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278 Notification Transaction

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Title: 278 Notification Transaction


1
278 Notification Transaction
  • April 2008

2
UHC Notification Program
  • UnitedHealthcare 24 hour notice of inpatient
    admission
  • Looking to get notice of inpatient admission 7
    days per week
  • Looking to improve patient outcomes through care
    coordination
  • Working with hospitals, vendors, clearinghouses
    to create path for automated notification to
    replace cumbersome phone and fax solutions

3
Notification Program Approach
  • Approach to notification automation
  • Create direct connectivity capability for real
    time and batch Connectivity Director
  • Coordinate development with EDI vendors through
    Ingenix EDI Solutions (UHGs clearinghouse)
  • Pilot transaction capability with selected
    hospitals in April-May 2008
  • Expand availability of transaction in Q4 2008

4
Issues for choice of Notification EDI
  • What is the impact of HIPAA?
  • What standard to use, if any?
  • What is the impact on facilities and vendors?

5
What is the impact of HIPAA?
HIPAA Compliance
HIPAA Rules for 278 Referral and
Authorization
  • HIPAA Transaction concerns
  • Covered Entity health plans, providers,
    clearinghouses and their business associates
  • Covered Business Events
  • Usage of HIPAA transactions rules and
    limitations

Subpart MReferral Certification
and Authorization 162.1301 Referral
certification and authorization transaction. The
referral certification and authorization
transaction is any of the following
transmissions (a) A request for the review of
health care to obtain an authorization for
the health care. (b) A request to obtain
authorization for referring an individual to
another health care provider. (c) A response to a
request described in paragraph (a) or paragraph
(b) of this section. 162.1302 Standard for
referral certification and authorization. The
Secretary adopts the ASC X12N 278Health Care
Services Review Request for Review and
Response, Version 4010, May 2000,
Washington Publishing Company, 004010X094 as the
standard for the referral certification and
authorization transaction. The implementation
specification is available at the addresses
specified in 162.920(a)(1).
6
HIPAA EDI conclusions
  • UHC is a covered entity
  • Notification is not a business event listed under
    HIPAA
  • A separate X12 Format is available for
    Notifications
  • Conclusion The HIPAA transaction rules and
    constraints do not govern this business event

7
What standard to use, if any?
  • Business Requirements for inpatient notification
    are similar to pre-certification/pre-authorization
    transaction under HIPAA
  • X12 has multiple Implementation Guides for 278
    transaction
  • Proprietary transactions have been created by
    other health plans and entities for this event
  • Conclusion There are multiple formats that could
    be used for this event

8
Choice of 278s
  • Multiple versions of 278 exist
  • 278 Healthcare Services Review and Response
  • This was chosen by HIPAA to cover HIPAA business
    events only
  • Authorization (including Pre-Certification) and
    Referral only
  • This version currently being used to accommodate
    UHC inpatient notifications for pilot program
  • 278 Healthcare Services Review Notification and
    Acknowledgement
  • This is a separate non-HIPAA-mandated
    Implementation Guide available for Notifications
  • Designed by X12 specifically for notification
    events not covered under HIPAA
  • This version recommended by X12 to CMS for
    adoption by HIPAA in future
  • This version will be long term format planned for
    Q4 2008
  • 278 Healthcare Services Review Inquiry/Response
  • A separate non-HIPAA-mandated version available
    for status information
  • Used to inquire as to the status of a previously
    submitted notification referral, or authorizations

9
What is the impact on facilities and vendors?
  • The 278 HIPAA transaction is not widely adopted
    as yet
  • Few clearinghouse vendors report significant
    volume for this transaction
  • The few vendors and health plans using the 278
    use the HIPAA version Healthcare Services
    Request for Review and Response (004010x094a1)
  • Proprietary transactions are expensive to build,
    and generally work only for one trading partner
    relationship
  • Conclusion Use the HIPAA format for pilot sites
    to possibly utilize what is in place for vendors
    and facilities today.

