Frequently Asked Questions About Quality Data Reporting

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1 Why am I being asked to submit claims for all of my patients if SQCN does not have any payer contracts? SQCN is a Clinical Integration (CI) network. The success of our network will depend upon our CI program s robust and multi-specialty quality improvement program. The only way to measure this is through your claims data which you have agreed to submit when signing the SQCN Participation Agreement. It is our belief that physicians who submit claims information for all of their patients will benefit the most from the CI network s quality program because they will be able to determine how they are doing across their entire panel of patients as opposed to just a subset of patients. Sharing quality information on all of your patients is permissible as long as your Notice of Privacy Practices (NPP) contains standard wording permitting the use of protected health information (PHI) for Treatment, Payment and Health Care Operations. Reporting on quality so that you can improve your patients care is covered under health care operations. What are the ways we can report quality data to SQCN? Consistent with quality data reporting for the Centers for Medicare and Medicaid Services, quality data can only be reported to SQCN, as follows: 1. Claims-based reporting (CPT 4, Diagnosis, and CPT II coding); or 2. EHR data extractions and reporting; or 3. Registry reporting, if available, at patient level. What information is used from my claims? SQCN only uses rendering provider information (NPI and Tax ID), patient demographics, date and place of service, diagnosis and procedure code information from the claims you submit. Our CI analytics vendor will not extract your billed charges from the claims you will upload to our secure web portal. If we outsource billing, do we need to complete the Role-Based Access Form? Yes, you still need to authorize access for the representative from your billing company who will have responsibility to upload claims. Page 1

2 How will the claims file upload process work if we use a billing company? Your billing company currently submits claims files either directly to a payer or through a claims clearinghouse. The same file submitted to payers/clearinghouses can be uploaded to our secure web portal. If I have to submit all claims for all of my patients, will this consume significant resources in my practice? We have tested this process and from testimonials we have received, it should only take a few minutes for practice staff to submit the same billing file created for submission to other payers, to our secure website. Please contact our Help Desk to schedule training with our Physician Practice Liaisons to assist your staff with the claims file uploading process. Can the claims upload process be automated? You would need to have this conversation with your billing office or your IT consultant. It may be possible for a vendor to create a script or an interface to handle this functionality and process. What are acceptable file formats for claims uploads? IHC Claims File Upload File Formats 4/8/13 File format File extension Status 837P and 837I Any Yes Pipe delimited.csv or. txt Yes* tab delimited.csv or.txt Yes* Comma delimited.csv or.txt Yes* Text.txt Yes* Database.dbf Yes* Excel file.xls, xlsx Yes* Hierarchical.xml Yes* Word.rtf,.doc,.docx NO Image.pdf,.xps, jpg NO Executable.exe NO * IHC will accept one spec per file format with schema Page 2

3 SQCN is asking providers to upload claims files to a secure website. My office uses an EHR so why do we need to send our claims? (1) In order for SQCN to aggregate claims from multiple providers, for a specific patient, we need to match the patient s data using demographic and other information (name, date of birth, address, insurance, etc.) which is not often contained in the EHR. (2) Claims data contains information, not always available in the EHR, which is required for measure compliance, such as diagnosis and procedure codes for a specific date of service, as well as rendering provider information. This information will be linked to the EHR data, including laboratory values and pharmacy information. (3) The measure specifications require CPT 4/HCPCS codes, Diagnosis Codes, Place of Service, Date of Service, and patient demographics in order to determine the patient attribution for each measure. In addition, we will need the rendering provider of service NPI and Tax ID. If all of this information can be included in the EHR data extract, then we would not need claims. (4) In order to satisfy the Federal Trade Commission s (FTC) regulatory requirements for a CI program, the SQCN must measure and report on the quality of the care provided within the network. SQCN needs claims files to report on quality. Dignity Health has previously taken 3 CI programs, including this program, before the FTC. Will submitting quality data from EHR replace the need for CPT II coding in claims? If quality data can be extracted from an EHR, the provider should not need to CPT II code claims. That being said, if you do not interface the EHR with a laboratory to store actual lab values resulted from orders, the data will not be extractable. Lab results on scanned documents will not provide the ability to submit usable quality data to SQCN. The same can be said for results of echocardiograms and other diagnostic procedures/services. Can the EHR upload process be automated? You would need to have this conversation with your EHR vendor. It may be possible for the vendor to create a script or an interface to handle this functionality and process but not only is every EHR different but each version of an EHR may be significantly different in its ability to store EHR records in a format that is easily extractable and reported out. When will I be able to submit EHR quality data through the secure SQCN website? We can provide you a list of data elements for many of the measures. A Physician Practice Liaison or Quality Management Nurse will contact you to schedule training and can provide an EXCEL file depicting the data elements for specialty-specific quality measures. Page 3

