Technical Consortium Meeting July 2014. Topics: Cost Sharing (Copay) Updates Encounter Claims Data...

Technical Consortium Meeting

July 2014

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Topics:• Cost Sharing (Copay) Updates• Encounter Claims Data Exchange/Blind Spots Updates• APR-DRG Project Updates• ICD10 Project Updates• FQHC/RHC Project Updates• PCP Rate Parity Project Updates• AHCCCS CRN Expansion Project (999 Lines)• TPL Workgroup• Other Updates

Reaching across Arizona to provide comprehensive quality health care for those in need

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Cost Sharing (Copays)• Additions and/or modifications under evaluation

and planned for 1/1/2015:o New mandatory Copay Levels, Services and Copay

Amounts for Expansion populations over 106% and Transplant Option 1 and 2 members

o Refinement of codes for existing Services categories for all Copay Levels


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Cost Sharing (Copays) (cont.)• Review of “draft Copays Matrix”


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Encounter/Claims Data Exchange/Blind Spots

o AHCCCS will manage an ongoing exchange of encounter and claims data to Contractors in order to eliminate “blind spots” for services provided to a member shared by multiple programs (In compliance with Federal privacy regulations); Contractors should use this information to develop short- and long-term strategies to improve care coordination

o Ongoing – provide at least quarterly; First 1/4ly report for January – March 2014 was run and distributed in April; and second 1/4ly report for April – June 2014 was run and distributed on 7/17 Reaching across Arizona to provide comprehensive

quality health care for those in need

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Encounter/Claims Data Exchange/Blind Spots (cont.) Planned additions to the Data Exchange include

the integration of - Medicare Paid Claims Data (Part D; D-SNP; Medicare FFS) – In progress

Quarterly data extracts are based on Claims and Encounters adjudicated within the reporting 1/4


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APR-DRG’s• On schedule for 10/1/2014 Implementation (based

upon Dates of Discharge) • Technical Workgroup meeting on an as needed

basis; Meeting materials available at http://www.azahcccs.gov/commercial/EDIresources/EDITechnicalWorkgroups.aspx

• 3 Key Forms of Project Documentation – o AHCCCS Policy Document o AHCCCS Ruleo AHCCCS DRG Calculator


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


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APR-DRG’s (cont.)• Finalized all Policy decisions and shared with all

Contractors (as well as 3M) as a component of the DRG Technical Workgroup; reviewing and responding to Contractor questions as submitted

• AHCCCS is currently Testing the 3M APR-DRG software

• Contractors will be provided with (in the next couple weeks) and will be required to successfully execute a defined set of test scenarios by no later than 10/1/14

• Contractor monthly project Milestone Reporting began in February, 2014


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APR-DRG’s (cont.)• Current DRG Project Milestones:

o Complete Requirements and Design - Completed - March 2014

o Complete Coding – Completed - May 2014o Internal Testing Begins – In Progress - May 2014o Internal Testing Ends - July 2014o External Testing Begins (all Contractors/providers/ATR):

ICD9/DRG Integrated End to End – In Progress - June 2014 ICD10/DRG Integrated End to End – October 2014

o System Implementation - September 2014


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ICD-10• The AHCCCS ICD10 Project was impacted by

Federal Legislation; direction from CMS as to timeframes and implementation requirements specifies a delay in implementation to 10/1/2015

• No impact to APR-DRG project timeframes


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ICD-10 (cont.)• Communication to Contractors – “It is AHCCCS’s

intent, as previously communicated, to continue to pursue finalization of our ICD10 system changes and to utilize the delay to expand the External Testing window afforded to our Trading Partners. We will also be soliciting feedback from each of our Contractors over the next few weeks as to your ability to or barriers from being able to follow the aforementioned approach to project timelines. Please do not stop work on your current timelines related to ICD10 project without first discussing revisions to your timelines with us.”


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ICD-10 (cont.)• “Revised” AHCCCS ICD10 Project Milestones

o Complete Requirements and Design – ReferenceCompleted

o Begin Coding – ReferenceCompleted

o Complete Requirements and Design – All other Completed

o Internal Testing Begins – ReferenceCompleted

o Begin Coding – All other System Areas In Progress

o Freeze Begins.....o System Implementation – Reference

Completedo Initial Reference Table Loads Completed


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ICD-10 (cont.)• Internal Testing Begins – System Areas In Progress• Internal Testing Ends – All System Areas September 2014• External Testing Begins (all Contractors/providers/ATR) (see detail)

o 837 Submissions – Claims/Encounters January 2014

o Claims/Encounters Editing and Results Reporting March 2014

o Reports June 2014

o ICD9/DRG Integrated End to End June 2014

o ICD10/DRG Integrated End to End October 2015

o Ongoing external testing supported through 9/30/2015


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ICD-10 (cont.)• System Implementation (with 10/1/2015 effective dates) – All

