Centricity™ Business Hidden Gems in Payer Connectivity Sharp HealthCare April 2015

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Agenda Hospital Admission Notification (278N) Claim Status/Claim Acknowledgments (276/277) Benefit Enrollment (MCA 834)

Hospital Admission Notification 278N This transaction is a request and response to a Healthcare Payer for authorization of admission for inpatient hospital services.

What are the Benefits? Streamline administrative tasks and increase productivity Reduce administrative costs through automation Increase data accuracy by reducing manual errors Accomplish more with less – fewer phone calls, faxes or keying

What are the Requirements? Enterprise Visit Management required Centricity Business 5.3 Payer is receiving and responding to 278N transactions

How does it Work? You can manually send a notification for a particular visit You can use the Notification Manager in the GE Healthcare EDI Toolkit to queue up multiple visits to have notifications automatically sent to the payer Responses are viewable directly from HPA There is the ability to Hold Bills if a claim requires notification and a response has not been received

Technical Description

The 278 is a hierarchical structure Sender Receiver Subscriber Dependent Patient Event Patient Event Providers Services Services Providers

Trading Partner Integration in HPA

Trading Partner Integration in HPA continued…

Interactive Request in HPA

Interactive Request in HPA continued…

Interactive Request in HPA continued…

Background Notification Requests (BNR’s)

Background Notification Requests (BNR’s) continued…

Background Notification Requests (BNR’s) continued…

Background Notification Requests (BNR’s) continued…

Background Notification Requests (BNR’s) continued…

Hold Bills and Follow-Up’s

Claim Status/Claim Acknowledgement 276/277 The 276 transaction set is the EDI X12 health care claim status request The 277 is the EDI X12 health care claim status response 276 277

What are the Benefits? EDI verification eliminates the need for follow up reps to go outside of Centricity Business and manually check payor websites or call for claim status. HPA 276/277 was originally developed as a real- time tool for users Batch allows for automated claim status retrieval, eliminating or reducing user interaction

276 Process

277 Process

Current Trading Partners Aetna Anthem Blue Cross Blue Shield United HealthCare Managed Care Application (internal Sharp payer)

Claims Overview (OV Action Code)

Claim Status Screen (CS)

Drill Down into Results

X12 Results

Insurance Follow Up Questions

Success Factors Since January 1, 2015*, Sharp HealthCare has sent 9496 requests and received 7855 responses.  That’s nearly 8,000 phone calls or website research login’s that weren’t necessary!  *(Data period 1/1/15 – 3/12/15)

MCA 834 Enrollment and Covered California About Sharp Health Plan Covered Lives: 75,000+ 23% of SHC Commercial Managed Care Best Health: 8,000 Additional Lives High Customer and Employee Satisfaction Highest CAHPS Scores (2013), 88th Nat’l percentile Broker (97.6%)and Employer (93.9%) Provider (93.2%) 90th percentile (The Myers Group) Above Market Retention (12 Month Average) NCQA Accreditation – Status of Excellence

Sharp Health Plan and Covered California – 2014 aka Year 1

Types of Coverage Individual Small Business Health Options (SHOP < 50 Employees) Employers > 50 Employees

Off Exchange Health plans are required to offer same coverage for off exchange as on the exchange.

Changes to GE Healthcare Centricity Business 834 Inbound 834 Outbound 999, TA1 Premium Billing & Statements 820 Premium Billing Capitation

834 File Flow

EDI 834 Inbound Member matching Contract matching Demographics fatal edits Covered California DBMS columns Covered California fields in Enrollment EDI 834I Employer Group Ruleset Modified REF segments in 834I specification

Covered California Enrollment Screen

EDI 834I Employer Group Custom Enterprise Ruleset

REF Segments in 834

Outbound 834 Capture the 834 Inbound data in enrollment MCA Enrollment EDI Select Queue Ruleset FDL application “EME” - MCA Benefit Enrollment Forms (834) MCA.834.O application class for specification 834 Outbound Run Manager

Enrollment EDI Select Queue

EDI 820 Outbound MCA Premium Payment EDI Select Queue Ruleset FDL Application “EMP” MCA.820.O Application Class for Specification New Spec 005010X306 820 Outbound Run Manager

Premium Billing Enhancements Individual Billing Fixed Rates based on data from inbound 834 (Yearly) Welcome Letters to Members via Optum prior to first payment

Premium Billing Turned on MCA AES MAP #156 to modify premium during compile Modified custom direct bill statements Created new custom activity for Covered California direct bill statements

Covered California – Year 2 Covered California sends multiple enrollment transactions per member/family. Many are duplicates or corrections for previous transactions During 2014 – Sharp worked with GE Healthcare Centricity Business to customize the 834 member and contract matching as much as possible THEN Covered California introduced 14 new issues/failures with the 2015 open enrollment

Ongoing Issues Who’s right? The Exchange says they are the source of truth for all demographic data but Sharp also has a Master Patient Index group A reconciliation process has not been established to report demographic discrepancies Since we don’t know if the member has paid on initial enrollment – we have to manually term members/enrollment until payment is received Exchange sends multiple add/change records for members that are out of sequence Ongoing issue with retro dates on change transactions – this is causing billing issues