4 What are the steps necessary for extracting data from my EHR? The steps are as follows: SQCN will provide a document describing data elements (lab results, Rx information, vitals, etc.) and the file layout specifications needed for ambulatory measure compliance. Medical group/physician will need to work with their EHR vendor or technical support team to determine where the data elements are stored in the application. Please note SQCN cannot assist with determining the location of data elements in every EHR and every version of an EHR. EHR Data Extracts will be uploaded to the CI Web Portal via a secure File Upload tool. There will be a period for EHR Data Extract testing with the SQCN data aggregation vendor until the file format and metric results are validated. This may require multiple rounds of extract revision and testing. Please be aware there may be a cost to working with your EHR vendor or technical support team to develop an extraction of data from electronic charts. We do not use an EHR and will need to CPT II code on our claims. Since there are a limited number of lines on a CMS 1500 form, how many CPT II codes can we put on a claim? While there are a limited number of lines on a paper CMS 1500 form, there are no limits to the number of procedure lines on an electronic HIPAA 5010 compliant claim. An electronic claim can only accommodate twelve (12) diagnosis codes and a provider cannot link more than four (4) diagnosis codes to one procedure code. Our EHR limits the number of procedure code lines and the CI Measures will require more lines than is available in our EHR. While your EHR may limit the number of procedure code lines per patient visit, it is unlikely any provider will document all of the required measures in a single visit during the reporting period. Should we notify our patients regarding participation in the CI Program and do we need to offer our patients the opportunity to opt out of data sharing in the CI Program? We encourage you to notify all patients of your practice s participation in a CI Program that is focused on improving quality and coordination for all of your patients. Outside of the Notice of Privacy Practices (addressed above), neither the FTC nor other payers require additional Page 4

5 notification to patients to share their information in order to improve the quality of care in the community. If your patients are uncomfortable with having their information used to report internally on quality, SQCN has a process to accommodate the patient s preference to opt out of data sharing. It should be noted that the benefit of an integrated network designed to improve quality of care and reduce costs will be diminished by not including all patients in the program. If one of your patients chooses to opt out of data sharing amongst the SQCN healthcare providers, the patient must make the request in written form. Please forward all opt out requests to the SQCN Physician Practice Liaison for further processing. What report formats will SQCN accept for EHR data extraction files? As indicated above, SQCN will provide a document describing data elements (lab results, medication information, vitals, etc.) and the file layout specifications needed for ambulatory measure compliance. Can we just send our quality data files to a person at SQCN or do we have to upload to the website? For data security, all quality data files must be uploaded to the secure website and only by practice personnel that the responsible physician or administrator authorizes access, in writing, using the Role-Based User Access Request Form. If you have any questions, please contact your Physician Practice Liaison or Quality Management Nurse. You can also contact the help desk and they can forward your request to the appropriate resource that can provide more detailed information. The help desk can be reached at QUALNET ( ) or by at CI/ACOHelpDesk@dignityhealth.org. Page 5