CYE ’09 Prospective Offeror Technical Overview. Introduction Technical Environment Interfaces Recipient/Health Plan Provider Provider Affiliation

CYE ’09 Prospective

Offeror Technical Overview

CYE ’09 Prospective Offeror Technical Overview

Introduction Technical Environment Interfaces

Recipient/Health Plan Provider Provider Affiliation Reference Encounters Reinsurance HIPAA

Questions


Provide all potential offerors with an overview of AHCCCS technical environment and data interface and standards.

INTRODUCTION



PSTN

Internet

Frame Relay

Telephone

Contractor

Firewall

HTTPS Server

Mainframe

PBX

VPN

AHCCCS Network Connectivity All information presented on this page is confidential.



•Interfaces•Recipient/Health Plan

•Encounters

•Provider/Provider Affiliation

•Reinsurance

•Reference

•Eligibility•Enrollment•Capitation•Processing•Data Exchange




DES

SSA

ACE

OTHER

ELIGIBILITY ADDS

DISCONTINUANCE

CHANGE TO

DEMOGRAPHICS

NAME

GENDER

DATE OF BIRTH

CHANGE IN ADDRESS

CONTRACTOR CHOICE

THIRD PARTY LIABILITY LEADS


DES

•1931

•S.O.B.R.A.

•TITLE 19 WAIVER

•HIFA PARENTS

•FEDERAL EMERGENCY SERVICES


DES

•SSI CASHSSA


DES

•ALTCS (ARIZONA LONG TERM CARE)

•SSI MAO

•FREEDOM TO WORK

•BCCTP

•MEDICARE COST SHARING

•KIDSCARE/HIFA PARENTS

•SSDI/TMC

SSA

ACE


DES• BEHAVORIAL HEALTH SERVICES

• CHILDRENS REHABILITATIVE SERVICES

• DES SPECIAL NEEDS (DDD)

• MEDICARE

• MEDICARE BUY IN

• MEDICARE HMO

• MEDICARE PART D

• VITAL STATISTIC (DOD)

SSA

ACE

OTHER



PRE-ENROLLMENT

Eligibility site provides Contractor availability information

Some eligibility sources will collect and send enrollment choice information or

Member may call Communication Center with choice

Member is enrolled in choice Contractor


BABY ARIZONA

Pregnant woman screened by Doctor

Application completed in Doctor’s office and sent to DES

Woman calls Communication Center from Doctor’s office with her choice of contractor

Member is enrolled in choice Contractor


ENROLLMENT DATES

Usually effective the day AHCCCS updates action

ProspectiveEnrollments

As of the 1st

of the next month(The Last Daily)

AdministrativeActions

Can be any day in the past

(Any Daily)

SystemUnavailable at

NotificationCan be retroactive

(Month End)

EXCEPTIONS:


DISENROLLMENT DATES

Normally effective the day prior to update

Date ofDeath

(Retroactive)

IncarcerationInstitutional

(Normal orRetroactive)

Linking / Duplicate

Enrollment


Administrative


For loss of eligibility, disenrollment is last day of month

VoluntaryWithdrawal

(Normal)

EXCEPTIONS:

CMDP(Foster Care)

(Normal)


COUNTY MOVES

Disenroll from current county effective day before and

Moves to a county which is served by current Contractor

enroll with same contractor in new county

Remain with contractor until end of month

Moves to a county which is NOT served by Contractor

Or until member chooses new Contractor

Member is AA if no choice is made by end of month

County to county move

County move with choice


ENROLLMENT RULES

90 day re-enrollment

Newborns

Family continuity

Enrollment choice

Native American on reservation zip code

Auto assignment

Less than 30 days of eligibility


ANNUAL ENROLLMENT CHOICE (AEC)

Each member case is assigned an anniversary month

AEC letter generated two months in advance

Members with Choice file generated to ContractorIdentifies all Contractor’s members who have opportunity to make a Contractor choice

Member makes choice

Potential Transitional ListingIdentifies all members who have made an AEC choice of the ContractorFile placed on VPN server with name of mmddyy.PTL

File placed on VPN server with name of ccyymm.MWC


OPEN ENROLLMENT

Special process when neededContractor terminationNew Contractor

Auto Assign population

Member makes choice (optional)

Potential Transitional ListingIdentified all member who will be enrolled into gaining contractor and those who will be leaving the losing contractor

