HCLT Whitepaper: HIPAA 5010 – Systems Impacts

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These new versions address a variety of unmet business needs and concerns that were not thoroughly analyzed during earlier versions.
The implementation of HIPAA 5010/ D.0 would require health plans to bring substantial changes to its business policies, processes and systems that submit claims, receive remittances, exchange claim
status, maintain membership, pricing details etc.

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HCLT Whitepaper: HIPAA 5010 – Systems Impacts

  1. 1. February 2010HIPAA 5010 – Systems Impacts
  2. 2. HIPAA 5010 – Systems Impacts | February 2010Current ScenarioThe Center for Medicaid and Medicare Services (CMS) requires thehealth plans to adopt modifications to the HIPAA electronic transactionstandards published on Jan 16, 2009, for exchanging healthcare specificadministrative and financial transactions. The current version adoptedby the industry is ASC X12 Version 4010A1 for healthcare transactionsand NCPDP Version 5.1 for pharmacy transactions. Health plans arenow required to implement recently published HIPAA version 5010and NCPDP D.0 standards by Jan 1, 2012.These new versions address a variety of unmet business needs andconcerns that were not thoroughly analyzed during earlier versions.The implementation of HIPAA 5010/ D.0 would require healthplans to bring substantial changes to its business policies, processesand systems that submit claims, receive remittances, exchange claimstatus, maintain membership, pricing details etc. HCL with its wide IT service portfolio uses ediTTM 5.1 solutionto help the health plans transition to HIPAA 5010 standards.HIPAA 5010 Changes SummaryThere are more than 3500 individual changes that have to be implementedacross the enterprise. These changes are complex and require health plansto upgrade their systems, processes, databases etc. Figure 1.1 demonstratesthe volume of changes in HIPAA version 5010 transactions.Changes in version 5010 can be categorized into four categories:Front matter, Technical improvements, Structural and Data contentchanges. HCL has studied the 5010 implementation guides in detailand evaluated the changes across different transactions. Based uponthe complexity associated with each change, HCL has analyzed itsimpact on different processes and applications across health plan.Table below describes the summary of changes between HIPAA4010A1 and 5010 for each transaction type. Figure 1.1 Figure 1.2© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  3. 3. HIPAA 5010 – Systems Impacts | February 2010There are many modifications to the physical components of thetransaction which would lead to system enhancements, database changesand report changes. Impact Changes System Impact Application changes Field length expansion Business logic change Change in screen inputs New elements Database changes Addition/deletion of elements Code value changes Field length expansion Interfaces User interface changes Modification to EDI interfaces External applications interfaces Report changes New fields Report layout Data Impact Data conversion Other Impact Business policies and processes Dual standard support during transitionHIPAA 5010 – Systems Impact5010 changes have impact on policies, processes and applications acrossa health plan. HCL’s understanding of the health plan’s IT landscapefacilitates the identification of impact of 5010/ D.0. Impact analysis outputdetails out the modifications required for seamless implementation ofchanges in systems, processes and applications. This ensures a smoothtransition to HIPAA 5010/D.0 with minimal disruption.Business Functions EntitiesHCL has done the initial assessment for each HIPAA transactiontype for identifying the impacted business areas and entities acrosshealth plans. In the table below, “ ” represents the impacted businessareas and entities across all transaction types and “ ” represents thenon impacted areas and entities. X12 Transactions 270 271 278 837 835 276 277 834 820 Electronic data interchange Electronic Medical Records Authorization Management Electronic Commerce Federal Regulations Management Data Analytics Member Benefits NCQA AccrediationBusiness Areas Claims adjudication Claims payable Providers network Management Provider Reimbursement Recovery and settlement Fee Schedule Utilization Management Case Management Accounting Member Services Accounts receivable© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved. Member Billing Affiliation
  4. 4. Claims payableBusiness Providers network Management Provider ReimbursementHIPAA 5010 – Systems Impacts | February 2010 Recovery and settlement Fee Schedule Utilization Management X12 Transactions Case Management 270 271 278 837 835 276 277 834 820 Accounting Electronic data interchange Member Services Records Electronic Medical Accounts receivable Authorization Management Member Billing Electronic Commerce Federal Regulations Management Affiliation Data Analytics Provider Payer Benefits Member NCQA Accrediation AdmissionImpacted Entities Areas Claims adjudication Employer Claims payable Member Business Providers network Management Address Provider Reimbursement Group Practice Service and settlement Recovery Fee Schedule Claim Information Contract Management Utilization Case Management Authorization Accounting Receipt Information Member Services Invoice Info Accounts receivable Claim Check Member Billing Procedure Drug Detail Affiliation Provider PayerApplication components Admission EmployerTable below describes the impact of HIPAA 5010 changes on Memberhealth plans application components. This is described using 270Impacted Entities Addresstransaction as an example, this is sent from providers to health plans Group Practiceto enquire about