Confidential | Copyright © 2014 TriZetto Corporation 1

2 NetworX Payment Bundling Administration Cathy Avery - Product Design

Confidential | Copyright © 2014 TriZetto Corporation 3 NetworX Payment Bundling Administration Welcome! Introduction to Payment Bundling concept NetworX Payment Bundling Application  Processing flow  PBA Terminology  Modules Configuration Codes Qualifier Groups Episode Definitions Episodes Patient Bundle & Patient Bundle Claim Details Claim Re-evaluation Users & Roles Administration  Integrations

Confidential | Copyright © 2014 TriZetto Corporation 4 What is payment bundling? A group of providers agrees to accept a single prospective payment for all services in a well-defined unit of care Targeted units of care are selected based on: Ability to clearly define the unit of care operationally Financial and quality impact

Confidential | Copyright © 2014 TriZetto Corporation 5 NetworX Payment Bundling Application Payment bundling automation benefits include: Functions as a re-pricing engine during adjudication Allows multiple notification methods to initiate a bundle Determines if a claim is part of a bundle and if so, how it should be paid Provides the ability to reconcile bundles retrospectively once the episode of care is completed Handles warranty events Allows inclusion of pre and post hospitalization care Allows bundles for professional services that do not include a hospital stay This product offering in the NetworX family of applications automates the administration of provider contracts that allow a group of providers to accept a single payment for all services within an episode of care.

Confidential | Copyright © 2014 TriZetto Corporation 6 Where does payment bundling fit into NetworX claim processing?

Confidential | Copyright © 2014 TriZetto Corporation 7 NetworX PBA Bundled payment process flow

A group of providers who agree to accept a single payment for all services… = Episode Episode Name Central DuPage Hip Replacement Contract ID = 111 Effective/Term Date 01/01/2000 – 01/31/2000 Claim Inclusion Days 10 before, 30 after Episode Definition Hip Replacement Providers = Dr. Joe Smith… Payment Bundling Pricing Method Retrospective Pricing FFS Episode Name Edwards Hospital Hip Replacement Contract ID = EHIP Effective/Term Date 06/01/2012 – 12/31/9999 Claim Inclusion Days 30 before, 90 after Episode Definition Hip Replacement Providers = Dr. Clare Knight... Payment Bundling Pricing Method Prospective Pricing Episode = $15000 or Anesthesia = $1000 Surgeon = $4000 …in a well-defined unit of care. = Episode Definition* Payment Bundling Terminology Episode Definition Name Hip Replacement Creation Rule(s) 1. 1 DRG Code(s) from 466 through 470 Content Rule(s) 2.1 Facility Qualifier Group DRG Code(s) from 461 through 462 ICD-9 Procedure All through * Rules for claims to trigger the start of an episode (creation rules), what claims are included or excluded, & pricing actions (content rules) Another Hip Replacement Episode but completely different hospital, providers, pricing, contract, dates, etc. Notice that the Hip Replacement Episode Definition can be shared by different episodes

Confidential | Copyright © 2014 TriZetto Corporation 9 So when Suzy Snowflake has her hip replaced at Edwards Hospital and qualifies for their Hip Replacement episode where are those claims captured?

Confidential | Copyright © 2014 TriZetto Corporation 10 A Patient Bundle is a collection of claims that qualified to be captured for a particular Episode for a particular claimant & date range! In Suzy’s case the patient bundle could include: Claim for preliminary primary care visit Claim for orthopedic consult Claim for pre-surgical blood work Claim for surgeon Claim for anesthesiologist Claim for physical therapist Etc. In a Patient Bundle!

Confidential | Copyright © 2014 TriZetto Corporation 11 Configuration Modules

Confidential | Copyright © 2014 TriZetto Corporation 12 Codes Module Code Types are used to define codes used and captured during claims processing. Cancel Reason Codes Cancel Reason Codes identify the reason for the cancellation of a patient bundle. Example: Patient death Service Category Codes Service Category Codes identify the role and pricing of the claim for which a rule applies. Examples: Physician, Hospital, Surgeon, Anesthesia, etc. Explanation Codes Explanation Codes identify details about how the claim is priced. Example: Included in Episode Supplemental Codes Supplemental Codes identify additional information about a claim. Examples: Readmission, surgical site infection, implantable device costs, etc.

Confidential | Copyright © 2014 TriZetto Corporation 13 Codes Module

Confidential | Copyright © 2014 TriZetto Corporation 14 Qualifier Groups Module Qualifier groups include qualifiers or conditions that a claim must meet in order for it to qualify for a specific action. For example, if a claim should have CPT4 codes in the range of through and also have an ICD diagnosis code in the range of , this set of conditions can be defined in a qualifier group. Qualifier groups can be shared by multiple episode definition rule sets Qualifier groups can be nested within another qualifier group Qualifier Group Header Includes the name of the qualifier group, effective dates and what condition should be followed when qualifiers of the same or different types are included in the same group (And/Or logic) Qualifier Details Specific qualifiers or qualifier groups included in the group For example: Patient age AND Claim Format Institutional

Confidential | Copyright © 2014 TriZetto Corporation 15 Qualifier Groups Module

Confidential | Copyright © 2014 TriZetto Corporation 16 Episode Definitions Module The episode definition includes the rules required to start a patient bundle, include and price claims in a patient bundle or cancel a patient bundle for a particular episode. Rules used to include claims in a patient bundle are available for configuration at the claim line or claim level Rules can be marked ‘complete’ in order to stop processing after a claim qualifies for that rule Episode definitions can be shared by Episodes Creation Rules The rule set including the qualifiers that define when a patient bundle is created. For example: Total Knee Replacement create when: Patient Age is 18 – 99, Qualifier Group – All Procedure Codes (CPT-4 Line is 2738 or 27447) OR (ICD-9 Procedure All is 81.54) AND Qualifier Group – Dx Codes (ICD-9 Diagnosis is from 715 to ) Content Line Inclusion Rules The rule set including the line level qualifiers that define when a claim is to be included and priced, excluded from or should cancel a patient bundle. Content Claim Inclusion Rules The rule set including the claim level qualifiers that define when a claim is to be included and priced, excluded from or should cancel a patient bundle.

