Click to edit Master title styleICD-10 Status June 2015 · > The 5010 claim form file format supports ICD-9 and ICD-10 codes and qualifiers. ... Track®). Testing included: o Receipt

Click to edit Master title style ICD-10 Status June 2015

> Testing scope

> Testing approach and evidence

> Operational readiness metrics and process

> Episodes of care test evidence documentation

> Episodes of care test scenarios

> Episodes of care test scenario: Mary Maternity

> Summary

2 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna

AGENDA

> The 5010 claim form file format supports ICD-9 and ICD-10 codes and qualifiers. > We performed internal testing of Cigna systems and conducted external door-to-door

claim intake testing with major clearinghouses (e.g., Emdeon®, Optum, and Post-n-Track®). Testing included: o Receipt of ICD-9 and ICD-10 coded test claims. o Confirmation of accept and reject logic based on date of service or discharge. o Routing of claims to all Cigna business units. o Processing and payment of both ICD-9 and ICD-10 claims. o Return of the following 5010 industry standard transactions: 999, 277, and 835. o Successful processing inpatient and outpatient hospital claims, professional

claims (including office visits), behavioral health, lab, radiology, and surgical claims with major vendors and trading partners.

> Inpatient diagnosis-related group (DRG) study was completed with ten hospitals. Any shifts in DRGs were related to coding inconsistencies between ICD-9 and ICD-10 based on medical records information. Cigna’s study aligns with industry results, which is less than a 1% shift.

TESTING SCOPE


Internal and external testing

Test evidence > Episodes of care test results show

claims are processed and priced the same in ICD-9 and ICD-10.

> Test evidence will be shared in a consistent, easy-to-interpret format and will be published on the Cigna for Health Care Professionals website (CignaforHCP.com).

> Test evidence provides documentation of Cigna’s readiness to support our clients, vendors, and health care professionals.


TESTING APPROACH AND EVIDENCE

Episodes of care testing approach > The episodes of care represent the

most common claim situations and are areas of particular interest to Cigna, as well as our trading partners, vendors, and major clearinghouses.

> The Cigna Information Protection (CIP) policy prohibits use of client, customer, and health care professional production data for testing.

> Information Technology (IT), business teams, and a certified coder worked together to populate the test platform with production-like benefit plans, customers, health care professionals, contracts, and fee schedules.

> Test contract types included, but were not limited to, percent of charges, fee for service, case rate, per diem, and all DRG types.

> We have identified key metrics for leading indicators.

> We have identified key metrics for lagging indicators.

> We have developed metric expectations and warning thresholds.

> We are creating plans for each metric to determine the approach if an unreasonable

variance is identified.

> We have designated accountable leaders within each Business and IT area to participate on the ICD-10 Operating Committee.

> We have defined the process for updating the ICD-10 Enterprise Dashboard and the governance model for review at daily meetings.

OPERATIONAL READINESS METRICS AND PROCESS


SAMPLE OPERATIONAL DASHBOARD


Completed by business area owners and reviewed by the ICD-10 Operating Committee

Business Area

Metric Goal /Range

Result AccountableContact

MetricContact

Status Action Steps

I/B Inpatient claim volume 15,000 - 30,000 11,539 TAKE ACTION Identify hospital, perform outreachI/B Professional claim volume 190,000 - 300,000 226,755 ACCEPTABLEO/B Inpatient claim volume 2,000 - 5,000 3,464 ACCEPTABLEO/B Professional claim volume 20,000 - 40,000 26,489 ACCEPTABLEI/B Claim Rejections (837) 1,000 - 3,500 2,244 ACCEPTABLE

Inpatient claim volume 5,000 - 10,000 5,012 WATCH Identify hospitalProfessional claim volume 5,000 - 10,000 4,975 WATCH Identify hospital

TTP % < 14 Days 92.00-94.00% 92.97% ACCEPTABLETTP % > 14 Days 6.00-8.00% 7.00% ACCEPTABLETTP % < 30 Days 97.00-98.50% 97.50% ACCEPTABLETTP % > 30 Days 1.50-3.00% 2.00% ACCEPTABLEAuto Adjudication Rate (AA) 75.00-80.00 77.80 ACCEPTABLEAdjustment Inventory 25,000-35,000 30,688 ACCEPTABLEAdjustment Inventory % >30 Days 0.00-1.00% 0.50% ACCEPTABLEAdjustment Inventory > 30 Days 0.00-0.25 0.15 ACCEPTABLE

