IBM Information Integration Solutions, Healthcare Sector Claims Attachments Underpinning

Transcription

1 Information Management II Session #4143 IBM Information Integration Solutions, Healthcare Sector Claims Attachments Underpinning Helen Gurevich - Director Healthcare & Insurance, Healthcare Sector February 13, 2006 IBM Software Group 2005 IBM Corporation

2 Agenda Information Management Claims Attachments Models Structures Human Decision Variant (HDV) vs. Computer Decision Variant (CDV) Standards: X12, HL7/CDA, LOINC Implementation Guides Additional Information Specification (AIS) Transactions Linkage Attachments Workflow Request for Additional Information Federal Register example IBM Information Integration Capabilities for Claims Attachments Implementation WebSphere DataStage TX Future Direction 2

3 Claims Attachments the road to adjudication automation and fast payment Additional information Payer receives a claim and needs more information Prescription for DME (e.g., wheelchair) Consent form signed by patient Rehabilitation Treatment Plan information X-rays (dental, spinal, etc.) Laboratory reports and/or results A mechanism to transmit clinical information in support of the administrative process Data content standardization will support claims adjudication automation More extensive collections of quality data will enhance medical management Fraud and Abuse prevention 3

4 Attachment Types Selected for HIPAA Recommendation 1. Ambulance 2. Emergency Department 3. Rehabilitative services 4. Lab results 5. Medications 6. Clinical notes 4

5 Attachment Models Unsolicited attachment sent with the claim Provider knows the attachment will be required e.g., consent form signed by patient Attachment sent to payer as response to a payer s request for additional information HIPAA Standard request for information 277 LOINC-codified request Attachment response 275 Non-structured, structured, codified LOINC matches answer to the question Entity to entity exchange of patient information 5

6 Unsolicited - electronic transmission from provider to payer 1 Request for payment by ASC X12N 837 & 275 / HL7 CDA attachment Provider Payer 2 Payment advice sent by ASC X12N 835 could be payment or denial 6

7 Solicited request - Electronic transmission between the provider & payer Request for payment by ASC X12N Provider 3 Request for additional information by ASC X12N 277 Additional information by ASC X12N 275 / HL7 CDA 2 Payer 4 Payment advice sent by ASC X12N 835 could be payment or denial 7

8 Attachment Structures Non-codified, Structured Non-Structured Scanned image (fax, pdf, rtf, html, or jpeg) <section> Codified, Structured <caption>ems TRANSPORT, DESTINATION SITE INFORMATION <caption_cd V=" "/> </caption> <paragraph> <caption>ems TRANSPORT DESTINATION SITE NAME <caption_cd V=" "/> </caption> <content>alfred Newman Neurological Institute</content> </paragraph> <paragraph> <caption>ems TRANSPORT, DESTINATION SITE ADDRESS <caption_cd V=" "/> </caption> <content>123 Main St; Anytown, UT <local_markup descriptor="ad"> <local_attr name="lit" value= 123 Main St"/> <local_attr name="cty" value= Anytown"/> <local_attr name="sta" value="ut"/> <local_attr name="zip" value="85912"/> </local_markup> </content> </paragraph> </section> HL7 CDA codified (HL7 v3 XML CDA mark-up) <section> <caption>history of Present Illness</caption> <paragraph> <content> Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his teens. He was h twice last year, and already twice this year. He has not been be weaned off steroids for the past several months. </content> </paragraph> </section> <section> <caption>past Medical History</caption> Marked-up Text (HL7 v3 XML CDA mark-up) Submitter (Provider) Information (Name, ID) Receiver (Payer) Information (Name, ID) Patient Information (Name, ID) Claim Information (Date, type, reference, control number) Attachment type Question that was asked by payer (LOINC) Response from provider (LOINC) 8

