V608 HIPAA Accelerator Jump Starts HIPAA EDI Implementations

1. V608 HIPAA Accelerator Jump Starts HIPAA EDI Implementations • Nicki Lelis • Product Manager • eBusiness Division • Nicki.lelis@sybase.com

2. HIPAA Accelerator Jump Starts HIPAA EDI Implementations Topics • Sybase product overview • Overview of Health Insurance Portability and Accountability Act • What is Sybase’s HIPAA Accelerator • How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations

3. HIPAA Accelerator Jump Starts HIPAA EDI Implementations Topics • Sybase product overview • Overview of Health Insurance Portability and Accountability Act • What is Sybase’s HIPAA Accelerator • How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations

4. Sybase e-Business PlatformComprehensive,Modular, Integrated and Open Enabling Your Customers Empowering Your Enterprise Enriching B2B Interactions Trding Partners Customers Enterprise Access Power Designer Enterprise Portal - Web & Mobile Access Integrate Process Server Biz Tracker Integration Server Application Adapters Web Services Develop Transact Java IDE Application Server Business Intelligence Replication Database Metadata Repository - Configuration Security - Install - Management SYBASE e-Business Platform

5. Power Designer Enterprise Portal - Web & Mobile Access, Openbiz Process Server Biz Tracker Integration Server Application Adapters Web Services Java IDE Application Server Business Intelligence Replication Database Metadata Repository - Configuration Security - Install - Management SYBASE e-Business Platform Sybase e-Business PlatformSupport for Web Services • Simple Web Services • Defined as: UDDI, WSDL, SOAP • Supported through • EAServer • PowerDesigner • Collaborative Web Services • Defined as: B2B, RosettaNet, ebXML • Supported through: • Web Services Integrator • OpenBiz

6. Sybase e-Business Platform Access Power Designer Enterprise Portal - Web & Mobile Access Integrate Process Server Biz Tracker Integration Server Application Adapters Web Services Develop Transact Java IDE Application Server Business Intelligence Replication Database Metadata Repository - Configuration Security - Install - Management SYBASE e-Business Platform

7. HIPAA Accelerator Jump Starts HIPAA EDI Implementations Topics • Sybase product overview • Overview of Health Insurance Portability and Accountability Act • What is Sybase’s HIPAA Accelerator • How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations

8. HIPAA Health Insurance Portability and Accountability Act of 1996 Title I Title II Title III Title IV Title V Fraud & Abuse Medical Liability Reform Administrative Simplification Insurance Portability Tax Related Health Provision Group Health Plan Requirements Revenue Off-sets Privacy Security EDI Transactions Code Sets Identifiers

9. Administrative Simplification Components of HIPAA Electronic Transactions, Unique IDs, Code Sets Implementation Standards used for the electronic transmission of specific health care transactions

10. Why HIPAA? – “Simplify the Administration of Health Insurance” • Reduce Direct and Overhead Costs • Reduce the Accounts Receivable Cycle • Improve Accuracy • Reduced Data Entry Time • Smaller/Faster Transmissions at Lower Cost • Reduce/Eliminate Rework • Avoid/Reduce Data Entry FTE • Reduce Operational Costs (office supplies, postal costs and telephone charges)

11. Why HIPAA? – “Simplify the Administration of Health Insurance” • Improve Process that directly impacts healthcare stakeholders - • Improved patient, provider and payer support • Efficient information delivery • Improved quality • Fosters “good will” with patients • Fosters closer working relationships between organizations

12. Providers, Payers, Clearinghouses • All must comply with the mandates of HIPAA Administrative Simplification with the following exceptions: • Providers who wish to conduct transactions via paper may continue to do so and avoid HIPAA compliance mandates* • Employers, Workers Compensations Plans, Life Insurance Plans not under HIPAA jurisdiction • * Under ASCA, Medicare will require electronic claim submission by 10/16/03 for providers of a certain size. Other payers may also choose to refuse paper transactions in the future.