Correspondence Inventory 30,000-40,000 35,091 ACCEPTABLECorrespondence Inv % >30 Days 3.00-4.00% 3.27% ACCEPTABLECorrespondence Inv > 30 Days 1,000-2,000 1,146 ACCEPTABLE

Volume (Provider & Member) 80,000-90,000 88,001 ACCEPTABLEAbandonment Rate (Provider & Member) 20.00-25.00 21.50 ACCEPTABLECall Handle Time 415-435 427 ACCEPTABLEAverage Speed to Answer 300-310 305 ACCEPTABLE

Status Key:AcceptableWatchTake Action

*There will be a separate tab for each line of business

Call

Complaints/Appeals

Claim

Paper Claims

Claim Intake

EPISODES OF CARE TEST SCENARIOS


TEST DATA ONLY

Episode of care

Claim type

1 Mary Maternity

Initial office visit, lab panel, delivery, obstetrician (OB) delivery charges

2 Joe Joint Replacement

Inpatient hospital, surgeon charges, durable medical equipment (DME) for wheelchair rental, physical therapy

3 Polly Preventive

Over 50 colonoscopy: Preoperative visit, procedure at clinic, and surgery; mammogram and interpretation

4 Paul Preventive

Well baby visit with immunization and lab

5 Carlton Cardiac

Ambulance, inpatient hospital, surgeon charges

6 Betty Behavioral

Substance abuse rehabilitation, psychology visits


Testing purpose: Validate claims will be processed the same in ICD-9 and ICD-10 ICD-10 test compliance date: 9/1/2014 Patient/benefit plan

Gender: Female Date of birth: 6/21/1969 Relationship: Employee Deductible: $200 per year in network Out-of-pocket maximum: $1,000 per year in network Coinsurance: 90% Preventive care: 100%

Claim Test script IDs Description Business processes tested

1 P10582_ICD10_EoC_1.0.1a (ICD-9 claim) P10582_ICD10_EoC_1.0.1b (ICD-10 claim)

Outpatient professional claim for the initial OB visit with lab services conducted in the physician’s office.

Claim intake Benefit plan and copay Pricing (same for 9 and 10) EOB and EOP* generation


Outpatient professional claim for the maternity lab panel.

Claim intake Benefit plan and copay Pricing (same for 9 and 10) EOB and EOP* generation


Inpatient hospital claim for delivery of baby.

Claim Intake Benefit plan and copay MS DRG** pricing (same for 9 and 10) EOB and EOP* generation


Inpatient professional claim for the OB delivery charges.

Claim Intake Benefit plan and copay Pricing (same for 9 and 10) EOB and EOP* generation

* Explanation of benefit and explanation of payment ** Medicare severity diagnosis-related groups

TEST DATA ONLY

EPISODE OF CARE 1: MARY MATERNITY


TEST DATA ONLY * Explanation of benefit and explanation of payment ** Medicare severity diagnosis-related groups

Test script 1: Initial OB visit with lab services conducted in the physician’s office

Claim type Description: Outpatient professional claim with bundled lab services Expected result: Gateway/claim engine accepts the claim based on date of service compared against the ICD compliance date

Claim shows field expansion to support ICD-10 Claim processes cleanly and all relevant codes are present on the claim Claim payment is the same for both ICD-9 and ICD-10 coded claims $41.37 finalized claim is charged against customer’s $200 deductible $0 is paid to the health care professional

Health care professional and contract Provider type: Practitioner – obstetrician-

gynecologist (ob-gyn) Contract type: Fee for service Discount: N/A

Claim data (both claims) Claim: Outpatient professional Point of service: Office (11) Non-ICD codes: 81025 (CPT) – Urine pregnancy test

99212 (CPT) – Office visit Billed charges: $125.00 Allowable charges: $ 41.37 Fee schedule for claim lines

Code Allowed amount 81025 $ 5.36 99212 $36.01 ICD-9 claim details ICD-10 claim details

Test script ID P10582_ICD10_EoC_1.0.1a P10582_ICD10_EoC_1.0.1b ICD diagnosis code 65960 O09529 Date of service 6/30/2014 9/1/2014

EPISODE OF CARE 1: MARY MATERNITY (CONT.)


