. Terminology and disease classification have been updated to be consistent with current usage and medical advances.

ICD-9 Background

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 19:02:00 +0000

ICD-9-CM is the United States’ modification of the International Classification of Diseases, Ninth Revision, developed by the World Health Organization. It is the most universally applied classification system for coding diagnoses, reasons for healthcare encounters, health status, and external causes of injury. The regulations regarding electronic transactions and code sets promulgated under HIPAA designate ICD-9-CM as the medical code set standard for diseases, injuries, or other encounters for healthcare services.

Some Facts about "Migration to ICD-10"

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 18:53:00 +0000

Migration to ICD-10

ü ICD-10 isn't new, it's now beginning to make a big impact on health plans.

ü ICD-10 was adopted in the United States in 1999 for reporting mortality, ICD-9-CM (Clinical Modification) remains the U.S. data standard for reporting morbidity.

ü Not only the national code will offer better monitoring of health status, they also believe it's a critical answer to improving the monitoring of disease and potential biological threats in the United States.

ü ICD-10 has the potential to improve interoperability between systems, provide greater specificity and granularity to support medical/disease management programs, and reduce the number of miscoded claims.

ü Most payers' systems will have to be changed because most systems are based on it or have pieces of ICD codes built into their logic.

ü However, payers won't take the biggest hit. While they'll face an enormous undertaking, Fox said physicians and health-care providers will bear the biggest brunt because they'll be the ones responsible for coding data.

ü But there are several things that first need to be done before the industry can tackle the ICD-10 conversion issue. "Industry and government need to take a look at the broader spectrum of other regulations out there that also need to be implemented. Capital and resources in the health-care industry are limited. There needs to be a comprehensive plan developed that identifies the value proposition of the various regulatory initiatives on the table. To some extent, value should drive the priority of activities.

ü The "5010" is a prerequisite for ICD-10 implementation.

ü The Secretary of Health and Human Services published a Final Rule that adopts the NPI its the standard unique health identifier for health-care providers. When implemented, covered entities will use the NPI as their primary identification number to identify health-care providers in all standard electronic transactions.

ü If you look at the costs associated with it, it's not just our costs but also that of physician practices and hospitals who will be looking to insurers to increase reimbursement. So it's a ripple effect, and ultimately comes back to the government, businesses and consumers who are voluntarily purchasing health care.

ü Not only will systems and business processes need to be redesigned to handle the new codes, health plans will have to offer extensive training of clinical and administrative personnel.

ANSI X12

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 18:35:00 +0000

X12 An ANSI-accredited group that defines EDI standards for many American industries, including health care insurance. Most of the electronic transaction standards mandated or proposed under HIPAA are X12 standards.

The ANSI X12 formats are messaging standards developed for the sole purpose of transmitting data between two entities referred to as trading partners in the HIPAA legislation. The organization of each ANSI ASC X12 standard is determined by well-defined business needs. Specific uses of each standard are defined in implementation guides.

Important ANSI ASC X12 Syntax Concepts
 Data in ANSI ASC X12 standards is organized into segments. Each segment contains multiple data elements, which are classified as simple or composite. Data elements may contain coded information maintained by ANSI ASC X12 (Internal code lists) or by outside organizations (External code lists) as well as qualified information.

 Multiple occurrences of information is supported by the looping structure in the 837 claim/encounter standard. Parent/Child relationships between loops is also supported in the 837 standards by use of Hierarchical Levels (HL segments).

 Segments and data elements in each loop are defined as either required or situational in each implementation guide. A statement of the usage of each situational data element is defined in the implementation guide.

Following are some ANSI X12 transactions used in the industry:

X12 148 The X12 First Report of Injury, Illness, or Incident transaction. This standard could eventually be included in the HIPAA mandate.

X12 270 The X12 Health Care Eligibility & Benefit Inquiry transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 271 The X12 Health Care Eligibility & Benefit Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 274 The X12 Provider Information transaction.

X12 275 The X12 Patient Information transaction. This transaction is expected to be part of the HIPAA claim attachments standard.

X12 276 The X12 Health Care Claims Status Inquiry transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 277 The X12 Health Care Claim Status Response transaction. Version 4010 of this transaction has been included in the HIPAA mandates. This transaction is also expected to be part of the HIPAA claim attachments standard.

X12 278 The X12 Referral Certification and Authorization transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 811 The X12 Consolidated Service Invoice & Statement transaction.

X12 820 The X12 Payment Order & Remittance Advice transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 831 The X12 Application Control Totals transaction.

X12 834 The X12 Benefit Enrollment & Maintenance transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 835 The X12 Health Care Claim Payment & Remittance Advice transaction. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 837 The X12 Health Care Claim or Encounter transaction. This transaction can be used for institutional, professional, dental, or drug claims. Version 4010 of this transaction has been included in the HIPAA mandates.

X12 997 The X12 Functional Acknowledgement transaction.

EDI

noreply@blogger.com (Sam) — Sun, 28 Mar 2010 18:21:00 +0000

EDI (Electronic Data Interchange) is a standard format for exchanging business data, the data could be finance data or health related information as we handle in healthcare industry.

EDI message contains a string of data elements, each of which represents a singular fact, such as a price, product model number, and so forth, separated by delimiter. The entire string is called a data segment. One or more data segments framed by a header and trailer form a transaction set, which is the EDI unit of transmission.

Benefits of the EDI Process

1.Reduced data entry errors: EDI does not involve data entry at multiple points. In the traditional process, a sender creates a purchase order on the system, prints the order, and then faxes or mails it to a trading partner. The receiver then rekeys the same information on his or her computer. The process is prone to data entry errors. This procedure is repeated when invoicing takes place. With EDI, data goes directly from one computer to another without involving a human being.

2· Reduced processing cycle time: The biggest advantage is the reduced processing time of the complete cycle. As soon as orders are entered into the system, they can be processed on the receiving side in seconds. There is a considerable savings in the processing time of document transfer.

3. Availability of data in electronic form: Data from EDI is in electronic form, which makes it easy to share across the organization.

4· Reduced paperwork: The entire EDI process can be handled without using a single piece of paper.

5· Reduced cost: Time is money. Any savings in time is directly linked to savings in money. The initial cost of an EDI setup is certainly higher compared to the paper process, but over a long period it is very cost−effective.

6· Reduced inventories and better planning: Companies do not have to keep a safety stock for the time taken with order processing. Changes to planning schedules can be communicated instantaneously. MRP (Material Requirements Planning) can take into account a shipment in transit as soon as an Advance ship notice (EDI 856) transaction is received.

7·Standard means of communication: Because EDI enforces standards on the contents of data,uniform naming standards and field sizes have emerged. Such consistency leads to clearer communication and less ambiguity.

8·Better business processes: Compared to traditional methods of exchanging business documents, EDI is certainly a better way of communicating with your trading partners. Companies are willing to share information and participate in inter−organizational issues. This environment enhances supply−chain management.

9·Competitive advantage: In many cases, companies that have implemented EDI have an advantage over their competitors, especially when dealing with government agencies or large corporations.

Interview for a Business Analyst position

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SWOT Analysis

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What Are Your Salary Expectations

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Why Do You Want To Work Here

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Why Should We Hire You

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Tell me about yourself

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