HIPAA Transaction Testing

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(No Transcript)
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HIPAA Transaction Testing

• Transactions_at_concio.com
• October, 2002
• Julie A. Thompson

Alliance Partners
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Agenda

• HIPAA Transaction Overview A whole new world
• Transaction Analysis The steps in the process
• Transaction Issues and solutions
• Test Planning
• Testing Methodologies
• Example Test Scenarios
• Other considerations
• Building Client Specific Test Data
• Certification/Testing Vendors
• Companion Documents
• The Implementation Process
• Contingency Plans
• Vendor Assessments
• Transaction Implementation

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A True Paradigm Shift
View from within the cave A whole new world

• In Platos famous analogy of the cave, describing
  a tribe of people have lived in a cave from their
  childhood. Their legs and necks chained so that
  they cannot move, and can only see before them.
  They cannot see above, or behind them.
• Yet, if only they would stand up, turn around and
  face the mouth of the cave. A whole NEW world was
  waiting!  
• Plato challenges all people to recognize that
  their perception of the world is limited and a
  simple stretch will open opportunities to visit
  new worlds.

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Changing Technology-Where are we going?
Healthcare Claims History
2004
EDI Outsourcing X12N-XML-eCommerce
1996
HIPAA
X12 Standard adopted by Healthcare
Internet First EDI Standard
1985
NSF electronic Standard
1982
UB-82
First Uniform Institutional Paper Form
HCFA 1500 Professional Claim Point to Point
1975
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Why X12N? How is the new world different?

• Previous Formats
• Claims only
• No Adjustments or Corrections
• Fixed Length Fields
• ? Fixed Length Records
• ? Fixed Number of Line Items
• ? Minimum fields
• ? No Payments

• X12N Format
• Claims, plus other standard healthcare
  transactions
• Allows for Payments, Adjustments, and Corrections
• Variable Length Fields
• ? Variable Length Records
• ? Variable Line Items
• 99 Lines on 837P
• 999 Lines on 837I
• ? Additional details such as provider taxonomy

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The new transaction worldTypes of Covered
Transactions
Providers
Claim 837
Remittance Advice 835
Claims
Payment/Remit Processing
Payors
Employers
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Where do we begin?

• What are the steps?
• What problems can we anticipate?
• How do we solve those problems?
• How do we test the solutions?
• How do implement the solutions?

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HIPAA Transaction TestingWhat are the steps?
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Steps in Transaction Analysis

• Define Transaction Strategy
• Build System, Application Inventory
• Build Maps based on the inventory
• Define Transaction Issues and Solutions
• Build a Document Library
• Trading Partner
• Business Rules
• Code Set Crosswalk
• Reports Gaps, Solutions, Plans, Budget

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How do we implement the transactions?
TpX Manager
CAP
MAP
Cohesion
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Concios Transaction Solutions
Phases
Activities
Tools
Resources
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HIPAA Transaction TestingWhat are the issues
and solutions?
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Remediation Solutions What is the impact?
The Impact
The Issue

• Both Payers and providers must communicate how
  repeating loops, segments, and element will be
  created, processed, and accepted.
• Providers may submit all valid Provider Ids to
  assure payment
• Payers tend to focus on only the require elements
  and the elements used in previous standards like
  NSF, HCFA 1500, and the UB92.
• Providers must utilize the situational and
  optional elements for proper reimbursement.

• Repeating Loops, Segments, Elements
• Up to 999 claim lines
• Unlimited Pay to Providers
• Up to 8 Secondary Provider IDs
• Situational and Optional Elements

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Remediation Solutions What is the impact?
The Issue
The Impact

• Repeating Loops and Segments
• Claims up to 999 lines
• Unlimited Pay to Provider Loop
• Code Set Cross walks
• Maintaining the original line number order.
  Payers, Clearinghouses, and/or Repricers may
  change original line order.

• Payers may choose to split claims to resolve this
  kind of issue. Providers should consider the
  impact on reimbursement and 835 remittance.
• Trading Partners may want to share all code set
  crosswalks.
• Providers require all original lines to be
  returned on the 835 in the original order.

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Remediation Solutions What is the impact?
The Issue
The Impact

• Payers and providers will need to consider adding
  new fields to their systems.
• A Transaction Repository is a valid
  solution and is used by other industries such as
  banking.
• Trading Partners need to communicate the usage of
  each of the 10 different types of Providers. Both
  on the claim level and the line level.