the health care benefits and eligibility associated Servicewith a subscriber or dependent. Claim Information ContractHCL has similar analysis done for all the other HIPAA 5010 Authorizationmandated Information Receipt transactions. Invoice Info Claim Check HIPAA Element Element Segment Description Data Migration / Update Procedure 5010 Identifier Description Database Changes External Interface Business Logic Changes Detail Drug Reports UI Segment HI Subscriber       added Healthcare Diagnosis Code AMT Subscriber Spend       Down Total Billed Amount HI Dependent       Healthcare Diagnosis Code Segment PER Info receiver contact       deleted info Change BHT03 Reference Beginning of       in Field Identification hierarchical Length transaction NM103 Name Last or Information Source       Organization Name Name NM104 Name First Information Source       Name© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  5. 5. HIPAA 5010 – Systems Impacts | February 2010 HIPAA Element Element Segment Description Data Migration / Update Database Changes 5010 Identifier Description External Interface Business Logic Changes Reports UI Change NM103 Name Last or Info Receiver Name       in Field Organization Length Name NM104 Name First Info Receiver Name       REF02 Reference Info Receiver Addn       Identification identification PRV03 Reference Info receiver provider       Identification info TRN02 Reference Subscriber Trace       Identification Number TRN03 Reference Subscriber Trace       Identification Number NM103 Name Last or Subscriber Name       Organization Name NM104 Name First Subscriber Name       REF02 Reference Subscriber add       Identification identification PRV03 Reference Provider Information       Identification REF01 Reference Subscriber add info       Identification Qualifier TRN02 Reference Dependent Trace       Identification Number TRN04 Reference Dependent Trace       Identification Number NM104 Name Last or Dependent Name       Organization Name NM105 Name First Dependent Name       REF02 Reference Dependent Add       Identification Identification PRV03 Reference Provider Information       Identification REF02 Reference Dependent Additional       Identification Info Code ISA11 Interchange Interchange Control       Value Control Header Added/ standards ID Deleted ISA12 Interchange Interchange Control       Control Version Header No GS01 Functional Functional Group       Identifier Code Header GS08 Version/ Functional Group       Release/ Header Industry identifier code BHT02 Transaction Set Beginning of       Purpose Code hierarchical transaction BHT06 Transaction Beginning of       Type Code hierarchical transaction© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  6. 6. HIPAA 5010 – Systems Impacts | February 2010 HIPAA Element Element Segment Description Data Migration / Update Database Changes 5010 Identifier Description External Interface Business Logic Changes Reports UI Code PRV02 Reference Info receiver provider       Value Identification info Added/ Qualifier Deleted NM108 Identification Subscriber Name       Code Qualifier REF01 Reference Subscriber add       Identification identification Qualifier PRV01 Provider Code Provider Information       DTP01 Date Time Subscriber Date       Qualifier EQ01 Service Type Subscriber Eligibility/       Code Benefit enquiry Info EQ03 Coverage Subscriber Eligibility/       Level Code Benefit enquiry Info EQ04 Insurance Type Subscriber Eligibility/       Code Benefit enquiry Info III01 Code list Subscriber Eligibility/       Qualifier Code Benefit add enquiry Info III02 Industry Code Subscriber Eligibility/       Benefit add enquiry Info DTP01 Date/Time Subscriber Eligibility/       Qualifier Benefit Date DTP03 Date Time Subscriber Eligibility/       Period Benefit Date REF01 Reference Dependent Add       Identification Identification Qualifier PRV01 Provider Code Provider Information       PRV02 Reference Provider Information       Identification Qualifier DTP01 Date/Time Dependent Date       Qualifier EQ Service Type Dependent Eligibility/       Code Benefit enquiry Info EQ03 Coverage Dependent Eligibility/       Level Code Benefit enquiry Info EQ04 Insurance Type Dependent Eligibility/       Code Benefit enquiry Info III01 Code List Dependent Eligibility/       Qualifier Code Benefit add enquiry Info Element DTP01 Date Time Dependent Eligibility/       Added Qualifier Benefit Date DTP03 Date Time Dependent Eligibility/       Period Benefit Date III01 Industry Code Dependent Eligibility/       Benefit add enquiry Info© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  7. 7. HIPAA 5010 – Systems Impacts | February 2010 HIPAA Element Element Segment Description Data Migration / Update Database Changes 5010 Identifier Description External Interface Business Logic Changes Reports UI Element ST03 Implementation Transaction Set       Added Convention Ref Header NM112 Name Last or Information Source       Organization Name Name NM112 Name Last or Info Receiver Name       Organization Name N407 Country Info receiver city/       Subdivision state/ zip code Code NM112 Name Last or Subscriber Name       Organization Name N407 Country Subscriber city/ state/       Subdivision zip code Code DMG10 Code List Subscriber       Qualifier Code Demographic Information DMG11 Industry Code Subscriber       Demographic Information EQ02- Product/ Subscriber Eligibility/       08 Service ID Benefit enquiry Info EQ05 Composite Subscriber Eligibility/       Diagnosis Benefit enquiry Info Code Pointer NM112 Name Last or Dependent Name       Organization Name N407 Country Dependent State/       Subdivision City/Zip Code Code DMG10 Code List Dependant       Qualifier Code Demographic Information DMG11 Industry Code Dependant       Demographic Information EQ02-8 Product/ Dependent Eligibility/       Service ID Benefit enquiry Info EQ05 Composite Dependent Eligibility/       Diagnosis Benefit enquiry Info Code Pointer Usage NM103 Name Last or Information Source       Change Organization Name Name NM103 Name Last or Info Receiver Name       Organization Name N402 State or Info receiver city/       province code state/ zip code N403 Postal Code Info receiver city/       state/ zip code© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  8. 