Generate letter with AA Contractor with choice material

File placed on VPN server with name of mmddyy.PTL


ID CARDS

A file generated daily to vendor

Cards created for

Initial enrollment

Change of Contractors

On request to Communications Center

Lost / damaged / never received

When a new card is issued the old card is inactivated

Not a guarantee of eligibility or enrollment



CAPITATIONContractors receive weekly payments

Activity based on enrollment actionsCapitation calculated on

Contractor

GSA

Contract Type

Rate Code

Capitation calculated on per diem basisRate Days in the month days of enrollment thru end of month

Contractors receive payment notification via weekly 820 files


CAPITATIONRecoupments are subtracted from Contractor’s

weekly payments

Rate Days in the month days of disenrollment thru end of month

Recoupment calculated on per diem basis

Contractors receive payment notification via

weekly 820 files


SPECIAL PAYMENTS

Delivery SupplementalPaid when Contractor notifies AHCCCS of birthMother was enrolled with Contractor on DOBMother was not in PPC period on DOBOne Delivery Supplemental paid per delivery

Multiple births are considered one delivery

Payment made on Mother’s record


MASS ADJUSTMENTSAbility to change capitation payment for a population (Risk Group)

Payments which were paid in the past

Contractors receives notification via 820 file

No enrollment activity

Only reflect changes of payment due to change in payment rate


MANUAL PAYMENTS

Error in record prevents enrollment/disenrollment action from appearing on daily 834 fileManual capitation correction on an individual record

Activity will also appear on Manual Payment file

When no capitation is involved

Manual notification to Contractor

Payments will appear on the weekly 820 file



UPDATESOnline eligibility and enrollment updates to PMMIS occur between 6 am and 6 pm daily

Eligibility data created by AHCCCS by 5 pm will be process the same day

Eligibility data received from DES or SSA after 5pm will be updated to PMMIS the next day

In the event a member needs services and the Contractor has not received the daily 834 file, enrollment for the member can be verified using one of the automated verification processes.


DAILY BATCH PROCESSING CYCLE

Start at 6pm every evening

834 files available to Contractors no later than 7am

Enrollment activity includesEnrollmentsRetroactive enrollment blocksDisenrollments

Disenrollment blocksDemographic changes

Email notification if files will be delayed


‘LAST DAILY’ PROCESSING CYCLEThird day before the 1st of the next month

1/29/08, 2/27/08, 3/29/08, 4/28/08, etc

LAST DAILY

29

3130

282726252423

22212019181716

1514131211109

8765432

1SATFRITHURWEDTUESMONSUN

MARCH 2008



Starts at noon if on weekdays, 2am on weekendsMonthly process schedule available on AHCCCS Web site

Activity includesEnrollments, Retroactive enrollment blocks

Disenrollments, Disenrollment blocks

Demographic changes

Rate Code Changes

‘LAST DAILY’ PROCESSING CYCLE

ftp://ftp.azahcccs.gov/content/notice/hplan/hplan.htm#downtime

Third day before the 1st of the next month1/29/08, 2/27/08, 03/29/08, 04/28/08, etc


Occurs immediately after Last Daily CycleMonthly Enrollment Notification

Full file of all members enrolled in Contractor as of the 1st of the month

Basis for prospective capitation payment

File to be used to validate Contractor’s data

Discrepancies in Contractor’s data to be reported to DHCM

Management Reports

MONTHLY PROCESSING CYCLE


Starts at 6pm after completion of Monthly CycleOutput files available to Contractors by 7amIncludes all enrollment activity since last daily

Enrollments & Retroactive enrollment blocksDisenrollments

Will recoup prospective capitation already paidDisenrollment blocksDemographic changes

These must be processed after Last Daily and Monthly Enrollment Notifications

‘NEXT DAILY’ PROCESSING CYCLE


LAST DAILY

29282726252423

22212019181716

1514131211109

8765432

1SATFRITHURWEDTUESMONSUN

MARCH 2008

30 31NEXT DAILY

NEXT DAILY



VERIFICATIONObtain Eligibility, Enrollment, Medicare and TPL Coverage

•Single date of service•Range of days

•IVR

Automated processes available to AHCCCS registered providers

•MEVS•WEB

Communications Center available to AHCCCS member and providers

Contractors are encouraged to have their providers use the automated verification processes


VERIFICATION

Integrated Voice Response (IVR)

Telephone based verifications Available 24/7 No cost to providers Information faxed back to local area providers

Requires input of AHCCCS ID or SSN Real Time inquiry

Single Request


VERIFICATIONMedicaid Eligibility Verification System (MEVS)

PC or POS based verifications Available 24/7 Hardware/software provided by contracted vendors Contracted vendors charge providers