• Handling fields not in core system
• Add field to core system. For example Providers
  Claim ID (CLM01) is required on the 835 payment
  remittance
• 10 types of providers on both the claim header
  and each line time Billing, Rendering, Pay-to,
  Referring, Purchased, Supervising, Ordering,
  Attending, Operating, Other

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Remediation Solutions What is the impact?
The Issue
The Impact

• All original lines must be returned to the
  provider in the original line number order on the
  835 payment remittance.
• Companion documents may be necessary but they
  must adhere to the HIPAA Transaction
  Implementation Guides.

• Multiple references to line numbers
• Provider line number
• Payer line number
• Providers may receive multiple trading partner
  companion documents for health plans.

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HIPAA Transaction TestingHow do we test the
solutions?
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Facing the Testing Challenges
Education
Assessment
Remediation
Testing
Monitoring

• How will your organization determine a Trading
  Partner has passed acceptance testing?
• High potential impact on corporate financials and
  market share
• Complex testing criteria multiple levels,
  systems
• Software changes in multiple systems and vendors
• High volume testing and numerous testing
  scenarios
• Multiplied by Large number of trading partners
• Potential delays in claim and eligibility
  processing
• Tight testing schedule begin by April 16, 2003
• Severe penalties for non-compliance

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Understanding the Basics

• Standard testing methodology terms
• Unit Is a date in the right format?
• System Does a single system pass information
  correctly to another system?
• Integration Does both system process both the
  request and the response correctly?

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Unit, System, and Integration
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Test Plan Design

• Easy Isolation of error source using test phases
• Gradually increasing complexity
• Clear identification of issue solutions

• Comprehensive evaluation of all potential
  situations
• Expect the unexpected
• Work Load Testing for high volume

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Test Phases Identifying source of errors
Phase 1 Translator Only
Phase 2 Single Pass System Testing
Core System
Core System

Payer
Provider
Provider
Payer
Phase 3 Full System Integration Testing
clearinghouse
Core System
Core System
Payer
Provider
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Integration Testing includes

• Testing System Components and Component
  Integration
• API and Middleware Testing
• Testing System Interfaces
• Testing the Integration of Front-Ends with Legacy
  Systems 

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HIPAA Transaction TestingTesting Consideration
for Claims and Claim Payments
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Integration Testing What is it?
Cohesion
X12N Covered Business Processes

• Match original claim to payment
• Validate bundling and unbundling
• Validate claim/payment corrections
• Validate repriced claims
• Validate split claim payments
• Verify Reissued claim handling
• 837 277 comparison

• Monitor Statistical/Encounter or Capitated claims
• Validate Patient Payments
• Estimate Prompt Payment liabilities
• Validate COB Primary processing
• Validate COB Secondary processing
• Validate Dental Predetermination claims
  (estimated claims)

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835 Test Scenario OverviewThe HIPAA Perspective
Covered Business Processes

• Claim adjustments
• Original Claim Payments
• 837 Claim Corrections
• (Demographic/Line Item Adjustments)
• Payment Reversals and Corrections
• Incoming Provider Adjustments
• COB claims (Primary Payer Adjustments)
• Claim Splits
• Line Bundling and Line Deletion
• Claim Predetermination/Estimates
• Patient Payments
• Repriced Claims
• Statistical Encounters

