CORE Participant Orientation Overview October 2005
Agenda • Vision • Phase I Scope • Guiding principles • Operations • Structure • Steering Committee • Work Groups • Voting • Timeline
Vision: Online Eligibility and Benefits Inquiry • Providers will send an on-line inquiry and know: • Which health plan covers the patient * • Whether the service to be rendered is a covered benefit (including copays, coinsurance levels and base deductible levels as defined in member contract) • What amount the patient owes for the service** • What amount the health plan will pay for authorized services** Give providers access to information before or at the time of service... Note: No guarantees would be provided. *Only HIPAA mandated data element; other elements are part of HIPAA, but not mandated ** These components are critically important to providers, but are not proposed for Phase I.
Vision: Online Eligibility and Benefits Inquiry • As with credit card transactions, the provider will be able to submit these inquiries and receive a real-time response*: • From a single point of entry • Using an electronic system of their choice • For any patient • For any participating health plan *CAQH initiative will initially support batch and real-time. … Using any system for any patient or health plan
Vision: What is CORE? Committee on Operating Rules for Information Exchange • A multi-stakeholder initiative organized and facilitated by CAQH to create, disseminate and maintain Operating Rules and to enable healthcare providers to obtain patient-specific information about the patient’s healthcare benefits
CAQH Role: Facilitator Step 4 Step 2 Step 3 Step 1 Establish vision/ charter Bring stakeholders together Build rules and tools for implementation Design structure, process and work plan • Physicians • Hospitals • Other providers • Clearinghouses • Government • Vendors • Non-CAQH health plans • Standard setting organizations • Medical societies
CORE Status • Orientation Meeting held January 11, 2005 • More than 125 representatives from 70 organizations • Payer community • Provider community • Technology vendors • Critical standard-setting organizations • Banking industry • Government agencies (CMS, ONCHIT) • CORE Participants • More than 70 organizations to date • Three Work Groups in process of crafting draft rules
Health Plans Aetna, Inc. Blue Cross Blue Shield of Illinois Blue Cross Blue Shield of Michigan Blue Cross and Blue Shield of North Carolina BlueCross BlueShield of Tennessee CareFirst BlueCross BlueShield Empire Blue Cross Blue Shield Excellus BlueCross BlueShield Health Net, Inc. Health Plan of Michigan Humana, Inc. Independence Blue Cross Kaiser Permanente WellPoint, Inc. Associations / Regional Entities / Standard Setting Organizations America’s Health Insurance Plans (AHIP) ASC X12 Blue Cross and Blue Shield Association (BCBSA) eHealth Initiative Healthcare Financial Management Association (HFMA) Healthcare Information & Management Systems Society (HIMSS) Maryland/DC Collaborative for Healthcare IT National Committee for Quality Assurance (NCQA) National Council for Prescription Drug Programs (NCPDP) Utah Health Information Network (UHIN) Utilization Review Accreditation Commission (URAC) Work Group for Electronic Data Interchange (WEDI) Providers Adventist HealthCare, Inc. American Academy of Family Physicians (AAFP) American College of Physicians (ACP) American College of Radiology (ACR) American Hospice, Inc. American Medical Association (AMA) Greater New York Hospital Association HCA Healthcare Laboratory Corporation of America (LabCorp) Medical Group Management Association (MGMA) Montefiore Medical Center of New York University of Wisconsin Medical Foundation (UWMF) University Physicians, Inc. (University of Maryland) U.S. Oncology Government Agencies Louisiana Medicaid – Unisys Michigan Department of Community Health Michigan Public Health Institute TRICARE United States Centers for Medicare and Medicaid Services (CMS) (Continued on Next Page) Current Participants as of October 2005
Vendors ACS State Healthcare Affiliated Network Services Athenahealth, Inc. Availity LLC Benefitfocus.com, Inc. CareMedic Systems, Inc. EDIFECS Electronic Data Systems (EDS) Electronic Network Systems (ENS) Emdeon First Data Corp. GHN-Online HTP, Inc. InterPayNet MedCom USA MedData Passport Health Post-N-Track ProxyMed Quovadx Siemens / HDX The TriZetto Group, Inc. ViPS (a Division of Emdeon) Other ABN AMRO Accenture Data Processing Solutions Marlabs, Inc. PNC Bank PricewaterhouseCoopers LLP Current Participants as of October 2005 (cont’d)
Phase I Scope: Functionality to be Addressed CORE will begin by drafting rules for the following: • Confirm which health plan covers this patient • Confirm health benefit plan coverage • Confirm Service Type (e.g., major medical, long-term care, laboratory, etc.) • Provide Co-Pay Amount* • Provide Base Deductible* • Provide Co-insurance Level* *Not accumulator, but amount defined in contract Data elements will be based upon HIPAA 270/271 standards. Additional functionalities will be addressed after rules are written for the scope above.