9 Human Decision Variant (HDV) vs. Computer Decision Variant (CDV) Human Decision Matches the most prevalent workflow: a person reviewing the information to make a decision low-impact on health plans (easy to display using common tools) low-impact on providers (supports low-cost document preparation and fax-like use of existing paper or document images) Computer Decision Permits computer-assisted adjudication or autoadjudication Includes specifications for breaking data down into computer-accessible elements Includes LOINC codes to identify the questions Includes answer codes suitable to the question Processable in humandecision mode by health plans that have not adopted a computer decision approach Can be applied selectively, one attachment at a time 9

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11 Linking the Transactions in the same transmission Attachment submitted with Claim ( ) ISA Interchange Control Header GS Functional Group Header ST 837 Transaction Set Header: Claim PWK Contains provider s control number SE Transaction Set Trailer GE Functional Group Trailer GS Functional Group Header ST 275 Transaction Set Header: Add l Info TRN contains provider s control number SE Transaction Set Trailer GE Functional Group Trailer IEA Interchange Control Trailer 11

12 CDA Attachment within BIN X12 wrapper BIN segment (BIN02) in the X12N-275 transaction set Start ST*275* BIN*1234* Attachment Information ~SE*16*1001~ End This is the XMLbased CDA document instance that describes an attachment in this case, an ambulance service attachment. <?xml version=*1.0*?> <levelone * * * > <clinical_document_header> * * * <document_type_cd V=* DN=* AMBULANCE SERVICE CLAIMS ATTACHMENT */> * * * <patient> * * * (identifies the patient by name, number, etc.) </patient> </clinical_document_header> <body> <section> <paragraph> <caption>ems TRANSPORT, DISTANCE TRANSPORTED<caption_cd V=* */></caption> <content>7</content> <content>mi<coded_entry.value V=*mi* S=* */></coded_entry> </content></paragraph></section> <section><paragraph> <caption>ems TRANSPORT, ORIGINATION SITE ADDRESS<caption_cd V=* */></caption> <content>124 Elm St, Elmo, UT 85912</content> </paragraph></section> * * * </body> </levelone> LOINC description and code 12

13 Request for Additional Information Provider Payer Deliver a service Provider submits a claim X12N 837 Need more info to pay? NO Assemble supporting documentation X12N 277 Request for Additional Information Request additional documentation Pay the claim Yes X12N 275 Additional Information Sufficient to pay? NO Deny the claim 13

14 Federal Register / Vol. 70, No. 184 / Friday, September 23, 2005 / Proposed Rules. p Provider Billing Application Conversion utility translates X12N 275 data for Payer Application Auto Adjudicate? Yes Payment criteria met? NO Yes NO X12N 275 with Attachment as Structured data Utility splits X12N 275 away from CDA based attachment Conversion utility translates CDA attachment data for Payer application Make claim and attachment available for manual adjudication Adjudicating staff views attachment via a web browser (using XSL style sheet) Notify provider of reason for denial Pay provider 14

15 Effective Information Integration is vital for Claims Attachments realization Payer Clearing Houses Providers Institutional /Professional Pharmacy Benefit Managers & Third Party Administrators Employers Subscribers Information Integration Capabilities 1. Integrate Administration and Financials SOA enablement Event driven processing Content based routing Complex transformation 2. Master Data Integration Data search, validation, audit Standardization Matching & survivorship Content integration Federated information access 3. Underpin Analytical Services Parallel execution Metadata management Data transformation Connectivity Federated access UIMA support Replication 15

16 Claims processing requires timely synchronization of complex information, inside and outside the healthcare enterprise EDI Document (837D, 837P, 837I,275) Healthcare HUB EDI Document (997, 277, 824, 835) 1. Integrate Administration & Financials Load ODS WebSphere DataStage TX HIPAA & EDI Pack Retrieve original Claim Data Update Claims System Claims Adjudication System Return Result Route Dental Claims Dental Adjudication System 16

