CORE Participant Orientation Overview

1

CORE Participant Orientation Overview October
2005
2
Agenda

• Vision
• Phase I Scope
• Guiding principles
• Operations
• Structure
• Steering Committee
• Work Groups
• Voting
• Timeline

3
Vision Online Eligibility and Benefits Inquiry
Give providers access to information before or at
the time of service...

• Providers will send an on-line inquiry and know
• Which health plan covers the patient
• Whether the service to be rendered is a covered
  benefit (including copays, coinsurance levels and
  base deductible levels as defined in member
  contract)
• What amount the patient owes for the service
• What amount the health plan will pay for
  authorized services

Note No guarantees would be provided. Only
HIPAA mandated data element other elements are
part of HIPAA, but not mandated These
components are critically important to providers,
but are not proposed for Phase I.
4
Vision Online Eligibility and Benefits Inquiry
Using any system for any patient or health plan

• As with credit card transactions, the provider
  will be able to submit these inquiries and
  receive a real-time response
• From a single point of entry
• Using an electronic system of their choice
• For any patient
• For any participating health plan
• CAQH initiative will initially support batch and
  real-time.

5
Vision What is CORE?

• Committee on Operating Rules for Information
  Exchange
• A multi-stakeholder initiative organized and
  facilitated by CAQH to create, disseminate and
  maintain Operating Rules and to enable healthcare
  providers to obtain patient-specific information
  about the patients healthcare benefits

6
CAQH Role Facilitator
Step 4
Step 3
Step 2
Step 1
Build rules and tools for implementation
Establish vision/ charter
Bring stakeholders together
Design structure, process and work plan

• Physicians
• Hospitals
• Other providers
• Clearinghouses
• Government
• Vendors
• Non-CAQH health plans
• Standard setting organizations
• Medical societies

7
CORE Status

• Orientation Meeting held January 11, 2005
• More than 125 representatives from 70
  organizations
• Payer community
• Provider community
• Technology vendors
• Critical standard-setting organizations
• Banking industry
• Government agencies (CMS, ONCHIT)
• CORE Participants
• More than 70 organizations to date
• Three Work Groups in process of crafting draft
  rules

8
Current Participants as of October 2005

• Health Plans
• Aetna, Inc.
• Blue Cross Blue Shield of Illinois
• Blue Cross Blue Shield of Michigan
• Blue Cross and Blue Shield of North Carolina
• BlueCross BlueShield of Tennessee
• CareFirst BlueCross BlueShield
• Empire Blue Cross Blue Shield
• Excellus BlueCross BlueShield
• Health Net, Inc.
• Health Plan of Michigan
• Humana, Inc.
• Independence Blue Cross
• Kaiser Permanente
• WellPoint, Inc.
• Associations / Regional Entities / Standard
  Setting Organizations
• Americas Health Insurance Plans (AHIP)
• ASC X12

• Providers
• Adventist HealthCare, Inc.
• American Academy of Family Physicians (AAFP)
• American College of Physicians (ACP)
• American College of Radiology (ACR)
• American Hospice, Inc.
• American Medical Association (AMA)
• Greater New York Hospital Association
• HCA Healthcare
• Laboratory Corporation of America (LabCorp)
• Medical Group Management Association (MGMA)
• Montefiore Medical Center of New York
• University of Wisconsin Medical Foundation (UWMF)
• University Physicians, Inc. (University of
  Maryland)
• U.S. Oncology
• Government Agencies
• Louisiana Medicaid Unisys
• Michigan Department of Community Health

9
Current Participants as of October 2005 (contd)

• Vendors
• ACS State Healthcare
• Affiliated Network Services
• Athenahealth, Inc.
• Availity LLC
• Benefitfocus.com, Inc.
• CareMedic Systems, Inc.
• EDIFECS
• Electronic Data Systems (EDS)
• Electronic Network Systems (ENS)
• Emdeon
• First Data Corp.
• GHN-Online
• HTP, Inc.
• InterPayNet
• MedCom USA
• MedData
• Passport Health
• Post-N-Track

• Other
• ABN AMRO
• Accenture
• Data Processing Solutions
• Marlabs, Inc.
• PNC Bank
• PricewaterhouseCoopers LLP

10
Phase I Scope Functionality to be Addressed

• CORE will begin by drafting rules for the
  following
• Confirm which health plan covers this patient
• Confirm health benefit plan coverage
• Confirm Service Type (e.g., major medical,
  long-term care, laboratory, etc.)
• Provide Co-Pay Amount
• Provide Base Deductible
• Provide Co-insurance Level
• Not accumulator, but amount defined in contract
• Data elements will be based upon HIPAA 270/271
  standards. Additional functionalities will be
  addressed after rules are written for the scope
  above.