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Original Claim Payments
All original lines returned with Payments
Payer System
Payment
Service Line 1 Paid Service Line 2 Paid Service
Line 3 Paid Service Line 4 Not Paid Service Line
5 Not Paid
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Gateway
Paid Line 1 Paid Line 2 Paid Line 3
835
HIPAA Transaction Relationships
837
Gateway
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
835 Processing
Provider System
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837 Claim (Demographic/Line Item
Adjustments)Corrections should be processed
electronically by both payer and provider to
assure 835 payment remittance can be processed by
the provider.
Phone corrections may not allow for proper
posting of the 835 by the provider
Payer System
X
Original and/or Corrected Payments
Original Claim
Demographic 1 Service Line 1 Service Line
2 Service Line 3 Service Line 4
Demographic 2 Service Line 1 Service Line
2 Service Line 3 Service Line 4 Service Line 5
Gateway
Corrected 837
Demographic 2 Service Line 1 Service Line
2 Service Line 3 Service Line 4 Service Line 5
Duplicate Claim Logic must consider resubmission
as updated claims
Claim Frequency Type Code (CLM05-3) 1 - ORIGINAL
(Admit thru Discharge Claim) 6 - CORRECTED
(Adjustment of Prior Claim) 7 - REPLACEMENT
(Replacement of Prior Claim) 8 - VOID
(Void/Cancel of Prior Claim)
835
837
837
Original Claim
Corrected Claim
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
835 Processing
Provider System
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Payment Corrections and Reversals
UPS Universal Payment System
Payer System
Original Payment
Line 1 paid 10.00 Line 2 paid 20.00 Line 3 paid
0.00
Gateway
Service Line 1 Service Line 2 Service Line 3
Line 1 paid 10.00 Line 2 paid 20.00 Line 3 paid
15.00
Payment Correction
HIPAA Transaction Relationships
837
835
835
Original
Line 1 paid 10.00 Line 2 paid 20.00 Line 3 paid
0.00
Gateway
835 Processing
Correction (CAS01 CR)
Line 1 paid 10.00 Line 2 paid 20.00 Line 3 paid
15.00
Provider System
Line 1 paid 10.00 Line 2 paid 20.00 Line 3 paid
15.00
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Incoming Provider Adjustments
Payer System
Original Lines with Payments
Payment
UPS
Gateway
Service Line 1 Paid Service Line 2 Paid Service
Line 3 Paid Service Line 4 Paid Provider
Contractual Adjustment (CAS)
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Provider Contractual Adjustment
(CAS)
Service Line 1 Paid Service Line 2 Paid Service
Line 3 Paid Service Line 4 Paid Provider
Contractual Adjustment (CAS)
HIPAA Transaction Relationships
835
837
Service Line 1 Paid Service Line 2 Paid Service
Line 3 Paid Service Line 4 Paid Provider
Contractual Adjustment (CAS)
Gateway
835 Processing
Provider System
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COB Claim(One Scenario - Awaiting HHS NPRM )
Payer System
All Original Lines
UPS Payment
ORIGINAL Provider Submitted Lines Original
Charge 25.00 Original Procedure Original
Units Adjudicated Charge 20.00 Adjudicated
Procedure Adjudicated Units SECONDARY
Payments SECONDARY Adjustments PRIMARY Payer
Adjudicated Services PRIMARY Incoming Adjustments
ORIGINAL Provider Submitted Lines (Secondary
Responsibility) Original Charge 25.00
Original Procedure Original Units
Adjudicated Charge 20.00 Adjudicated Procedure
Adjudicated Units SECONDARY
Payments SECONDARY Adjustments
Medicare Secondary COB
ORIGINAL Provider Submitted Lines Original
Charge 25.00 Original Procedure Original
Units PRIMARY Payer Adjudicated Services PRIMARY
Incoming Adjustments
PRIMARY Payer Adjudicated Services PRIMARY
Incoming Adjustments
Transaction Repository
HIPAA Transaction Relationships
837
835
835 Processing
Provider System
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Split Claims and the associated payments
Payer System
Week 2 Payment
Service Line 4 Service Line 5
Claim 1
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Week 1 Payment
Service Line 1 Service Line 2 Service Line 3
Claim 2
835
835
HIPAA Transaction Relationships
837
Total Charges will differ from the original
claim, first 835 and second 835.
Service Line 1 Service Line 2 Service Line 3
Week 1
835 Processing
Week 2
Service Line 4 Service Line 5
Provider System
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Line Bundling and Line Deletion
Payer System
Original Lines with Payments
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Gateway
Service Line 1 Service Line 2 Service Line 3
Line Bundling - or - Lines Deleted
Service Line 4 Service Line 5
Transaction Repository or Remediated Core System
HIPAA Transaction Relationships
835
837
False aging may occur without all the original
lines on the 835 claim payment
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
835 Processing
Provider System
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Predetermination Claim Estimates (Dental)
Completed Service Lines with Payments
Payer System
Dental Predetermination Claim Processing, No
Payment for Predetermination
Date of Service Blank Service Line 1 Service
Line 2 Service Line 3 Service Line 4 Service Line
5
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Gateway
Date of Service filled Service Line 1 Service
Line 2 Service Line 3 Service Line 4 Service Line
5
HIPAA Transaction Relationships
835
837D
837D
Services Rendered
Predetermination Claim (CLM19 PB)
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
835 Processing
Provider System
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Repriced 837 Claim
Return all Original lines in the original order
Payer System
Original Claim
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Gateway
Service Line 3 Service Line 4 Service Line
5 Service Line 2 Service Line 1
Claim Repricing
HIPAA Transaction Relationships
837
835
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
835 Processing
Repriced References (REF019A,9C)
Provider System
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Statistical Encounter(Managed Care)
Payer System
Related transaction 276/277 Claim Status
No Payment to be made
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
Service Line 1 0.00 Paid Service Line 2 0.00
Paid Service Line 3 0.00 Paid Service Line 4
0.00 Paid Service Line 5 0.00 Paid
Claim Status Processing
Entire batch is capitated
837
HIPAA Transaction Relationships
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277
BHT06 RP
Claim Status 105, Claim captiated.
278 Claim Status Processing
Provider System
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HIPAA Transaction TestingTesting Consideration
for Eligibility
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Eligibility (270/271) Batch .vs. Real Time

