Electronic Claims Attachment Electronic Claims Attachment Pilot - - PowerPoint PPT Presentation

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Aug 06, 2023 374 likes •543 views

Electronic Claims Attachment Electronic Claims Attachment Pilot Pilot Presented by: Maria Ward Member, WEDI Advisory Task Group on Empire Pilot Co-Chair, HL7 Attachments Special Interest Group Co-Chair, WEDI Claims Attachments WG Pilot

SLIDE 1

Electronic Claims Attachment Electronic Claims Attachment Pilot Pilot

Presented by: Maria Ward Member, WEDI Advisory Task Group on Empire Pilot Co-Chair, HL7 Attachments Special Interest Group Co-Chair, WEDI Claims Attachments WG

SLIDE 2

Pilot Overview Pilot Overview

Problem: Extremely manual paper-based process that increases provider Days Receivable Outstanding and contributes to high claims processing costs for payers Solution: Standards-based solution for exchanging data electronically

SLIDE 3

Pilot Overview Pilot Overview

CMS Pilot

EMS and WEDI proposal for pilot EMS funded as a Medicare fee for service

contractor

Funding was limited to a proof of concept

and not a working model

Pilot information available at the EMS

website: www.empiremedicare.com

SLIDE 4

Purpose Purpose

Demonstrate the use of standards in the exchange of electronic claim attachments between a payer and providers

Request X12 277 Version 4050 Response X12 275 Version 4050 Response HL7 CDA Release 1.0 LOINC

SLIDE 5

EMS Selects Participants EMS Selects Participants

EMS vendors to assist with the payer end of the Pilot

Claredi ViPS

Practice management vendor selected

NextGen

Several providers selected to participate

Montefiore Hospital – Part A and

Part B

Memorial Sloan Kettering Cancer

Center –Part A

Horizon Eye Care – Part B
Hudson Eye Physicians – Part B
Urological Surgical – Part B

SLIDE 6

Objective Objective

277 Transaction Successfully used by provider in place of paper request 275/CDA

Provider able to generate using

the medical record information at their facility/office

Payer able to translate and

process

Medical Claims Examiners Consistent claim adjudication decisions based upon the electronic attachment

SLIDE 7

Scope Scope

Medicare shared system modifications would not

be made.

Solicited 275 only Attachment types representing highest volume

Rehabilitation Services Clinical Reports

All received X12 275/CDAs will be processed as

HDV

Pre-pay medical review requests only

SLIDE 8

275 Payer Approach 275 Payer Approach

X12 275/CDA files received by EMS and

transmitted to Claredi for processing

Claredi unbundling process used to separate

the X12 275/CDA into component parts

Validation of the X12 275/CDA file based

n the standards

Claredi produced several files for each valid

X12 275/CDA file

SLIDE 9

Benefits Benefits

Providers will see benefits by:

Reduced processing time by control receipt of the

277

Reduce review by clinicians result in lower

processing costs.

Reduced untimely denials with the automated

response.

SLIDE 10

Benefits Benefits

Payer return on investments

Eliminate paper request mailing – Reduce costs -

$25,000

Eliminate paper attachments handling – Reduce

costs - $86,000

Reduce appeals and adjustments from untimely

denials – Potential savings - $143,000

SLIDE 11

Pilot Findings Pilot Findings

Demonstrated that the standards were successful

in the exchange of both the request and the response.

Need to supplement X12 expertise with HL7,

XML, MIME technical and clinical expertise.

Discovered minor discrepancies in the standards

documentation.

Six Claims Attachments standards met 86% of the

Medicare medical review business needs.

Claim payment determination consistent with

paper attachments.

SLIDE 12

Pilot Findings Pilot Findings

Data included on the electronic attachment was

equal to the paper attachment, no more no less.

Full medical records were not exchanged. Institutional providers attachments ranged from 1

to 68 pages and from 2.2 MB to 190 MB in size.

Professional providers attachments ranged from 1

to 4 pages and from .01 MB to 1.3 MB in size.

BIN segments were not greater than 8 MB. 277 request alone is valuable

SLIDE 13

Pilot Findings Pilot Findings

Paper requests not always specific Medical policies not met 100% with

proposed six attachment types

– Will vary across payers

Allows for the exchange of scanned/imaged

documents

SLIDE 14

Next Steps for EMS Next Steps for EMS

Move X12 277 request to production for

EMS Medicare providers.

Assess the X12 275/CDA for production

SLIDE 15

Next Steps for the Industry Next Steps for the Industry

Enhance your HIPAA X12 transaction

knowledge to include claim attachments

Analyze current requests to determine

business requirements

Analyze document storage systems Analyze your ability to integrate financial

and clinical systems.

SLIDE 16

Thank You Thank You

EMS Pilot information is available on the

Empire Medicare Services web site:

http://www.empiremedicare.com/hug/ECAPfiles/ecapindex.htm