HIPAA 5010 Overview

June 2009
June,
HIPAA 5010 Readiness
 5010 Readiness

5010 Discussion Topics

• Why 5010 and Version D.0?

• 5010 Roadmap
• CSC Offering
• Solution and Approach
• Proposed Solution Architecture
• Why CSC?
• Value Proposition and Key Payoffs
• Appendix

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 5010 Readiness

Why Version 5010 and Version D?

• Federal regulatory compliance

• Current standard is six years old
• Enhancements are needed to address problems in current standard (4010A1)
• Improvement to payers — improved implementation instructions for consistent
implementation for trading partners
• Transactional improvements — both structural and data content
• Support for ICD
ICD-10
10
• Standard for the Medicaid pharmacy subrogation transaction
• Clarifies NPI instructions

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 5010 Readiness

Timelines

HHS Proposed Timelines

January 2012 Transaction Code Set of Version 5010 compliance date

Transaction Code Set of Version 5010 compliance date for small
January
y 2013
health plans

October 2013 ICD-10 HIPAA Transaction Code Set compliance date

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 5010 Readiness

Types of Changes in 5010

Front Matter Changes

Clarifications Business Scenarios Examples

Technical Improvements
Change to the implementation Multi-Functional segments Data representation more
guide architecture itself separated into own consistent across guide
representations

Structural Changes
Format changes, data elements Composites added/ Segments
added/modified removed
added/modified, modified/removed added/modified/removed

Data Content Changes

g
Remove redundant and unnecessary content Add new information required by the industry

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 5010 Readiness

5010 Conversion — CSC Offering

Deep Domain Expertise

Assessment and Gap Analysis
Pre-built X12 4010- 5010 and Version D Gap
p reports
p
S,
nt Services / Tools, IMS

Impact analysis and assessment framework

X12 5010 Road Map Template
nts

Implementation Services
Prebuiltt componen

X12 5010 Processor Service (with custom DB)

Mapping between 4010 to 5010 X12 format and vice versa
Validation of received X12 5010 transaction in compliance with HIPAA
Procedure codes and diagnosis codes validation
Assessmen

Integration Management Service Application (IMS)

5010 Wrapper (Prebuilt components)
X12 5010 EDI Gateway Framework
Asset: A

Testing Services
Trading partner set-up and testing
User Acceptance Testing

Large pool of domain SMEs and Implementation Specialists with

extensive 4010 Implementation experience

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 5010 Readiness

Tools Overview

Assessment Phase
• 4010 to 5010 X12 mapping repository
Gap Analysis • System study templates and checklists

• A
Assessmentt fframework,
k checklists,
h kli t
Impact Analysis guidelines and work-plan accelerator

• Mapping tool for 4010 and 5010 X12 formats

X12 5010 Validation • Inbound X12 5010 transactional
X12 40

X12 50
ation Phase

compliance tool
010

010
Integration • Integration
I t ti Management
M t Tool
T l
Implementa

• Transaction Specific pre-post processor

Customization toolkit Ex
Ex. 834/837 pre-post processor
• Integration Management Tool
Testiing
ase
Pha

T ti
Testing • Test
T t case and
d scenario
i starter
t t sett

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 5010 Readiness

Solution Approach

Implementation
Services Production
•Prebuilt X12 Readiness
4010-5010 Gap •UAT
reports •Functional Testing •Performance
•X12 5010 Processor
•Analysis and Service •Integration testing Tuning
•Regression testing •Training •Production and
assessment •Integration
framework Management •Dual Workflow •Knowledge Support
System Transfer
•X12 5010
Migration Road •X12 5010 Wrapper
Map •X12 5010 EDI Client Sign /
Gateway Testing Go live
Assessment/Gap
Analysis

Migration Tools
CSC Tools
• Gap Analysis Report and Assessment Framework
• X12 5010 Processor
• EDI Gateway
• Integration Management System