• HHS FAQ What level of service is required
  to be provided under HIPAA when an entity
  implements batch and/or real time submission of a
  standard transaction?
• 45 CFR 162.925 states "a health plan may
  not delay or reject a transaction, or attempt to
  adversely affect the other entity or the
  transaction, because the transaction is a
  standard transaction."
• If the standard transaction (e.g., ASC
  X12N 270/271) is offered in a batch
  (non-interactive) mode, the health plan has to
  offer the same or higher level of service as it
  did for a batch mode of transaction before the
  standards were implemented by the plan.
• If a health plan offers the transaction
  in a real time (interactive) mode, the level of
  service has to be at least equal to the
  previously offered level for a real time mode of
  transaction.
• If a transaction is offered through
  Direct Data Entry (DDE), the level of service,
  again, has to be at least equal to the level
  offered for the DDE transaction before
  implementation of the HIPAA standard.

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Patient Eligibility Real Time .vs. Batch
Current response time must be maintained
Payer System
Currently providing real time, 271 must provided
real time
Real Time (GS02)
GS03 (real time/batch) Real Time
Linkage BHT03 TRN 2000C, 2000D
Gateway
Batch (GS02)
Information Receiver a provider, payer,
employer, not a clearinghouse or van (2100B loop
NM1)
Information Source, a provider or payer, not a
clearinghouse or van (2100A loop NM1)
271
270
See clearinghouse discussion page 19
Service Line 1 Service Line 2 Service Line
3 Service Line 4 Service Line 5
835 Processing
Provider System
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Eligibility (270/271) Levels

• The 270/271 may convey the following
  information regarding a patients eligibility
• Eligibility to receive health care under the
  health plan.
• Coverage of health care under the health plan.
• Specific benefits associated with the benefit
  plan.

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Eligibility - Types of Requests

1. General Request - All Providers, all benefits
2. Categorical Request All Benefits for a provider
   type
3. Specific Request Detailed Benefits for a
   specific submitter

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Eligibility - General Request

• Request For All Provider Types and All
  Medical/Surgical Benefits and Coverage
• Segment EQ01 60 General Benefits
• Response
• eligibility status (i.e., active or not
  active in the plan)
• maximum benefits (policy limits)
• exclusions
• in-plan/out-of-plan benefits
• C.O.B information
• deductible
• co-pays

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Eligibility - Categorical Request

• Request For a Specific Provider type All
  Benefits Pertinent to Provider Type
• Segment PRV01 Type of Provider Code
• EQ01 60 General Benefits
• Response
• eligibility status (i.e., active or not
  active in the plan)
• maximum benefits (policy limits)
• exclusions
• in-plan/out-of-plan benefits
• C.O.B information
• deductible
• co-pays

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Eligibility - Specific Request
Segment EQ01 not equal to 60 General

• Hospital Psychiatric Treatment
• Hospital O.P. Surgery
• Nursing Home Physical Therapy Services
• Other Allied Health Providers Occupational
  Therapy
• Pharmacy Prescription Drugs
• Physician Well Baby Coverage
• Physician Hospital Visits

• Ambulatory Surgery Center Hernia Repair
• D.M.E Wheelchair Rental
• Dentist Bonding
• Free Standing Lab Diagnostic Lab Service
• Home Health Nursing Visits
• Hospital Pre-Admission Testing
• Hospital Detoxification Services

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Eligibility - Specific Response
Segment EB

• procedure coverage dates
• procedure coverage maximum amount(s) allowed
• deductible amount(s)
• remaining deductible amount(s)
• co-insurance amount(s)
• co-pay amount(s)
• coverage limitation percentage
• patient responsibility amount(s)
• non-covered amount(s)

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HIPAA Transaction TestingAdditional
Considerations Test Data, Certification,
Companion Documents
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Creating Client Specific Test Data
NSF
Valid Partner Specific 837
HCFA 1500
UB92
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Certification Options

• Claredi Certification Portal
• Concio Cohesion In Line, All the time
• Hipaatesting.com
• Foresightcorp.com
• HCCO HIPAA Conformance and Certification
  organization
• http//www.hcco.us/leadership.htm