10
Final Choice and Roadmap Step 1
  • UHC Inpatient Notification project team has
    chosen to use the HIPAA version as the basis for
    the notification transaction meet the immediate
    need for a pilot Notification transaction
  • Advantages
  • HIPAA 278 Map already in use at UHC for HIPAA
    referrals and authorizations
  • 278 format can supply 99 of the data needs for
    this one particular notification
  • Same internal UHC systems already use the HIPAA
    278 for authorization

11
Final Choice and Roadmap Step 2
  • Migrate to the X12 Healthcare Services
    Notification and Acknowledgement (005010x216) for
    Q4 2008
  • Advantages
  • This transaction more flexible in long term for
    multiple notification events provides
    capability for two-way notification
  • Likely to be chosen if/when HIPAA chooses to
    cover notification business event (already
    recommended by X12 to CMS)
  • Promotes the use of standardization in healthcare
  • Requires minimal mapping change from HIPAA
    version
  • Provides a clearer option for the long term no
    confusion with HIPAA transaction

12
Appendix
  • X12 Committee Descriptions -Transaction Usage
    for X12 278 Transactions

13
278 Authorization (Pre-certification) and Referral
  • X12 278 Healthcare Services Request for Review
    and Response (taken from HIPAA-required version
    004010x094a1 Guide)
  • 1.3 Business Use and Definition
  • The 278 has the flexibility to accommodate the
    exchange of information between
  • providers and review entities. This section
    introduces the business events and
  • processes associated with the 278.
  • 1.3.1 Business Events Supported in this Guide -
  • Request and Response
  • This implementation guide covers the following
    business events.
  • ? admission certification review request and
    associated response
  • ? referral review request and associated response
  • ? health care services certification review
    request and associated response
  • ? extend certification review request and
    associated response
  • ? certification appeal review request and
    associated response
  • (NOTE HIPAA defines certification as the event
    which authorizes healthcare services, when a
    health plan requires prior authorization for
    services)

14
278 Notification (non-HIPAA)
  • X12 278 Healthcare Services Notification and
    Acknowledgement (taken from current version 5010
    Guide)
  • 1.4 Business Usage
  • The 278 has the flexibility to accommodate the
    exchange of information between
  • providers and review entities. This section
    introduces the business events and
  • processes associated with the 278.
  • 1.4.1 Business Events Supported in this Guide
  • This implementation guide supports the following
    health care service review business
  • events.
  • 1.4.1.1 Notification
  • The 278 can be used to send unsolicited
    information among providers, payers,
  • delegated UMO entities and/or other providers.
    This information can take the
  • form of copies of health service reviews or
    notification of scheduled, or the beginning
  • and end of treatment. A participant who is the
    recipient of the information
  • may acknowledge they received the data, or reject
    the data due to specific application
  • layer processing, but may not respond with any
    review decision outcome.
  • This implementation guide supports the following
    categories of notifications.
  • Advance Notification for
  • ? scheduled inpatient admissions

15
General Process Flow
278 Referral Authorization With Notification data
Hospital System
UHC FTP
B2B Mercator ETL Translate Record
278 Notification
Needed to support Industry Standard 278
Notification
278 Notification Response
Real-time or Batch
single/multiple admits
UHG Clinical Systems
CCS
B2B Gateway
278 Notification Response
CareOne
Hospital Registrar
Look up Eligibility Look up Provider
Hospital sends notification to UHC EDI FTP UHC
Sends back a 278 Notification Response
Hospital ADT system creates EDI X.12 278
Notification Record
UHC B2B Translates the received record into our
internal format
Eligibility confirmed record routed to internal
Clinical system which provides a response
16
UHC 278 Notification Companion Guide
  • Differences from HIPAA Authorization 004010x094a1
    IG to UHC 278 Notification Companion Guide
  • No violations of HIPAA 278 structure
  • Some situational elements are required for
    inpatient event
  • Patient Condition (when diagnosis is unavailable)
    is entered into the MSG segment
  • Admission Time is optional, and can be entered in
    the MSG segment

17
Companion Guide Notes
  • Sample from Companion Guide

18
Companion Guide Notes
Sample from Companion Guide
19
Future 278 Considerations
  • Review 278 Notification and Acknowledgement for
    usability since it is not widely used, there
    may be bugs or shortcomings that need to be
    reported to X12
  • Become more involved in supporting 287
    Notification at X12 meetings
  • Need to determine if Admission Time is critical
    to business need, and incorporate into
    transaction
  • Review applicability of 278 Inquiry and Response
  • Not designed for interaction with 278
    Notification?
  • Status of a notification has not been clearly
    defined in the implementation guide
  • Time is optional, and can be entered in the MSG
    segment
  • Evaluate 278 Notification response transactions
    in light of WEDI whitepaper on acknowledgements

20
Questions
  • Questions?
  • Feedback?
  • Suggestions?
  • ALL ARE WELCOME!
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