1. Confidential | Copyright © 2014 TriZetto Corporation 1

2. 2 Solutions for Federal Regulatory and Compliance Enablement Susan Scardina – Sr QicLink Product Manager Laura Gerling – Mgr of Product, Partner & Acct Mgmt

3. Confidential | Copyright © 2014 TriZetto Corporation 3 Agenda  5010 Modifications  Billing PCORI and Transitional Reinsurance Fees  Combined / Shared Accumulations  Unique National Health Plan ID  CAQH CORE IV

4. Confidential | Copyright © 2014 TriZetto Corporation 4 5010 Transactions

5. Confidential | Copyright © 2014 TriZetto Corporation 5 5010 Regulations  Federal Register – January 16, 2009  45 CFR Part 162  Modifications to HIPAA Final Rule  Effective date of final rule – March 17, 2009  Mandatory compliance date – January 1, 2012  Adopts updated versions of the standards for electronic transactions  ASC X12 Standards for Electronic Data Interchange Technical Report Type 3  Version 5010 enforcement discretion period ended on June 30, 2012

6. Confidential | Copyright © 2014 TriZetto Corporation 6 5010 Transactions – Purpose  Enhanced business functions and content  Added  Improved  Removed  Supports ICD-10  NPI implementation clarification

7. Confidential | Copyright © 2014 TriZetto Corporation 7 5010 to 4010 Cross Reference Transactions  212 – Health Care Claim Status Request and Response (276/277)  217 – Health Care Services Review — Request for Review and Response (278)  218 – Payroll Deducted and Other Group Premium Payment for Insurance Products (820)  220 – Benefit Enrollment and Maintenance (834)

8. Confidential | Copyright © 2014 TriZetto Corporation 8 5010 to 4010 Cross Reference (Cont’d) Transactions  221 – Health Care Claim Payment/Advice (835)  222 – Health Care Claim: Professional (837)  223 – Health Care Claim: Institutional (837)  224 – Health Care Claim: Dental (837)  279 – Health Care Eligibility Benefit Inquiry and Response (270/271)

9. Confidential | Copyright © 2014 TriZetto Corporation 9 220 Benefit Enrollment Maintenance

10. Confidential | Copyright © 2014 TriZetto Corporation 10 Change Description

11. Confidential | Copyright © 2014 TriZetto Corporation 11 5010 Additional Information  Center for Medicare and Medicaid Services  4010A to 5010 comparison PDF and Excel documents  837 Professional Claim  837 Institutional Claim  835 Health Care Claim Payment Advice  276/277 Health Care Claim Status Request and Response  270/271 Health Care Eligibility Benefit Request and Response  http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp http://www.cms.gov/ElectronicBillingEDITrans/18_5010D0.asp  Workgroup for Electronic Data Interchange (WEDI)  Strategic National Implementation Process (SNIP)  Transactions and Code Sets Workgroup

12. Confidential | Copyright © 2014 TriZetto Corporation 12 5010 Impact on QicLink  5010 compatible versions of all HIPAA transaction programs  CBLD calls:  CBLD1 for ECSIF  CBLD2 for 4010 version 837 inbound transactions  CBLD3 for 5010 version 837 inbound transactions  GS control segment determines program overlay  GS08 Version/Release/Industry Identifier Code  004010X098 for 4010 version 837 Professional  005010X222 for 5010 version 837 Professional  Multiple GS control segments with different GS08 values in same batch not allowed

13. Confidential | Copyright © 2014 TriZetto Corporation 13 System Name Maintenance (SN-5)  HIPAA 4010 complnt date (was HIPAA Compliant Date)  HIPAA 5010 complnt date  Controls 835 transaction output version  Default value is equal to zeroes  5010 Compliant Date equal to zeroes  All 835 transaction output in 4010 version format  5010 Compliant Date entered  835 transaction output controlled by new Version field in Provider Maintenance (PM) if system date is prior to 5010 Compliant Date  All 835 transaction output in 5010 version format if system date is equal to or greater than 5010 Compliant Date

14. Confidential | Copyright © 2014 TriZetto Corporation 14 837 Transaction Modifications  Additional claim header diagnosis codes and pointer codes  Calculation of other carrier allowed amounts  4010 Loop 2320 AMT data segments eliminated  COB Approved Amount  COB Allowed Amount  COB Patient Responsibility  Based upon two models of benefit coordination  Provider-to-Payer-to-Payer  Prior payer payment plus total of all patient responsible amounts (CAS segments)  Provider-to-Payer-to-Provider  Prior payer payment plus remaining patient liability amount (AMT segment)

15. Confidential | Copyright © 2014 TriZetto Corporation 15 PPACA Billing PCORI and Transitional Reinsurance Fees

16. Confidential | Copyright © 2014 TriZetto Corporation 16 PCORI Billing Fee  Affordable Care Act (ACA) established the Patient- Centered Outcomes Research Institute.  Institute helps patients, clinicians, purchasers and policy-makers make informed health decisions by advancing clinical effectiveness research.  Funded by the Patient-Centered Outcomes Research Trust Fund.  Funded in part by fees paid by issuers of certain health insurance policies and sponsors of certain self-insured health plans.  Rate multiplied by the average number of lives covered under the policy for that policy year.