11
Phase I Scope Topics for Consideration

• Standard and clear definitions and
  interpretations of the data elements
• Roles and responsibilities of all parties
• Technical transmission standards and formats
• Standards for data timeliness of batch and
  real-time transactions encourage market to move
  to real-time transactions over a specified
  timeline
• Error resolution
• Exception processing
• Certification
• Security
• Standardized response reporting

12
Guiding Principles Phase I

• Participants will work towards achieving COREs
  mission Providing easier access to consistent,
  predictable eligibility and benefits information
  at the point of care
• All stakeholders are key to COREs success No
  single organization, or any one segment of the
  industry, can do it alone
• CAQH serves as the facilitator, while CORE
  participants draft and vote on the rules
• Participation does not commit an organization to
  adoption
• Participating organizations will attempt to
  maintain consistency with regard to their
  appointed CORE representatives
• Rules will be built upon HIPAA to promote
  interoperability. CORE will coordinate with other
  key industry bodies in order to promote
  interoperability, assure compatibility and avoid
  redundancy organizations, e.g. X12 and Blue
  Exchange
• Where appropriate, CORE will address emerging
  interest in XML
• Whenever possible, CORE will use existing market
  research and rules

13
Guiding Principles Phase I (contd)

• CORE will develop a methodology to measure
  success and evaluate the market impact of
  operating rules
• As part of finalizing the rules, CORE will
  provide guidance to stakeholders regarding staff
  implementation and training needs
• Safeguards will be put in place to make sure that
  a health plan's benefit and payment information
  is shared only with the requesting provider and
  is not available to other participating health
  plans

14
Operations CORE Structure
15
CORE Steering Committee
POSITION COMPANY INDIVIDUAL
Chair WellPoint Carl Volpe, Vice President of Strategic Initiatives
Vice Chair HCA Eric Ward, CEO of Financial Services
Policy Work Group Chair Humana Bruce Goodman, Senior Vice President CIO
Rules Work Group Chair PNC Bank J. Stephen Stone, SVP Director of Product Management
Technical Work Group Chair Siemens Mitch Icenhower, Director, HDX
At Large Members Health Plan 1 Aetna Paul Marchetti, Head of Network Contracting, Policy and Compliance
At Large Members Health Plan 2 BCBSMI Deborah Fritz-Elliott, Director, Electronic Business Interchange Group
At Large Members Vendor Org. TriZetto Dawn Burriss, Vice President, Constituent Connectivity
At Large Members Provider Organization Montefiore J. Robert Barbour, JD, Vice President, Finance for MD Services and Technical Development
At Large Other Organization HIMSS H. Stephen Lieber, President CEO
Other (Ex-officio or Advisor) CAQH Robin
Thomashauer, Executive Director CMS Stanley
Nachimson, Senior Technical Advisor, Office of
E-Health Standards and Services ASC X12 Donald
Bechtel, Co-Chair, X12 Healthcare Task Group
(also with Siemens) WEDI Jim Schuping,
Executive Vice President NACHA Elliott McEntee,
President and CEO
16
Operations Work Group Relationships
See next page for Work Group Subgroups
17
CORE Work Groups and Subgroups
18
Operations Work Group Meetings

• CAQH staff support CAQH, the Steering Committee
  and its Work Groups. As appropriate, CAQH will
  retain consultants to provide technical expertise
  and general support to the Work Groups
• NACHA
• Technical consultants, e.g. BIG, PwC
• Meeting frequency
• During the Start-Up phase, there will be monthly
  Work Group conference calls and at least one
  in-person meeting
• Call schedule will be developed and communicated
  by CAQH
• Meeting materials
• CAQH will draft all meeting materials and will
  make them available on the CAQH website at least
  24 hours prior to the call
• Minutes will be created after each call/meeting
  and approved by the Work Group
• The Work Group Chairs will approve all meeting
  materials before they are issued to the Work
  Group
• Participants
• The number of Work Group members per
  participating organization is not limited
• All Work Group, CORE and Steering Committee
  meetings, votes, etc will be based upon the CORE
  Governing Procedures

19
Achieving the CORE Seal
20
Operations Initial Work Groups

• Initial Work Groups
• Policy Work Group
• Rules Work Group
• Technical Work Group
• Potential Future Work Groups
• Communications Work Group
• Legal and Regulatory Issues Work Group