Requires input of AHCCCS ID or SSN or key demographic information Real Time inquiry Single or batch request

Ability to print information


VERIFICATION

WEB Based Verification

Internet based verifications Available 24/7

No cost to providers

Requires advance registration

Requires input of AHCCCS ID or SSN or key demographic information Real Time inquiry

Ability to print information


VERIFICATIONCommunications Center

Staffed by Customer Service Representatives Limited to business hours availability

No cost to providers Provides service to members and providers

Problem research and resolution Real Time inquiry

Accepts Newborn notifications from Contractors

Not available weekends


DATA EXCHANGEFrom AHCCCS to Contractors

Daily FilesEnrollment Notification (834)

Rate Code Summary

Manual Payment file

Third Party Liability File (in addition to 834)

Active Care File

Prior Plan File

yymmdd.DLR

yymmdd.MPR

yymmdd.DRC

yymmdd.TPL

yymmdd.ACR

yymmdd.PPL



Weekly Files

Capitation Notification (820)yymmdd.820



Monthly FilesEnrollment Notification (834)

Rate Code Summary

FYI data is included in 834

Members with Choice file

Potential Transitional Listing

Management Summary Reports

ccyymm.MTR

ccyymm.SUM

ccyymm.MWC

yymmdd.PTL

http://www.azahcccs.gov/Statistics/



Unscheduled Files / As needed

Open Enrollment

Potential Transitional Listing

Mass Adjustment

Capitation Notification (820)


DATA EXCHANGEFrom Contractors to AHCCCS

Third Party Liability Updates

Electronic file

Newborn Notifications

Phone call Real Time entry/update


TESTING

Testing must be completed prior to:

Production implementation of a new Contractor

Change in software vendor or version upgrade

Change by AHCCCS resulting in an impact to any data exchange

Must be completed prior to any implementation



AHCCCS has contracts and agreements with Contractors, the AHCCCS Pharmacy Benefit Manager and other AHCCCS contractors to deliver medically necessary services to members.

AHCCCS requires that all providers utilized by Contractors to provide these services be registered with AHCCCS.

WHAT IS PROVIDER?


PROVIDER INTERFACEConsists of two files found in the VPN ShareINFO folder

Provider Profile

Provider Record

Produced weeklyCreated every WednesdayAvailable to Contractors Thursday

Provider Includes all provider types, service codes, and categories of service

Includes all AHCCCS registered providersIncludes active, terminated and suspended providers

Name: PROFILE.ZIP

Name: PROVIDER.ZIP


PROVIDER INTERFACEData included

Demographic dataProvider statusCategories of serviceService ratesLicenses/certificationsSpecialties

Medicare coverageRestrictionsService/billing addresses



PROVIDER AFFILIATION TRANSMISSION

The Provider Affiliation Transmission (PAT) is an integral part of the monitoring process in the Division of Health Care Management (DHCM) to ensure that Contractor’s provider networks are adequate and meet the minimum contractual requirements to deliver medically necessary services to members. This information is also used for reporting to CMS, legislature and other entities.

These requirements are presented in the AHCCCS Provider Affiliation Transmission User Manual.



Submitted quarterly Includes information about each individual provider within the Contractor’s network

Each PAT must represent the Contractor’s entire provider network

Contractor is responsible for submitting true and valid information Certain fields of the PAT are not systematically edited prior to acceptanceEach PAT must have an error rate of less than 3.0% for the fields that are edited prior to acceptance



If incorrect, Contractor may be considered to be noncompliant with obligation to submit an accurate PAT

Contractor may be required to make corrections immediately, submit a corrective action plan and subject to sanctions

AHCCCS conducts verification procedures to monitor accuracy of data submitted


PROVIDER AFFILIATION TRANSMISSIONReports

Transmission Validation Report

Provides information about the status of PAT

If all conditions are met, the transmission passes and is accepted for loading

If transmission fails, the transmission is rejected and returned to the Contractor for correction and resubmission

Found on VPN server under LGmmddyy.TXT



Reports

PAT Comparison-Exception by Provider

Provides a list of all exception errors that occurred during the PAT load process

All exception errors must be corrected prior to next submission

Sorted by Provider ID

Aids the Contractor in error correction

Found on VPN server under EPmmddyy.TXT



Reports

PAT Comparison-Exception by Field

Provides a list of all exception errors that occurred during the PAT load process