Explanation of Benefits (EOB)


TEST DATA ONLY

ICD-9 claim

ICD-10 claim



TEST DATA ONLY

Explanation of Payment (EOP) Test script 1: Initial OB visit with lab services conducted in the physician’s office

ICD-9 claim

ICD-10 claim



TEST DATA ONLY

Inbound 837 x 12 record

ICD-9 ICD-10 HL*1**20*1~NM1*85*2*ICD-OBSTERICS MD OLYVIA*****XX*1003007089~N3*8013 BILLINGS AVENUE~N4*NEW YORK*NY*000010003~REF*EI*201412121~HL*2*1*22*0~SBR*P*18*1502023******15~NM1*IL*1*INB-MATERNITY*MARY****MI*U93031634~N3*76 GROVE STREET~N4*NEW YORK*NY*000010003~DMG*D8*19691013*F~REF*SY*915021914~NM1*PR*2*CIGNA*****PI*029053964~CLM*CYC1_ICD_1A_P0113*125***11:B:1*Y*C*Y*Y~REF*D9*CYC1_ICD_1A_P0113~HI*BK:65960~LX*1~SV1*HC:81025*50*UN*11***1~DTP*472*D8*20140630~LX*2~SV1*HC:99212*75*UN*11***1~DTP*472*D8*20140630~SE*28*0001~GE*6*1~IEA*1*000000001~

HL*1**20*1~NM1*85*2*ICD-OBSTERICS MD OLYVIA*****XX*1003007089~N3*8013 BILLINGS AVENUE~N4*NEW YORK*NY*000010003~REF*EI*201412121~HL*2*1*22*0~SBR*P*18*1502023******15~NM1*IL*1*ITB-MATERNITY*MARY****MI*U93031635~N3*03 LAURAS LANE~N4*NEW YORK*NY*000010003~DMG*D8*19690621*F~REF*SY*915021915~NM1*PR*2*CIGNA*****PI*029053964~CLM*CYC1_ICD_1B_P0113*125***11:B:1*Y*C*Y*Y~REF*D9*CYC1_ICD_1B_P0113~HI*ABK:O09529~LX*1~SV1*HC:81025*50*UN*11***1~DTP*472*D8*20140901~LX*2~SV1*HC:99212*75*UN*11***1~DTP*472*D8*20140901~SE*28*0002~GE*6*1~IEA*1*000000001~



The ICD-10 Operating Committee will support proactive communication to our partners.

> We have successfully completed internal and external testing for ICD-9 and ICD-10.

> We have published results of its episodes of care testing on the Cigna for Health Care Professionals website: CignaforHCP.com > Resources > Medical Resources > ICD-10

> Operational readiness contingency planning is in progress.

> Metrics have been defined.


SUMMARY

https://cignaforhcp.cigna.com/web/public/resourcesGuest/!ut/p/b1/hY7JboMwAES_JR9Q2bQJcDU4LAlbwhLiC2ITO6aCQPDXh_aedqQ5jPRGM4CAEJA-nqsinirax-1PJnxkqyLPaS7U1JOjQN2Bss657hcU4QbcNwC-EYL_9W8ghPvIrcXBXKfQYPLs1cxdTWxvPkKztplpJU4WXH0JYeZLhxKcAClammz3boD8Dvyxb2m0y8F#Z7_OG861HS0HGJPF0IP0CI1SS3085

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2015 Cigna

Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. “Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. All models are used for illustrative purposes only. THN-2015-238 6/15 © 2015 Cigna. Some content provided under license.

Documents

Click to edit Master title styleICD-10 Status June 2015 · > The 5010 claim form file format supports ICD-9 and ICD-10 codes and qualifiers. ... Track®). Testing included: o Receipt