RWJF & HHS Provider Network Challenge

Robert Wood Johnson Foundation & U.S. Health &

Human Services Provider Network Challenge

Informational Webinar

November 19, 2014

On Today’s Call: Katherine Hempstead, Director of Coverage Robert Wood Johnson Foundation Richard Kronick, Director, Agency for Health Care Research & Quality U.S. Health & Human Services Reed Mollins, Vice President, Business Development Doctor.com John Riney, Technical Evangelist PokitDok Alicia Davis, Challenge Manger Health 2.0 Graeme Ossey, Senior Challenge Manager Health 2.0

Agenda for the Webinar • Challenge Background and Goals • Overview of the Data Set • Overview of Challenge Details • Additional Resources • Q&A

Katherine Hempstead Director, Robert Wood Johnson Foundation

Richard Kronick Director, Agency for Health Care Research & Quality

Focus of Challenge • Allow consumers to determine which providers in

their network are conveniently located • Method of verification to determine if providers are

accepting patients under each insurance • Allow & crowd source patient reviews for providers • Allow consumers to search for providers based on

specific health needs and determine if insurance covers specific procedures.

What Are We Looking For? • Effective integration of the Health Insurance Carrier

Provider Network data • Creativity and innovation • Design, usability and intuitiveness of application • Potential to help consumers understand provider networks

and make informed decisions on choosing a provider • Potential and realistic plans for adoption in the community

Criteria to Apply • Business & nonprofit entities must be formed and

maintain a principal place of business in the U.S. • Individuals must be citizens or permanent residents of

the U.S. • Teams must have no more than 5 members • Individuals must be of legal age of majority, at the

time of entry, to form valid contracts I their respective jurisdiction of legal residence

Submission Requirements

Phase I: • A text description of the app or tool (no

more than 1500 characters) including what data were used, how they were used, need, solution and business plan for dissemination and use

• Wireframes or similar design layout of the application

• Slide deck of no more than 10 slides describing the app and operating plan (in PDF format)

The challenge will take place in two phases. Phase I will require teams to submit concepts and wireframes, while phase II will require working prototypes. The submission requirements for each phase can include (but not limited to):

Phase II: • All of the above • A video pitch (no more than 5 minutes)

describing the app/tool and how it would be used by the public to make better health plan purchasing decisions

• Link to working application

Prizes & Timeline • Prizes

• Phase 1: • Five (5) finalist will receive $5000 • Phase 2: • First Place: $50,000 • Second Place: $15,000 • Third Place: $10,000

• Timeline • Challenge Launched September 22, 2014 • Applications for Phase I will be due on March 6, 2015 • Phase I Finalist Announcement : April 3, 2015 • Applications for Phase II will be due on July 10, 2015 • Phase II Winners Announced in August 2015

Q1 2014 Company Overview CONFIDENTIAL

2Bringing Consumer Expertise to the Healthcare Enterprise

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3The Power of Results Ranking

1. Eye-Tracking Analysis of User Behavior in WWW Search, Cornell University -- 2011

4Implementation Example: Facility Profile Page

API Introduction for

RWJF Provider Network Challenge Webinar

Hello!

John Riney Technical Evangelist

john.riney@pokitdok.com

API Overview With our platform, access simple X12 processing, our comprehensive provider listings, and proprietary cash pricing data for healthcare procedures. Our documentation guides you through testing the APIs from the command line & how to use our open-source client libraries for Python, Ruby, Java, C#, NodeJS, and PHP.

The Power of our Platform E-Commerce Marketplace APIs

Providers Search for providers from one of the largest provider directories. Our directory provides biographical information, education, credentialing and other quality and business information. Use this API to let customers select providers based on a variety of factors.

Cash Prices Based on our proprietary database, this API calculates the average cash price providers within a certain geographic area charge for a specific service. This is a good reference point for customers to use when selecting a provider for services or for selecting a geographic area to obtain those services.

Insurance Prices Based on our proprietary database, the Insurance Prices API calculates the average price for a service that providers are submitting to insurance carrier within a specified area. This information can be used by customers to get an idea of how much they might save between a cash price or insurance price. It can also be used as a guide to select a geographic location for obtaining health care services.

X12 Claims & Eligibility

Authorization API (ANSI 278) The Authorizations API allows an application to submit a request for the review of health care in order to obtain an authorization for that health care. This lets you determine if a given procedure or service is covered under a patient’s plan.

Claims API (ANSI 835/837) Submits a Professional CMS 1500 claim to the specified insurance carrier. Please note, the Claims API only submits claims to an insurance carrier, it does not scrub claims. This API can be used to make sure a patient’s up front cash payment counts against their deductible.

Claims Status API (ANSI 276/277) Checks with the insurance carrier what the status of a claim is. It has information on the outstanding claims for a patient, and what claims have been received, are being processed, or have been finalized. This is especially important for office billing managers who need a complete picture of where high dollar claims stand on a real time basis.

Eligibility API (ANSI 270/271) Checks to see if your customer is a current and active member of specific health plan. It’s currently available for 152 health plans, covering 71% of covered lives across the U.S. It provides information on what the customer’s deductible is and how much has been satisfied, helping to calculate a customer’s out-of-pocket expense for a healthcare transaction.

X12 Claims & Eligibility, Continued Enrollment API (ANSI 834) The Enrollment API allows the enrollment of new members into an insurance plan, updating of information, or changes the status of a member’s enrollment. An insurance broker or plan administrator would use this API to electronically enroll a customer or make benefit changes in the case of a life event.

Plans API The Plans API can check a customer’s insurance carrier and see what their plan design is. This information is used in determining the benefits, copayments or coinsurance a patient has.

Referrals API The Referrals resource allows an application to request approval for a referral to another health care provider.

Trading Partners API This utility API lets you determine what trading partners we connect with and what transactions they support.

Getting Started

Sign up at

platform.pokitdok.com

Questions?

platform@pokitdok.com

Questions? www.health2challenge.com

http://bit.ly/provnet2

Contact Alicia Davis at:

alicia@health2con.com