All exception errors must be corrected prior to next submission

Sorted by field in error

Aids the Contractor in error correction

Found on VPN server under EFmmddyy.TXT



Reports

PAT Comparison-Detail Report

Provides a complete list of all PAT data loadedSorted by Provider ID

Found on VPN server under LDmmddyy.TXT



Reports

Summary Totals Report

Provides summarized information about the providers listed on the PATIncludes totals of

PCPsPCPs with EPSDT servicesPCPs with OB servicesOB providersBH providers

Found on VPN server under ‘STmmddyy.TXT



REFERENCE

Recipient produces one reference fileMaster Carrier ID file

Complete file of TPL Carrier ID numberProduced every FridayPlaced in the ShareINFO folder as ‘RFCARIDmmddyy.TXT’


Three Encounter Reference files producedInternal Field Information

Error to Internal Field relationship

Error Codes and Descriptions

Provides mapping of Field name on a specific Form to an Internal table and Field name/number

Provides mapping for each Error Code on a specific Form and which Fields are used

Provides each Error Code and description

REFERENCE

Found in ShareINFO folder on VPN with name of ECFLD.TXT

Found in ShareINFO folder on VPN with name of ECERRFLD.TXT

Found in ShareINFO folder on VPN with name of ECERR.TXT


REFERENCE

Four service code related Reference files are produced

Procedure Tables

Procedure Modifiers

Provides Procedures, Maximum Allowable Charge, Categories of Service, Revenue to Bill Types and Revenue to Procedure Code information

Provides valid Modifiers for Procedure Codes

Found in ShareINFO folder on VPN with name of REFER01.ZIP



REFERENCEOutpatient Fee Schedules

ASC Group Reference

Provides OPFS Procedures Indicators and Values, Bundled Rate Driver Codes, Bundled Revenue codes, CCI Codes, Multiple Surgery Exception Codes, Limit Override Modifiers, Override Modifier Action Codes, Valid OPFS Procedure Modifiers and Limit Override Procedures

Provides valid ASC Group Bundled Service codes





AHCCCS ENCOUNTERS

The contents of an encounter record must meet the requirements prescribed by the Centers for Medicare and Medicaid Services (CMS) and accepted by AHCCCSA.

These requirements are presented in the AHCCCS Encounter Reporting User Manual.


ENCOUNTER SUBMISSION

Submitted by Contractor

837 FILES

HIPAA 837P (Professional)

HIPAA 837I (Institutional)

HIPAA 837D (Dental)

NCPDP V5.1 (Pharmacy)

Further details can be found in the Implementation Guides and AHCCCS Companion Documents


SUBMISSIONS

Submission standards are defined in the Encounter Reporting User Manual

AHCCCSA defines the receipt date for encounters as the date the encounter is received on the AHCCCS FTP server


SUBMISSIONS

Encounter data is loaded daily to a mainframe staging area where the encounter is held until loaded for processing

A copy of the encounter in its received form is maintained in a staging area

Contractors may submit as often as they deem necessary as each file is date and time stamped on the server


TECHNICAL ASSISTANCEThe Encounter Operations Technical Assistance staff are available Monday through Friday (excluding State holidays) to assist Contractors in resolving encounter errors or to research specific encounter issues.

Contractors are notified of the name and telephone number of their assigned Technical Assistant, who is their main point of contact for encounter related issues.

Encounter Operations Unit offers training on how to correctly submit encounters

•This training is mandatory for new Contractors and is available to existing Contractors as requested.


SET UP

Before a Contractor may submit encounter data, AHCCCS requires the completion of certain agreements, authorizations and control documents. These documents are as follows:

Form 1:Contractor Encounter Submission Notification and Transmission Submitter Number (TSN) Application

Form 2:Electronic Data Interchange Agreement Form


PROCESSING CYCLEEncounters now process twice monthly beginning at 5:00 P.M. on the 1st Friday after the 1st Wednesday of the month and on the 3rd Friday of the month

The 1st cycle of the month is a complete process to include Reinsurance Case Creation and processing

The 2nd cycle processing is equal to the 1st cycle except is does not include Reinsurance Case Creation and processing, and only includes Voids/ Replacements not associated with RI Cases


PROCESSING CYCLEBoth Cycles include:

CRN Assignment

Edits and Audits

File and Report generation


PROCESSING CYCLE

Encounters are processed through Validation

Submitted data can be viewed / modified in Transaction Insight. This is a web based productAcknowledgements (997,824,TA1) are returned

Data is translated for the adjudication system

Pend Files and 277U transactions returned after cycle


FTP Server

Mainframe

Internet

Contractors

CommunityManager

TransactionInsight

Validation Translation

Good and Bad

Transactions

ModifiedTransactions

837 (P,I,D) NCPDP

Transactions

Acknowledgement Return

(997, 824, TA1)

ValidTransactions

Pend and 277U Response files

TranslatedTransactions


TESTINGNew Contractors must go through a testing phase before submitting official encounter data to AHCCCSA.