Confidential | Copyright © 2014 TriZetto Corporation 17 Episode Definitions Module

Confidential | Copyright © 2014 TriZetto Corporation 18 Episodes Module The episode includes details such as the contract, the episode definition, dates, pricing methodology, service rates and providers associated to a particular episode. Episode Header Details such as the episode name, contract, episode definition (rule set) to be used, effective and termination dates as well as the typical length of stay. Claim Inclusion Days The number of days before the admission or after discharge that claims should be considered for inclusion in the patient bundle. Pricing Methodology – Prospective or Retrospective Budget – Pre-defined episode budget for consideration during prospective processing or for comparison to actual totals for retrospective processing. Pricing Rates – Services and associated rates for use during claim inclusion processing Contracts Contracts that can create a patient bundle Providers Providers that can create a pateint bundle

Confidential | Copyright © 2014 TriZetto Corporation 19 Episodes Module

Confidential | Copyright © 2014 TriZetto Corporation 20 Patient Bundle Module

Confidential | Copyright © 2014 TriZetto Corporation 21 Patient Bundle Module List of all the patient bundles created including details about the patient bundle and the claims captured for a particular claimant and episode. Example of claims found in a patient bundle: Claim for pre-surgical blood work Claim for surgeon Claim for anesthesiologist Claim for physical therapist Patient Bundle grid Patient bundle ID, status, claimant, provider, related dates and related episode. Can also open a patient bundle to view claim details or cancel a patient bundle in this module. Patient Bundle claims List of claims in patient bundle, including details for the provider, service pricing, total charges, pre-episode & episode pricing, budget to actuals variance and supplemental data captured. Can also delete a claim from a patient bundle in this module.

Confidential | Copyright © 2014 TriZetto Corporation 22 Patient Bundle & Patient Bundle Claim Details

Confidential | Copyright © 2014 TriZetto Corporation 23 Claim Re-evaluation Module

Confidential | Copyright © 2014 TriZetto Corporation 24 Claim Re-evaluation Module Provides the ability to identify claims that may require reprocessing due to patient bundle changes that have taken place. For example: Joe Smith’s hip surgery was rescheduled from April 1 st to March 19 th. His patient bundle date processing window was adjusted to account for this change. Running the claim re-evaluation process in this case provides the ability for the claims prior to April 1 st that otherwise would have been omitted, to be identified for re-adjudication and subsequent payment bundle processing. Claim re-evaluation job grid Details for prior runs of the claim re-evaluation process including job ID, status, start and end dates/times, number of patient bundles and claims processed, total claim identified as needing review and number of claims not yet reviewed. Initiate a re-evaluation job or open a particular job to view claims. Claims identified for review After opening a particular re-evaluation job run from the main grid, this view provides a list of the claims in that job that have been identified as those that may require re-adjudication due to a change that occurred. Details about those claims are listed as well as the ability to mark claims as reviewed. This list of claims can be exported to Excel for ease of reprocessing.

Confidential | Copyright © 2014 TriZetto Corporation 25 Claim Re-evaluation Module

Confidential | Copyright © 2014 TriZetto Corporation 26 Test Price

Confidential | Copyright © 2014 TriZetto Corporation 27 Test Price Module

Confidential | Copyright © 2014 TriZetto Corporation 28 Users & Roles

Confidential | Copyright © 2014 TriZetto Corporation 29 Users & Roles Modules Provide the ability to define users and roles for increased application security. Users Details including ID, password (minimum requirements enforced), status and contact details and associated roles for particular application users. Can also edit or delete a user if desired. Roles Roles can be defined for each module that provide view, update, delete and export access as applicable. Users can then be assigned particular roles in order to limit the level of functionality they have available.

Confidential | Copyright © 2014 TriZetto Corporation 30 Users & Roles Modules

Confidential | Copyright © 2014 TriZetto Corporation 31 Administration

Confidential | Copyright © 2014 TriZetto Corporation 32 Administration Module Setup subscribers for data publish purposes and ability to import external files. Subscriber Configuration When the publish option is used to copy data from one NxPBA environment to another for data such as qualifier groups or episode definitions, the selected data is exported to every active destination subscriber system defined on this tab. Import Choose the data to import from a third party, such as PROMETHEUS data.

Confidential | Copyright © 2014 TriZetto Corporation 33 Administration Module

Confidential | Copyright © 2014 TriZetto Corporation 34 Administration Module

Confidential | Copyright © 2014 TriZetto Corporation 35 Integrations

Confidential | Copyright © 2014 TriZetto Corporation 36 Integrations  Facets  NetworX Pricer  Non-TriZetto Core Systems o REST service for Patient bundle creation o REST service for Claim processing

Confidential | Copyright © 2014 TriZetto Corporation 37 Workshop Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should have received an 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.

Confidential | Copyright © 2014 TriZetto Corporation 38 Thank You!