21
Policy Work Group(Chair Bruce Goodman,
Humana)

• Charge
• Identifies policies CORE should develop and makes
  recommendations to the Steering Committee
• Key areas
• Standard agreements between participants and CAQH
  
• Certification and auditing
• Enforcement
• Third party service provider requirements
• Granting variances to the rules
• Exception processing
• Error resolution
• Participants
• Management-level staff who are able to make
  policy decisions and are familiar with relevant
  industry issues as well as overall stakeholder
  perspectives
• Subgroups
• Contracting
• Certification / Enforcement
• Long-Term Vision

22
Technical Work Group(Chair Mitch Icenhower,
Siemens)

• Charge
• Determines technical specifications for CORE
• Key areas
• Connectivity
• Security
• Technical requirements of organizations
  initiating and transmitting inquiries
• Technical requirements of payers receiving
  inquiries and generating responses
• Test protocols
• Role of Network/System/Router (if appropriate)
• Participants
• Individuals familiar with the technical
  implications of supporting the exchange of
  information between trading partners, the various
  technology solutions and options, and the
  individual system requirements of their
  organization, as well as industry requirements
• Subgroups
• Connectivity / Security
• Testing

23
Rules Work Group (Chair J. Stephen Stone, PNC
Bank)

• Charge
• Writes the detailed business rules that will be
  reviewed by the Steering Committee and then voted
  on by CORE
• Ensures CORE and its operating rules are
  coordinated with standard setting entities such
  as X12
• Key areas
• Detailed requirements of organizations initiating
  and transmitting inquiries and organizations
  receiving inquiries and generating responses,
  including response formats and content
• Definition of data terms
• Methodology to address member search criteria
• Acknowledgements
• Response time
• Coordination with standard setting entities such
  as X12
• Participants
• Individuals with experience in the business
  requirements for exchanging information between
  key trading partners and a background in
  coordinating specifications with daily operations
• Subgroups
• Functional Responsibilities
• Definitions
• Identifiers
• Acknowledgements and Reporting

24
Examples of Resources Available to Work Groups

• Reference documentation
• Analysis of technical and strategic approaches
• Analysis of rules currently adopted or under
  consideration by regional initiatives, health
  plans and vendors
• Analysis of relevant eligibility transaction
  standards
• Subject matter experts
• Range of consultants will help CAQH staff the
  Work Groups
• Health care consultants who are well-versed in
  different aspects of the eligibility transaction
  and/or the market trends impacting
  interoperability
• NACHA (an organization that has assisted the
  financial industry in writing interoperable rules
  for transactions such as direct deposit)

25
Time and Resource Commitment

• CORE
• Meeting frequency
• In-person meetings approximately twice per year
  may hold conference calls between meetings
• Skill set
• Represent your organizations/stakeholder
  perspective regarding issues being discussed by
  CORE
• Communicate with your organizations leadership
  regarding COREs status as it impacts your
  organization and whether/when your organization
  should adopt/challenge the rules
• If your organization agrees to adopt the rules,
  oversee, or gain commitment from your
  organization to assign someone to the
  implementation process
• Assign Work Group members

• CORE Work Groups
• Member participation is voluntary
• Meeting frequency
• During rule writing phase, monthly conference
  calls and at least one in-person meeting annually
  
• Skill set
• Different for each Work Group

If an individual is appointed to the CORE
Steering Committee or to Chair a CORE Work Group,
level of time and resource commitment will
increase.
26
Voting Governing Procedures

• Quorum
• CORE 60 of COREs voting membership must be
  present to transact business
• Steering Committee and Work Groups 60 of their
  respective memberships must be present to
  transact business
• Voting
• Approval of new rules, amendments to rule or
  amendments to the Governing Procedure requires a
  super majority (66.67) of voting CORE members
• All other items reviewed by CORE, e.g.,
  administrative issues, or other CORE bodies,
  require a simple majority (greater than 50) of
  present voting members

27
2005 2006 Timeline
Activity Month
Orientation Meeting January
Applications ongoing
CORE leadership invitations February
Work Groups launch March
Work Group rule writing Detailed concept development March - May
Work Group meetings to review draft concepts June
Issue Mid-Year Communication July
Work Group rule writing Finalize rules, incorporating feedback August - November
Voluntary testing of rules and revisions as needed Winter
Vote on 1st set of rules Winter
Sign the Pledge 180 days after signing, become CORE-certified 2006 (by June)
Receive metrics on Phase I Measures of Success (from early adopters) Mid-2006
Vote on Phase II scope and begin Phase II rule development Summer 2006