17 Synchronized claims processing information can be integrated with member master data in real time Member Information Management Jerry O Donnell 2. Master Data Integration EDI Document (997, 277, 824, 835) EDI Document (837D, 837P, 837,275) Load ODS Healthcare HUB Internal: J. O Donnel Dependent: JJ Internal: Patient: A1 Dependent: JJ-99 Finance: ABC 123 Patient: A Finance: ABC 123 Integrate Structured & Unstructured Information Update Claims System DataStage TX HIPAA & EDI Pack Retrieve original Claim Data On Demand Check Master Member Index Consolidated EHR Claims Adjudication System Return Result Route Dental Claims Dental Adjudication System SOA Edition QualityStage & Content Edition 17

18 IBM Information Integration Solutions provide a mechanism for effective information integration for Healthcare IT initiatives Migrate and consolidate applications Claims processing streamlining Disease management Fraud detection and control Harvest research and clinical data Health and wellness management Single view of the member/ patient Market to the individual IBM WebSphere Information Integration platform Service-Oriented Architecture Understand Cleanse Transform Federate Discover, define, model, and govern information quality and structure Data Standardize, merge, and correct information Transform and enrich information Integrated Metadata Management Parallel Processing Connect Virtualize access to disparate information Content Access, publish, and replicate information 18

19 WebSphere Business Integrator Message Broker with WebSphere DataStage TX: Unparalleled Capabilities, Unparalleled Value Complex, Hierarchical Data Transformation and additional support for industry standards + Powerful Enterprise Services Bus Solution Industry Packs (SWIFT, EDI, HIPAA, HL7) optional WebSphere DataStage TX Complex Transformation Engine WebSphere DataStage TX Plug-in for WebSphere Message Broker WebSphere Business Integrator Message Broker The Most Powerful Any-to-Any Integration Broker in the Market XSLT transformation Compute ESQL transformation Compute Java transformation Mapping transformation 19

20 Enhance the Transformation Capabilities of your ESB Scenario Customer needs to enhance existing transformation capabilities for complex, hierarchical data processing Customer needs broad industrystandard data format libraries and support Value Reduce your hand-coding and development time for new applications and complex integrations Extends your current MQ & Broker investments Common, codeless method for all transformation types WebSphere Offerings Core: WebSphere Business Integration Message Broker WebSphere DataStage TX Extended: Industry Packs, Adapters 20

21 HIPAA Data Integration Ingredients Hospitals Partner administration Transaction validation Auditing / error handling Alert generation Message routing Logging / archiving Partner Profiles Doctors VAN / PRIVATE NETWORK HTTP FTP VANs Trading Manager Applications Resource Integration Patients HC Data services INTERNET Output marshalling Target resolution Adapter invocation Routing and Distribution IBM WebSphere DataStage TX File System Clearing Houses Semantic Transformation UB92 to HIPAA NSF & CMS flat files XML to HIPAA Adjudication API to HIPAA Message queues Databases File directories Event Manage -ment Resource Integration Applications Middleware DBMSs File systems System services Message Queue Database 21

22 The IBM WebSphere DataStage TX Healthcare products and services Pack for HL7 Ver. 2.1, 2.2, 2.3 Ver. 3.0 XML DTDs & Schemas Importers and adapters CDA Schemas Importers Pack for NCPDP Batch 1.1, Communication 5.1 Pack for HIPAA EDI All X12, NSF, UB92, CMS Flat Files Trading Manager X12, HIPAA, EDIFACT Healthcare HUB Solution 22

23 The Benefits of a Standards-based Approach to Information Integration Healthcare compliance solutions leveraging a standards-based approach to enterprise data integration provide: The Fastest Time to market and Highest Value impact The Easiest to maintain and most Responsive to changes The Highest ROI in terms of technology, hardware and personnel Extremely Scalable and Reliable solutions adaptable to existing IT infrastructures Support for the Complexity of integration paradigms LOWEST COST OF OVERALL OWNERSHIP LOWEST-RISK INTEGRATION APPROACH GREATEST OPPORTUNITY FOR SUCCESS 23

24 Information Management Thank You IBM Software Group 2005 IBM Corporation