17. Confidential | Copyright © 2014 TriZetto Corporation 17 Transitional Reinsurance Fee  Affordable Care Act (ACA) established the Transitional Reinsurance Program as a risk- spreading program.  Provide payments to health insurance issuers that cover higher-risk populations.  Spread the financial risk more evenly carried by issuers.  This program will impose a fee on health insurance issuers and self-insured group health plans.  For 2014, HHS announced a national contribution rate of $5.25 per month ($63 per year).

18. Confidential | Copyright © 2014 TriZetto Corporation 18 QicLink™ Modifications in 2014  Billing Rate Maintenance  2 New Calculation Types  All Enrollees/Spouses/Members  Check Enrollment (Enr/Sp/Mem)  Enrollment Listing  Option to include or exclude terminated spouses/members  Option to enter up to six benefit types  Sort by benefit type

19. Confidential | Copyright © 2014 TriZetto Corporation 19 Combined / Shared Accumulators

20. Confidential | Copyright © 2014 TriZetto Corporation 20 Combined / Shared Accumulators  Public Health Service (PHS) Act section 2707(b)  Added by the Affordable Care Act  Provides that a group health plan shall ensure that any annual cost-sharing imposed under the plan does not exceed the limitations provided for under section 1302(c)(1) and (c)(2) of the Affordable Care Act. Section 1302(c)(1) limits out-of-pocket maximums for employer-sponsored plans  No guidance provided by ACA as to ‘how’ to administer (no formal Operating Rules similar to CAQH CORE Phase I, II, and III)

21. Confidential | Copyright © 2014 TriZetto Corporation 21 Current QicLink Data Solutions Inbound  History Accumulator Load – HCMLOAD  20 different history accumulator record types overall  Data submitter to populate various required fields  Claim History Load – CLMLOAD  Data submitter to populate up to 24 required data elements  Detail Accumulator Load – ACCLOAD  Update history accumulators Outbound  Ad-hoc enrollment data extract query  Ad-hoc history accumulator data extract query

22. Confidential | Copyright © 2014 TriZetto Corporation 22 QicLink Standard Modification  Create a history accumulator data extract for defined history accumulator types and history accumulator codes  Provide the ability for User to define history accumulator types and codes to extract by group/plan  Create history accumulator types and codes  Delete history accumulator types and codes  List history accumulator types and codes

23. Confidential | Copyright © 2014 TriZetto Corporation 23 Proposed Funded Development Solution - First Phase  Vendor interface functionality  Multiple interface vendors can be assigned to employer group/plan  Pre-defined required data elements maintenance  Ability to store and cross-reference interface vendor ID for employer group to QicLink™ group ID  Inbound claims data with minimally required data elements to be provided by data submitter  Automatic assignment of claim/worksheet numbers for inbound claims

24. Confidential | Copyright © 2014 TriZetto Corporation 24 Proposed Funded Development Solution - First Phase  PBM claims-based prescription drug history data element storage  Drug Quality, Days Supply, Brand/Generic Flag, Formulary Flag, Dispensed As Written Code, Drug Name/Description, Preventative Flag  History accumulator update for inbound interface vendor claims  Premier Partnership Program data extracts expanded for PBM drug history data elements  Generate HIPAA-formatted outbound enrollment  5010 ASC X12 834 (220A1) Benefit and Enrollment Transactions  Create health coverage enrollment crosswalk data elements

25. Confidential | Copyright © 2014 TriZetto Corporation 25 Proposed Funded Development Solution - Second Phase  Display of drug history data elements  Accumulator Over Limit Report  Accumulator Reconciliation Report  Manual check payment/reimbursement to a third-party vendor from passed flag claims data load records  Process outbound 5010 ASC X12 834 (220A1) Benefit and Enrollment transactions through QicLink™ HIPAA Gateway  Inbound interface vendor proprietary-formatted claims translation function  Outbound interface vendor proprietary-formatted history translation function

26. Confidential | Copyright © 2014 TriZetto Corporation 26 Unique National Health Plan ID

27. Confidential | Copyright © 2014 TriZetto Corporation 27 Unique National Health Plan Identifier  HHS published proposed rule April 17, 2012  Department of Health and Human Services (HHS) establishes a unique health plan identifier (HPID) under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for electronic health care transactions.  The rule also proposes a data element that will serve as an “other entity” identifier (OEID) for entities that are not health plans, health care providers, or individuals, but that need to be identified in standard transactions.

28. Confidential | Copyright © 2014 TriZetto Corporation 28 CAQH CORE (QicLink™ Phase IV)

29. Confidential | Copyright © 2014 TriZetto Corporation 29 CAQH CORE (QicLink™ Phase IV)  7/1/2014 Final Rule will be published  1/1/2016 Compliance Date of operating rules for:  Health claim or equivalent encounter information  Enrollment and disenrollment in a health plan  Health plan premium payments  Referral certification and authorizations  1/1/2016 Compliance Date of standard operating rules for:  Health claim attachments

30. Confidential | Copyright © 2014 TriZetto Corporation 30 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.

31. Confidential | Copyright © 2014 TriZetto Corporation 31 Thank You!