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HCCO At-a-Glance

• Launched July 2002
• Over 100 Members and Covered Entities
• Aligned with NIST, SQE, ISO, UCC
• Transactions, Privacy and Security
• Best practices organization
• Accreditation and Certification

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HCCO Certification

• Interoperability Testing
• Covered Entity Certification
• IT Products Certification
• IT Services Certification

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Transaction certification observations

• Further educational awareness on transactions
• Upgrade the use of proper testing processes
• Upgrade quality assurance methodologies
• 3rd party testing efforts must be portable
• Clear definitive interpretation of the guides are
  needed
• IG ambiguities must be identified and resolved
• Software interoperability concerns must be solved
• Clear certification guidelines must be published
• Time and money saving initiatives must be
  implemented

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Companion Documents

• Some trading partner relationships may require
  specific content
• Some Health Plans have prepared companion
  documents for their trading partners
• HHS requires that companion documents adhere to
  the HIPAA Implementation Guidelines without
  exceptions, limitations, or other restrictions.

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Trading Partner Companion Documents
Providers
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HHS FAQ Should health plans publish companion
documents that augment the information in the
standard implementation guides for electronic
transactions?

• Additional information may be provided within
  certain limits.
• Electronic transactions must go through two
  levels of scrutiny
• Compliance with the HIPAA standard. The
  requirements for compliance must be completely
  described in the HIPAA implementation guides and
  may not be modified by the health plans or by the
  health care providers using the particular
  transaction.
• Specific processing or adjudication by the
  particular system reading or writing the standard
  transaction. Specific processing systems will
  vary from health plan to health plan, and
  additional information regarding the processing
  or adjudication policies of a particular health
  plan may be helpful to providers.

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Companion Document Guidelines

• Such additional information may not be used to
  modify the standard and may not include
• Instructions to modify the definition, condition,
  or use of a data element or segment in the HIPAA
  standard implementation guide.
• Requests for data elements or segments that are
  not stipulated in the HIPAA standard
  implementation guide.
• Requests for codes or data values that are not
  valid based on the HIPAA standard implementation
  guide. Such codes or values could be invalid
  because they are marked not used in the
  implementation guide or because they are simply
  not mentioned in the guide.
• Change the meaning or intent of a HIPAA standard
  implementation guide.

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HIPAA Transaction TestingHow do we implement
the solutions?
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Riding the wave.
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Assure ComplianceEstablish a contingency plan

• 1) Vendor / clearinghouse compliance assessment
• 2) Develop a backup plan. Some options are
• Choose a new vendor
• Choose a new clearinghouse
• Choose a transaction translator
• If plans are satisfactory, assure plans
• can be executed within budget and time frames.
• If plans NOT satisfactory, consider
• implementation of the backup plan.

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Decide on a course of actions
October, 2003
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HIPAA Compliant Vendor Assessment

• Software Compliance Assessment Services
• HIPAA Tools are available for assessment
• Mapping Tools
• Testing Tools
• Certification
• Issues Reporting
• QA Strategy and Test Planning
• Supporting Document Library

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Vendor Assessment Objectives

• Develop Overall Project Plans for the Assessment
• Develop Contingencies Plans
• Establishment of Process Flows for Standard EDI
  Transactions
• Electronic Transaction Code Set Remediation
• Convert and Certify Key Trading Partner
  Electronic Data Exchanges (Unit and System only)

• Review and Validate HIPAA Ready Version
• Develop New Policies/Procedures
• Develop New Training Program
• Evaluate/Design Modifications for Standard
  Identifiers
• Trading Partner Readiness Survey (in multiple
  phases)
• Develop a Comprehensive Quality Assurance (QA)
  Approach and Testing Strategy (Integration
  Testing)

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The Implementation Process

• Legal Agreements
• Trading Partner Specifics
• Security Compliance
• Privacy Compliance
• Testing Process Instructions
• Test Result Reporting
• Implementation and Sign off

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Summary

• HIPAA Transaction Overview
• Transaction Analysis
• Transaction Issues and solutions
• Test Planning
• Testing Methodologies
• Example Test Scenarios
• Other considerations
• Building Client Specific Test Data
• Certification/Testing Vendors
• Companion Documents
• The Implementation Process
• Contingency Plans
• Vendor Assessments
• Transaction Implementation

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Questions? THANK YOU
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Select HIPAA Clients
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Comprehensive HIPAA Solutions
Minimize the Hurdles