Phase I Scope: Topics for Consideration • Standard and clear definitions and interpretations of the data elements • Roles and responsibilities of all parties • Technical transmission standards and formats • Standards for data timeliness of batch and real-time transactions; encourage market to move to real-time transactions over a specified timeline • Error resolution • Exception processing • Certification • Security • Standardized response reporting
Guiding Principles: Phase I • Participants will work towards achieving CORE’s mission: Providing easier access to consistent, predictable eligibility and benefits information at the point of care • All stakeholders are key to CORE’s success; No single organization, or any one segment of the industry, can do it alone • CAQH serves as the facilitator, while CORE participants draft and vote on the rules • Participation does not commit an organization to adoption • Participating organizations will attempt to maintain consistency with regard to their appointed CORE representatives • Rules will be built upon HIPAA to promote interoperability. CORE will coordinate with other key industry bodies in order to promote interoperability, assure compatibility and avoid redundancy; organizations, e.g. X12 and Blue Exchange • Where appropriate, CORE will address emerging interest in XML • Whenever possible, CORE will use existing market research and rules
Guiding Principles: Phase I (cont’d) • CORE will develop a methodology to measure success and evaluate the market impact of operating rules • As part of finalizing the rules, CORE will provide guidance to stakeholders regarding staff implementation and training needs • Safeguards will be put in place to make sure that a health plan's benefit and payment information is shared only with the requesting provider and is not available to other participating health plans
CORE Steering Committee Other (Ex-officio or Advisor): CAQH: Robin Thomashauer, Executive Director; CMS: Stanley Nachimson, Senior Technical Advisor, Office of E-Health Standards and Services; ASC X12: Donald Bechtel, Co-Chair, X12 Healthcare Task Group (also with Siemens); WEDI: Jim Schuping, Executive Vice President; NACHA: Elliott McEntee, President and CEO
Operations: Work Group Relationships See next page for Work Group Subgroups
Operations: Work Group Meetings • CAQH staff support CAQH, the Steering Committee and its Work Groups. As appropriate, CAQH will retain consultants to provide technical expertise and general support to the Work Groups • NACHA • Technical consultants, e.g. BIG, PwC • Meeting frequency • During the Start-Up phase, there will be monthly Work Group conference calls and at least one in-person meeting • Call schedule will be developed and communicated by CAQH • Meeting materials • CAQH will draft all meeting materials and will make them available on the CAQH website at least 24 hours prior to the call • Minutes will be created after each call/meeting and approved by the Work Group • The Work Group Chairs will approve all meeting materials before they are issued to the Work Group • Participants • The number of Work Group members per participating organization is not limited • All Work Group, CORE and Steering Committee meetings, votes, etc will be based upon the CORE Governing Procedures
Operations: Initial Work Groups Initial Work Groups • Policy Work Group • Rules Work Group • Technical Work Group Potential Future Work Groups • Communications Work Group • Legal and Regulatory Issues Work Group
Policy Work Group(Chair: Bruce Goodman, Humana) • Charge • Identifies policies CORE should develop and makes recommendations to the Steering Committee • Key areas • Standard agreements between participants and CAQH • Certification and auditing • Enforcement • Third party service provider requirements • Granting variances to the rules • Exception processing • Error resolution • Participants • Management-level staff who are able to make policy decisions and are familiar with relevant industry issues as well as overall stakeholder perspectives • Subgroups • Contracting • Certification / Enforcement • Long-Term Vision
Technical Work Group(Chair: Mitch Icenhower, Siemens) • Charge • Determines technical specifications for CORE • Key areas • Connectivity • Security • Technical requirements of organizations initiating and transmitting inquiries • Technical requirements of payers receiving inquiries and generating responses • Test protocols • Role of Network/System/Router (if appropriate) • Participants • Individuals familiar with the technical implications of supporting the exchange of information between trading partners, the various technology solutions and options, and the individual system requirements of their organization, as well as industry requirements • Subgroups • Connectivity / Security • Testing
Rules Work Group (Chair: J. Stephen Stone, PNC Bank) • Charge • Writes the detailed business rules that will be reviewed by the Steering Committee and then voted on by CORE • Ensures CORE and its operating rules are coordinated with standard setting entities such as X12 • Key areas • Detailed requirements of organizations initiating and transmitting inquiries and organizations receiving inquiries and generating responses, including response formats and content • Definition of data terms • Methodology to address member search criteria • Acknowledgements • Response time • Coordination with standard setting entities such as X12 • Participants • Individuals with experience in the business requirements for exchanging information between key trading partners and a background in coordinating specifications with daily operations • Subgroups • Functional Responsibilities • Definitions • Identifiers • Acknowledgements and Reporting
Examples of Resources Available to Work Groups • Reference documentation • Analysis of technical and strategic approaches • Analysis of rules currently adopted or under consideration by regional initiatives, health plans and vendors • Analysis of relevant eligibility transaction standards • Subject matter experts • Range of consultants will help CAQH staff the Work Groups • Health care consultants who are well-versed in different aspects of the eligibility transaction and/or the market trends impacting interoperability • NACHA (an organization that has assisted the financial industry in writing interoperable rules for transactions such as direct deposit)
CORE Meeting frequency In-person meetings approximately twice per year; may hold conference calls between meetings Skill set Represent your organization’s/stakeholder perspective regarding issues being discussed by CORE Communicate with your organization’s leadership regarding CORE’s status as it impacts your organization and whether/when your organization should adopt/challenge the rules If your organization agrees to adopt the rules, oversee, or gain commitment from your organization to assign someone to the implementation process Assign Work Group members CORE Work Groups* Member participation is voluntary Meeting frequency During rule writing phase, monthly conference calls and at least one in-person meeting annually Skill set Different for each Work Group Time and Resource Commitment* *If an individual is appointed to the CORE Steering Committee or to Chair a CORE Work Group, level of time and resource commitment will increase.
Voting: Governing Procedures • Quorum • CORE: 60% of CORE’s voting membership must be present to transact business • Steering Committee and Work Groups: 60% of their respective memberships must be present to transact business • Voting: • Approval of new rules, amendments to rule or amendments to the Governing Procedure requires a super majority (66.67%) of voting CORE members • All other items reviewed by CORE, e.g., administrative issues, or other CORE bodies, require a simple majority (greater than 50%) of present voting members