13. What happens if I do not comply? • Penalties for transaction non-compliance specified in the Act: • “not more than $100 for each such violation, except that the total amount imposed on the person for all violations of an identical requirement or prohibition during a calendar year may not exceed $25,000”

14. What happens if I do not comply? • Penalties for wrongful disclosure of individually identifiable health information specified in the Act: • Fine of not more than $50,000, not more than 1 year imprisonment • False pretenses, fine of not more than $100,000, not more than 5 years imprisonment • Commercial advantage, personal gain, malicious harm, fine of not more than $250,000, not more than 10 years imprisonment

15. Status of the HIPAA Regulations • TRANSACTIONS • Final Rule was made effective 10/16/00 • Original Compliance date 10/16/02 • ASCA 1-yr Extension date 10/16/03 • Claim Attachment in development • Report of First Injury in development

16. Patient information Subscriber Patient information Subscriber information Premium Payment Premium Payment Prior AuthorizationReferral/CMN Prior AuthorizationReferral/CMN Claim/ Encounter Claim/ Encounter Claim Status Claim Status HIPAA X12N Transactions Payer Provider Eligibility Inquiry 270 Eligibility Response 271 Sponsor Enrollment 834 Request for Review 278 Premium Payment 820 Review Response 278 Claim/Encounter 837 Remittance Advice 835 Request Additional Information 277 Attachments 275/HL7 Additional Information 275/HL7 Status Inquiry 276 Status Response 277

17. HIPAA Accelerator Jump Starts HIPAA EDI Implementations Topics • Sybase product overview • Overview of Health Insurance Portability and Accountability Act • What is Sybase’s HIPAA Accelerator • How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations

18. What is Sybase’s HIPAA Accelerator Sybase’s HIPAA Accelerator jump starts HIPAA implementations by: • Predefined Standards that reflect the implementation guides to jump start data transformation maps • Providing compliance maps to verify the EDI data against the HIPAA implementation guides

19. HIPAA – X12 Cross Reference HIPAA Transaction ASC X12 Standard Health Care Claim/COB Professional X12N 837 X098 Institutional X12N 837 X096 Dental X12N 837 X097 Claim Attachment X12N 277 & 275 + HL7 Enrollment/Disenrollment X12N 834 X095 Eligibility X12N 270 & 271 X092 Premium Payment X12N 820 X061 Payment & Remittance Advice X12N 835 X091 First Report of Injury X12N 148 X086 Health Claim Status X12N 276 & 277 X093 Referral X12N 278 X094

20. What is Sybase’s HIPAA Accelerator Standards • Reflect the structure specified in the HIPAA Implementation Guides for each transaction • Segment and loop sequence • Segment and loop occurrences • Segment and loop requirements

21. Transaction Structure

22. What is Sybase’s HIPAA Accelerator Standards • Data element requirements

23. Data Element Requirements

24. What is Sybase’s HIPAA Accelerator Compliance Maps • Verify the structure for each transaction specified in the HIPAA Implementation Guides • Segment and loop sequence • Segment and loop occurrences • Segment and loop requirements

25. What is Sybase’s HIPAA Accelerator Compliance Maps • Verify data element conditions

26. Data Element Conditions

27. What is Sybase’s HIPAA Accelerator Compliance Maps • Verify code lists as defined in the HIPAA Implementation Guides

28. Code Lists

29. What is Sybase’s HIPAA Accelerator Compliance Maps • Contain gray box rule logic

30. Gray Box rules

31. What is Sybase’s HIPAA Accelerator Also contains: • Business Case Scenarios • Test Data

32. Business Case Scenario

33. HIPAA Accelerator Jump Starts HIPAA EDI Implementations Topics • Sybase product overview • Overview of Health Insurance Portability and Accountability Act • What is Sybase’s HIPAA Accelerator • How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations

34. How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations Map Development: • Provides standard definitions for each transaction per the HIPAA implementation guides • Identifies required, situational and not used data elements for each transaction • Provides X12 based code lists with the values specified in the HIPAA implementation guides for each transaction

35. How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations Compliance Maps can be easily modified: • To add site specific edits • To add external code list lookups

36. How Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations In production: • Compliance maps to validate X12 data against the HIPAA implementation • Generation of the X12 997 transaction to report results back to the originator • The ability to process only the data that passes compliance maps through data transformation maps

37. Sybase’s HIPAA Accelerator jump starts HIPAA EDI Implementations Questions