8. HIPAA 5010 – Systems Impacts | February 2010 HIPAA Element Element Segment Description Data Migration / Update Database Changes 5010 Identifier Description External Interface Business Logic Changes Reports UI Usage PRV02 Reference Info receiver provider       Change Identification info Qualifier PRV03 Reference Info receiver provider       Identification info N401 City Name Subscriber receiver       city/ state/ zip code PRV02 Reference Provider Information       Identification Qualifier PRV03 Reference Provider Information       Identification EQ04 Insurance Type Subscriber Eligibility/       Code Benefit enquiry Info AMT02 Monetary Subscriber spend       Amount down amount N401 City Name Dependent City/       State/ Zip code PRV01 Provider Code Provider Information       PRV02 Reference Provider Information       Identification Qualifier PRV03 Reference Provider Information       Identification EQ03 Coverage Dependent Eligibility/       Level Code Benefit enquiry Info EQ04 Insurance Type Dependent Eligibility/       Code Benefit enquiry Info Name ISA11 Interchange Interchange Control       Change Control Header standards ID BHT04 Date Beginning of       hierarchical transaction INS Subscriber Subscriber       Relationship Relationship INS06 Medicare Plan Subscriber       Code RelationshipHCL has a complete knowledge base of impacted policies,processes, applications and the impacted entities in a health plan.This knowledge will enable faster understanding of the existinglandscape and transition to desired TO-BE state meeting thefederated timelines.© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  9. 9. HIPAA 5010 – Systems Impacts | February 2010Why HCL? TM• HCL ediT 5.1 solution covers methodologies for Enterprise discovery, Impact Analysis, System enhancements, Testing and Transition Support for HIPAA 5010 and NCPDP D.0• Solution architects and consultants experienced in X12N 4010A1/5010 and NCPDP D.0 standards• Existing knowledge base for impacted policies, business processes, work flows, people, entities and fields• Testing toolkit READY; compliance and trading partners• Center of Excellence for leading B2B and EDI platforms• Subject matter experts in Payer and Provider business processes• Dedicated HIPAA security and privacy (GRC) consulting practice• HCL has a HIPAA security and privacy consulting practice• Certified consultants in HIPAA from HIPAA Academy, USA – Certified HIPAA Professional• Footprint across major healthcare Clients including: One of the largest Blue Cross Conglomerates, Regional Health Plan, Leading Diagnostic Company, Leading HMOAuthors Narender Dureja is Practice Director – Healthcare at HCL Technologies Ltd. He is a certified professional in hospital information management systems. Narender had been involved in crafting solutions for different industry verticals for the last 20 years. He currently drives the HIPAA 5010 solution at HCL. Mahima Bahri is Senior Consultant – Healthcare at HCL Technologies Ltd. She is a Certified HIPAA Professional. She has worked on multiple areas within healthcare domain and is currently engaged in building HIPAA 5010 solution for HCL.© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.
  10. 10. 10HIPAA 5010 – Systems Impacts | February 2010ABOUT HCLHCL TechnologiesHCL Technologies is a leading global IT services company, workingwith clients in the areas that impact and redefine the core of theirbusinesses. Since its inception into the global landscape after itsIPO in 1999, HCL focuses on ‘transformational outsourcing’,underlined by innovation and value creation, and offers integratedportfolio of services including software-led IT solutions, remoteinfrastructure management, engineering and RD services andBPO. HCL leverages its extensive global offshore infrastructureand network of offices in 26 countries to provide holistic, multi-service delivery in key industry verticals including FinancialServices, Manufacturing, Consumer Services, Public Services andHealthcare. HCL takes pride in its philosophy of ‘Employee First’which empowers our 55,688 transformers to create a real valuefor the customers. HCL Technologies, along with its subsidiaries,had consolidated revenues of US$ 2.5 billion (Rs. 11,833 crores),as on 31st December 2009 (on LTM basis). For more information,please visit www.hcltech.comAbout HCL EnterpriseHCL is a $5 billion leading global Technology and IT Enterprisethat comprises two companies listed in India - HCL Technologies HCL Infosystems. Founded in 1976, HCL is one of India’soriginal IT garage start-ups, a pioneer of modern computing, anda global transformational enterprise today. Its range of offeringsspans Product Engineering, Custom Package Applications,BPO, IT Infrastructure Services, IT Hardware, SystemsIntegration, and distribution of ICT products across a wide rangeof focused industry verticals. The HCL team comprises over60,000 professionals of diverse nationalities, who operate from26 countries including over 500 points of presence in India. HCLhas global partnerships with several leading Fortune 1000 firms,including leading IT and Technology firms. For more information,please visit www.hcl.in© 2010, HCL Technologies. Reproduction Prohibited. This document is protected under Copyright by the Author, all rights reserved.

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