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NJ SHORE September 25, 2003 HIPAA Transactions & You Vendor Panel. Pat Hewitt Siemens Medical Solutions Siemens Confidential. Objectives. Provider Readiness Status Siemens Readiness Initiatives & Status Challenges Recommendations. Providers are Ready.

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Nj shore september 25 2003 hipaa transactions you vendor panel

NJ SHORE September 25, 2003HIPAA Transactions & YouVendor Panel

Pat Hewitt

Siemens Medical Solutions

Siemens Confidential


  • Provider Readiness Status

  • Siemens Readiness Initiatives & Status

  • Challenges

  • Recommendations

Providers are ready
Providers are Ready

  • “We received our first remittance within two weeks of submitting our first live claim to Medicaid,” said Peter Courtway, CIO, Danbury Hospital. “Our claims were adjudicated as expected and the entire process was smooth and seamless. Quicker payment on those claims means major improvements to our revenue cycle, so we’re pleased to be up and running ahead of the game.”

  • “Hartford hasn’t experienced one denied claim since we went intoproduction with the 837,” adds John Matakaetis, Director of Patient Accounting, Hartford Healthcare.

  • “Receiving payment so quickly is almost a miracle in this line of work,” adds Donna Small, MSO Systems Administrator at Health First. “We have some very happy people around here – and it’s nice to see the fruits of our collective labor paying off with such positive outcomes.”


  • Data Gap Analysis

  • Remediation

  • Testing

  • Implementation

We're All in This Together!!

Data Gap Analysis (DGA)

The Claim DGA, Two pre-requisites:

  • Comprehensive understanding of how your current processes work that provide data to and support your billing process

  • Comprehensive understanding of the relevant Implementation Guides: 837I & 837P

    • Purpose of each transaction

    • How each transaction works

    • Required & situational data elements

    • Required code sets/values

Data Gap Analysis

The DGA Identifies:

  • New required & situational data elements based on the services you provide (continues after 10/16)

  • Current processing flow gaps

  • Identification of NEW workflows, procedures, and/or data collection processes

  • Masterfile changes (new code sets, charge master changes)

  • System set up requirements: decision tables, master files, billing options

Data Gap Analysis

About Payer Companion Guides:

  • Most Companion Guides are available now. They contain:

    • Additional Payer specific requirements

    • Edits that will ease claims adjudication with that payer

    • Additional Payer billing instructions

  • All their requirements must conform to the National Guides – they can’t require anything beyond the National Guides and they can’t reject a claim if it has more data than they want.

Data Gap Analysis


  • A customized spreadsheet identifying if/how you currently populate required and situational fields, which fields, based on your business, you will need to populate and how these will need to be set up to bill properly

  • A Remediation Plan identifying the specific work that will be needed to build HIPAA compliant claims

    Average time to complete a DGA for either the 837I or 837P is between two and three weeks


  • Data Gap Analysis

  • Remediation

  • Testing

  • Implementation


Remediation is the work of addressing your data gaps:

  • Set up new, needed data elements in the system

  • Implement procedures for capturing the data, including identifying where data will be captured and training staff to obtain and enter new data

  • Master file changes

  • System set up based on payer Companion Guides


  • Data Gap Analysis

  • Remediation

  • Testing

  • Implementation



  • Most providers appear to be either testing 837 transactions internally or externally with third party testing tools, clearinghouses or with payers

  • Certification Agency testing – a good idea if Payers aren’t ready when you are.

  • Providers that have used third party testing tools and have done DGA appear to be further along in the process

Prepare for testing
Prepare for Testing

  • Create Test Plans and prepare for testing

    • Identify business functions and billing scenarios

    • Understand Payer requirements (volume, scenarios, real or test data)

    • Create test patients or identify accounts for re-bill

  • Success in prep work will reduce rework in testing phase

  • If using your Test system make every effort to Simulate Production—decision tables, master files, patient data

  • Document all Test system changes made while testing

  • Plan to update Production with all Test system updates

Testing options
Testing Options

  • Through Testing Certification Organization

  • Through HIS Vendor

  • Through Claims Clearinghouse

  • Directly to Payer

Vendor initiatives
Vendor Initiatives

HIPAA Support

  • HIPAA Central (1Q00); HIPAA Central-Customers Only (4Q00)

  • HIPAA Readiness National Kickoff w/CMS, BCBSA (3Q00)

  • Statement of Direction, HIPAA U (1Q00, ongoing)

  • Planning bulletins, Customer memos (4Q99, ongoing)

  • HIPAA Security Summit (4Q99), Seminars (1Q00), Webcasts (4Q00, ongoing)

  • Transaction support Claredi Certified (2Q02, ongoing)

  • Successful customer/payer tests (4Q02, ongoing)

Vendor initiatives1
Vendor Initiatives

HIPAA Support

  • HIPAA Ask The eXperts “RadioShow”

  • Payer Testing Status Updates

  • HIPAA Readiness Executive Briefing Kit (& Website)

  • Product-specific Readiness Report Cards

  • Product-specific Readiness Checklists

  • Customer Success Bulletins

  • "Putting it all Together" Transactions Workshops

  • Refreshed HIPAA Central

  • HIPAA ExcelerateTM (including payer testing help!!!)


  • Data Gap Analysis

  • Remediation

  • Testing

  • Implementation


  • Cutover and Review acceptance/rejection reports

  • Re-adjust process, system decision tables

  • Divide and conquer

  • CMS Guidance on Compliance


Contingency Planning

  • CMS Guidance, Complaint driven process (don’t tell, don’t ask)

    • Trading partner mutually agreeable solutions, okay for transition

    • Must finish the transition

    • Contingency plans to ensure payment during transition are okay

  • Demonstrate “Good Faith” efforts – you will need evidence

    • Testing with some trading partners

    • Implementation with some trading partners

    • Testing and Certification evidence

  • Testing payer requirements in absence of direct payer testing

    • Third party testing can accelerate implementation - show due diligence

    • Certification will reduce testing requirements with many payers

  • Be prepared to run dual solutions, best approach least impact

    • Claims 837 and Legacy formats e.g. NSF, 1500, UB92


Our “Best Guesses” about Oct. 16, 2003:

  • Very few payers will have more than 837s, 835s and 270/271 supported day 1. There are lots and lots of transactions

  • Some Medicaids will still rely on local codes and may require current processes for some time after October 16.

  • Payers will be committed to paying every claim possible – even if it’s not completely compliant.

  • Cash flow impact minimized if you are making “good faith” efforts!

Siemens status
Siemens Status

  • Claims—837P, 837I, COB GA

  • Claims Dental GA

  • Claim Status TBD

  • Remittance GA

  • Eligibility GA

  • Referrals & Authorizations GA