1. Implementing HIPAA Centers for Medicare & Medicaid Services Fourth National HIPAA Summit April 25, 2002 Jared A. Adair Director Office of Operations Management

2. CMS’s Commitment to Implementing HIPAA Office of Operations Management –New –Focal Point for the Agency for Administrative Simplification –Work continues throughout the Agency HIPAA Steering Committee HIPAA Roundtable Discussions

3. CMS’s Dual Roles Responsible for regulations that adopt HIPAA standards… …and modifications to those standards Operate health plans that must be compliant –Medicare (fee-for-service and managed care) –Medicaid and SCHIP

4. Medicare Fee-for-Service CMS directly responsible for readiness Business partners –Medicare carriers and fiscal intermediaries –Claims processing systems maintainers Environment: Quarterly systems releases

5. Medicare FFS - Basic Concepts Can’t do it all at once –Risk –Resources Used WEDI sequencing white paper as guidance Minimize changes to ‘core system’ processes

6. Medicare FFS - Implementation Instructions Effort began almost two years ago JAD technique, involving our partners extensively Instructions contain: –Requirements –Flat file formats/crosswalks –Edit documents and other guidance

7. Medicare FFS - Instructions Progress Published: –Inbound claim and outbound COB (837) –Remittance Advice (835) –Claims status query/response (276/277) –Testing In Progress: –Eligibility query/response (270/271) –Referral/authorization (278) –Retail Pharmacy (NCPDP)

8. Medicare FFS - Status Medicare contractors using Claredi for testing and certification Testing with partners is sequenced by transaction: –Claim - began mid-April –Remittance Advice - mid-May –COB - mid-June –Claims Status - mid-July

9. Medicare Managed Care Providing technical assistance and oversight Sponsoring conferences and training Transactions: –Will use 820 for premium payments –Plans will have the option of batch 270/271 or DDE for eligibility inquiries –Plans will have the option to use 837 to report risk adjustment data to CMS (this transaction does not require a HIPAA standard)

10. State Medicaid Programs Providing technical assistance and oversight Developed a HIPAA compliance “road map” for States –CD-based tool –Provides gap analysis, resources Facilitating cooperative working relationships among States to identify issues

11. CMS Outreach Tremendous effort to reach entire health care industry - not just Medicare and Medicaid Providers Website Periodic satellite broadcasts and video tapes Industry roundtable conference calls Participation in major industry conferences We are challenged to reach everyone...