HIPAA COW Eligibility Workgroup

1
HIPAA COW Eligibility Workgroup

• October 8, 2004 Fall Conference
• Presented By
• Chris Duprey, Vice President and Co-Owner
• CARIS Innovation, Inc.

2
EDI Eligibility Sub-Group Goals and Objectives

• Identifying current eligibility verification
  procedures used by providers/health plans
• Identifying the data elements and procedures
  important to the providers
• Identifying reasonable and feasible data elements
  for a provider and a health plan to exchange and
• Identifying existing solutions in the industry,
  the concerns surrounding the solutions and the
  success of these solutions from the provider/plan
  perspective.

3
Eligibility Verification Procedures for
Providers/Health Plans

• Time consuming and far from ideal solutions
• Point of service versus point of scheduling
• Exceptions WI Medicaid
• Disclaimers
• No guarantees for payment
• Batch/Real-Time Transactions
• Demand

4
Existing Solutions in the Industry

• Phone verification
• On-line web browsers directly connected to the
  health plan
• Swipe cards with eligibility information
• Clearinghouse solutions utilizing web-browsers

5
Recommended Data Elements

• Voluntary participation
• Minimum recommendation concerns
• Payer versus Provider needs
• Elements needed at the point of service
• Elements needed at the point of scheduling
• Elements needed once the patient has been seen

6
(No Transcript)
7
Future Goals of this Team

• Increased payer participation to solidify the
  voluntary elements
• Discuss search criteria required by the payer
• Strategize solutions to meet both provider and
  payer needs and
• Increased voluntary participation to the
  recommendations of the team

8
How Can You Help?

• Sign up for the EDI Workgroup Sessions
• Contact Chris Duprey at 1.920.434.6804 or
  chris_at_carisinnovation.com if you are interested
  in participating and
• Provide our group with your thoughts and insights
  to the documents weve produced.

9
Conclusion - Eligibility

• Questions?

10
HIPAA COW EDI WorkgroupNational Provider
Identifier (NPI)

• Presented By
• Chris Duprey, Vice President and Co-Owner
• CARIS Innovation, Inc.

11
Purpose of the EDI Workgroup

• Will work with WEDI SNIP to fill in the gaps at a
  regional level
• To provide education to WI covered entities
• To provide recommendations for the implementation
  of NPI not covered by WEDI SNIP

12
Gaps

• What do the payers need in addition to the NPI to
  be able to process the transactions? (i.e.,
  Taxonomy Codes)
• Are there state laws that also cross the NPI?
• What level of granularity will be used for
  enumerating the provider groups? (i.e., by type,
  by facility or by location)

13
Deliverables

• Questionnaire to find out where organizations are
  at with regards to the NPI
• Recommendations regarding Bulk Enumeration
• Recommended timeline for NPI implementation

14
How Can You Help?

• Sign up for the EDI Workgroup Sessions
• Contact Chris Duprey at 1.920.434.6804 or
  chris_at_carisinnovation.com if you are interested
  in participating and
• Collaborate with other healthcare organizations
  to address this change.

15
Conclusion - NPI

• Questions