Led by: Keith Herbert, TriZetto, and Karla Chavez, HealthNet Plan Facets Rules Automation – Workflow, BPA and Customizing Rules Led by: Keith Herbert, TriZetto, and Karla Chavez, HealthNet Plan

About BMC HealthNet Plan Boston Medical Center founded Boston Medical Center Health Plan, Inc. in 1997 as a non-profit managed care organization doing business in Massachusetts as BMC HealthNet Plan. BMC HealthNet Plan is the managed care organization with the largest number of MassHealth and Commonwealth Care members in Massachusetts BMC HealthNet Plan is ranked in the top 10 among Medicaid plans in the nation according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Rankings 2013-2014. BMC HealthNet Plan also continues to maintain Excellent Accreditation from NCQA as a Medicaid health maintenance organization. In addition, BMCHP’s QHP program has been awarded Accredited status from NCQA, the highest accreditation level available at this time. In New Hampshire, the business name is Well Sense Health Plan. Well Sense Health Plan was one of three managed care organizations selected by the New Hampshire Department of Health and Human Services to provide health care coverage to New Hampshire’s Medicaid recipients.   Well Sense Health Plan is the largest Medicaid managed care organization in New Hampshire. Total membership as of 5/6/2014: Massachusetts (BMC HealthNet Plan) – 312,414 New Hampshire (Well Sense Health Plan) – 48,711

Business Process Automation TriZetto recommended that clients use a set of applications introduced in Facets release 4.81 for creating rules for service code conversions as they relate to ICD-10 implementation. These applications are found in the Medical Plan application group, and appear online in this order: Supplemental Conversion Qualifier Group Supplemental Procedure Conversion Rules Supplemental Revenue Conversion Rules

Using BPAs for ICD-10 configuration Supplemental Conversion Rules Supplemental Conversion Tables used ‘heavily’ Diagnosis Code Ranges dominated 124 Qualifiers 680 rules

Using BPAs beyond ICD-10 configuration BMCHP expanded coverage services into the state of New Hampshire in 2012. Benefit configuration was needed to be setup “from the ground up” which presented an opportunity to utilize new applications for non-ICD10 related rules. Rules created included Coverage determination, Clinical Policies, Vendor arrangements.

Using BPAs beyond ICD-10 configuration 425 Qualifiers 485 Rules Original configuration was setup to apply all rules to all types of services and use the qualifiers to restrict processing

BPA issues Release 5.10.002 (Tracking Number: 00497595) Trizetto introduced a modification to address the processing performance of the Supplemental Conversion Rules. The Section Header table (SHDR) data was introduced into the application so that the qualification process of supplemental conversion rules can be done in a more efficient manner.

Benefits of using “BPA” BPA tables streamline configuration by building the business rules in one qualifier group and applying it to many services. Business rules contained in Qualifier Groups are easy to read and can be audited by business owners. Maintenance is easier and quicker. Change is made once and applied across services rather than making the configuration change multiple times.

We would like to extend you an opportunity to provide candid feedback. Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should have received an e-mail notification for you to take an on-line survey. If you could take a few minutes to complete at this time , we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

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