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 5010 Readiness

CSC Has Developed a High-level Solution Architecture for

Implementing 5010 X12 Compliance For Health Plans

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 5010 Readiness

The CSC Difference

Expertise in Business Modeling and HIPAA Consulting Expertise

Modeling Tools — IBM Web sphere,
EA, BPM AquaLogic

Strong Health Infrastructure

Plan Industry Services
Experience
Healthcare Reduced Client
Techno Domain Management
Focus Group Overhead
PAHM and Q alit
Quality
FAHM Certified assurance
Domain through SEI
Experts CMM Level 5
and ISO 27001
certification

Microsoft, Sun
Microsoft
CSC
and Oracle
Certified Packaged
Technical Application
Architects Implementation

“Domain
Domain
Wrapped”
Cost-Effective Blended Shore X12 Architects Healthcare
Approach
Blended Shore Center of
Model Excellence

Establish Hands-On
Hands On Experience in X12
Federal / State Regulatory Compliance Implementation

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 5010 Readiness

Value Proposition and Key Payoffs

• End-to-End Migration Offering

– Assessment,
Assessment analysis and design
design, execution
execution, verification
verification, validation
validation, training and setup
– Deep domain experience
– Single Supplier
• Reusable Components and Tools
– Increase p
productivity
y through
g use of CSC’s home g
grown tools like 5010 Processor,, EDI Gateway
y
• Total Cost of Ownership
– Reduces migration cost by at least 50% and migration cycle time by about 65%
– Reduce maintenance overhead
• Cost Savings
– Reduced migration cost by at least 50% due to matured processes, proven approach and tools
– Eliminates or reduces dependency on client resources, this enables the client mgmt to focus their
highly skilled resources for other strategic activities
• Regulatory
g y Compliance
p
– Address the risk of incurring penalties for not meeting Federal regulatory compliance requirements
• True Global Delivery Model — Proven and Cost Effective
– Proven processes and methodologies to achieve over 90% offshore execution
– Leverage existing infrastructure and processes at Global Delivery Centers
– Ability to ramp up and ramp down rapidly to optimize cost

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Appendix
 5010 Readiness

ASC X12 Changes Required by HIPAA 5010

ASC X12 5010

Major Changes
Transaction

• Ability to report new control totals in QTY segment [e.g., Employee Total (ET), Dependent Total (DT)
and Transaction Total (TO)]
• New set of qualifiers to support new maintenance reason codes (e.g., addition or deletion of a
834
dependent due to student status change, limiting age of dependent)
• Privacy related improvements - drop off location separate from home
• ICD -10 support to report pre-existing conditions
• RMR — Individual Premium Remittance Detail segment changed from situational to Required
820 • Added premium receiver’s remittance delivery method
• Added
Add d service,
i promotion,
ti allowance,
ll or charge
h information
i f ti loop
l
• Required alternate search options
• Added support for 38 new Patient Service Type codes
270
• Burn care, brand name prescription drug (formulary and non-formulary), coronary care, screening x-
ray and
d llaboratory
b
• Requires payer responses to include
– How to report patient on subsequent transactions
271 – Plan name, effective dates, required demographic info
• Nine categories of benefit information must be reported: medical care, chiropractic care, dental care,
hospital, emergency services, pharmacy, professional visit — office, vision, mental health, urgent care

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 5010 Readiness

ASC X12 Changes Required by HIPAA 5010

ASC X12 5010

Major Changes
Transaction

• Restructured to support patient event and service level requests which aligns transactions closer to
claims
• Enable service level to support institutional, professional, and dental detail segments
278
• Medical services reservation (Medicaid)
• Added support for ICD-10

• Added support for ICD-10

• Present on Admission indicator for institutional claims
• Ambulance pick-up
pick up and drop
drop-off
off locations
837 (P/I/D)
• Remaining patient liability (clarifies COB — 837I and P)
• National health plan ID (to support when identifier is adopted)
• 837P anesthesia minutes
• Subscriber
S b ib and dd
dependent
d t lloop d
data
t were made
d more consistent
i t t
276/277 • Eliminated sensitive patient information that was unnecessary for business purpose
• Added pharmacy-related data segments and the use of NCPDP Payment Reject Codes

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 5010 and
Readiness
ICD-10 Implementation Approach

Sample Implementation Approach

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Contact
Craig Combs
443.253.1551
Eric Schenk
310.993.1447