Prior to beginning the testing phase, Contractors must have provided all necessary control documents to the AHCCCS Encounter Manager, and has been assigned a Transmission Submitter Number (TSN)

Technical assistance is available from Encounter Operations Unit staff during the testing period.

When AHCCCSA verifies that a Contractor has successfully completed the testing process, the Contractor will be allowed to begin submitting encounters.

A training session for the Contractor and/or designated subcontractor is scheduled during which the testing process will be reviewed.


TESTING (cont’d)

Initial Testing begins with Community Manager. This product validates Encounter transactions against our Implementation Guide. This product is web based

Next set of testing involves submitting Encounters to the FTP server for processing



WHAT IS REINSURANCE?Reinsurance is a method of partially reimbursing Contractors when the cost of care for a member for reinsurance covered services exceeds a deductible amount within a Contract Year.

The deductible is based on the number of statewide members enrolled with a Contractor at the beginning of a Contract Year

Services covered under reinsurance are detailed in contract and in the Reinsurance Processing Manual. Not all AHCCCS covered services are covered under reinsurance.

All members (with limited exceptions) enrolled with a Contractor that meet the deductible limits are eligible for reinsurance


WHAT IS REINSURANCE?AHCCCS also provides for reconciliation and adjustment of RI payments as needed in which Encounters used in RI payment calculation are replaced or voided.

The RI system generates the following monthly reports:Reinsurance Case InitiationReinsurance ReconciliationReinsurance Case SummaryReinsurance Remittance Advice

Upon the creation of a RI case the Encounters are processed through the RI edits/audits.

AHCCCS established RI cases using a monthly process that scans the Encounters database for approved, historical Encounters for each Contractor’s members.

The monthly RI Case Creation cycle runs after the 1st

monthly Encounter cycle


PROCESSING

RI cases are generated automatically by AHCCCS based on Encounter data (with limited exceptions). An on-line interface allows the Contractor to view RI data.

After an RI Encounter passes edits/audits and is approved, the RI payment process calculates the amount due the Contractor.

The Contractors can change the RI Encounters using the Reinsurance Correction Process via the PMMIS on-line system.

The Reinsurance Remittance Advice is then processed by the Finance system for payment to the Contractor. Contractors are required to notify AHCCCS of any third party coverage identified in a Reinsurance case.


CATASTROPHIC REINSURANCEProvided to partially reimburse Contractor for the cost of care for a member who meet the criteria and requirements for Catastrophic Reinsurance.

Contractor is responsible for identifying members and submitting written notification to the Division of Health Care Management (DHCM), Medical Management Unit.

Supporting medical documentation must accompany request. Details are include in the Reinsurance Processing Manual


TRANSPLANT REINSURANCE

Provided to partially reimburse Contractor for the cost of care for a member who meet the criteria and requirements for Transplant Reinsurance.

Covers members eligible to received AHCCCS covered solid organ or tissue transplants

Contractor is responsible for identifying members and submitting written notification to the Division of Health Care Management (DHCM), Medical Management Unit.


REPORTINGREINSURANCE CASE INITIATION

Recipient’s Name, AHCCCS ID and Case Type

Case Initiation Date

Associated Encounters in case by CRN

REINSURANCE CASE RECONCILIATIONShows Encounters that could be associated to an existing Reinsurance case when the Encounter Pend is cleared.

Case Type, Recipient AHCCCS ID and Reinsurance Case Number

CRN number of pended Encounter


REPORTING

REINSURANCE CASE SUMMARY

Shows members by Contractor with RI cases.

Recipient’s Name, AHCCCS ID and Case Type

CRN (Claim Reference Number)

Coinsurance percentage and status

Total Case Value

Deductible

Total Paid



HIPAAHIPAA Implementation Guides can be purchased at

http://wpc-edi.com/

AHCCCS Companion Documents can be found on our website or bidder’s library with additional information

http://www.azahcccs.gov/commercial/EDIresources/EDIresources.aspx

Next phase (2008) outbound 820s, 834s, 277Us will be processed through the Validator

Currently all 837s and NCPDP5.1 files are processed through the Validator

During this contract period 2008 – 2012, HIPAA transactions will be upgraded from the 4010A1 to the 5010 versions


QUESTIONS