Systems September 2014 • Freeze Ends.....• External Testing Ends No earlier than September 2015

ICD10 Effective Date - October1 2015 (OP Dates of Services or IP Dates of Discharge)


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ICD-10 (cont.) Ongoing Contractor Milestone Reporting and

Tracking should continue until 10/1/15


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FQHC/RHC Project• FQHC/RHC Payment Alignment

o Contractor’s will need to pay FQHC/RHC unique PPS rates for each “visit” (separate service not with same discipline)

• Timeline o Targeted for a 1/1/2015 implementationo Provider registration letter and spreadsheet (In progress,

due by 8/15/14)o Testing window for Contractors and providers (beginning

in August 2014)


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FQHC/RHC Project (cont.)o AHCCCS will establish a unique provider type for FQHCs

and a unique provider type for RHCs; Provider types 29 and C2

o AHCCCS has requested and is working with all FQHCs and RHCs to register and obtain a unique AHCCCS Provider ID under these applicable provider types

o To facilitate this registration and AHCCCS claims processing, AHCCCS is requesting that FQHCs or RHCs have a unique NPI (not already associated with any other active AHCCCS Provider ID) to be on file and utilized for related claims submissions

o AHCCCS has provided a streamlined approach for provider registration


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FQHC/RHC Project (cont.)o FQHC and RHC claims will identify the unique NPI of the

FQHC or RHC as the service/rendering providero FQHCs and RHCs can be reimbursed on same day for

each “unique” visit, (.e. a separate service not within same discipline (e.g. dental and medical)); no change from the current process

o FQHCs and RHCs will bill AHCCCS and its Contractors for each “unique” visit utilizing appropriate CPT Evaluation and Management codes and including all related services for the visit utilizing a 1500 claim format

o FQHCs and RHCs will be paid an all inclusive "visit" rate per visit that will serve a full reimbursement for the individual visit regardless of other related services for the visit


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FQHC/RHC Project (cont.)o Visit payments will be paid associated with the billed E&M

“visit” codes and any other related services will be valued at $0.00

o AHCCCS will implement a unique Provider specific fee schedule (equivalent to the PPS rate) for each FQHC and RHC where visit E&M codes will reflect the appropriate per visit rate effective for the date of service and in which all other related service codes will reflect a rate of $0.00 (due to bundling under the per visit rate as noted above)

o Current FQHC Pharmacy (340B) billing will remain as is under the Pharmacy provider type, etc... and will not be impacted by this change


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FQHC/RHC Project (cont.)• AHCCCS will continue to have a quarterly payment and

reconciliation process (as needed) but the amounts that are part of the quarterly payments will be updated to reflect that fact that Contractors will be paying considerably more to avoid recoupments as part of the reconciliation


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PCP Rate Parity• AHCCCS will make quarterly cost-settlement

payments to the Contractor based upon adjudicated/approved, error free PCP Rate Parity encounter data

• Contractors will be required to refund payments to AHCCCS for any reduced claim payments in the event that a provider is subsequently “decertified” for enhanced payments as result of subsequent audits or other changes to providers

• A650/A655 Edits targeted to be changed to external pends for no later than 9/1/2014


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PCP Rate Parity (cont.)• “Catch-up” cost-settlement report for qualified

encounters adjudicated/approved between 8/1/2013 and 12/31/2013 a well as the first 1/4ly report for the January through March time period were run and distributed to Contractors; AHCCCS also ran Error Reports out of these processes for each plan of those items excluded due to Plan error or Federal claiming concerns

• Contractor Error Reports as noted above will be distributed to the plans for correction of included encounters in the next few weeks


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Security Audit• First audit due no later than June 1, 2014 was

submitted by all contractors; internal technical review of results in progress and individual contractor feedback as well as overall feedback expected to be sent to each contractor later this week

• Next full audit will be due June 1, 2015


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AHCCCS CRN Expansion Project (999 Lines)• AHCCCS 999 UB Lines HIPAA compliance changes

proposed for mid to late 2015• Will fully remediate the PMMIS system to expand

the CRN by 1 additional digit for all form types; i.e.… AHCCCS CRN’s will go from 14 digits to 15 digits in length

• Will impact and require testing with Contractors and Trading Partners

• Detailed timelines in development


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TPL Workgroup Updates• Refer to Webpage http://www.azahcccs.gov/commercial/EDIresources/EDITechnicalWorkgroups.aspx






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Other Updates• Greater AZ ADHS RFP – Effective

10/1/2015• GMH/SA Duals Alignment – Effective

10/1/2015• Other?


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Questions?


28Reaching across Arizona to provide comprehensive quality health care for those in need

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Thank You.


Technical Consortium Meeting July 2014. Topics: Cost Sharing (Copay) Updates Encounter Claims Data...

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Transcript of Technical Consortium Meeting July 2014. Topics: Cost Sharing (Copay) Updates Encounter Claims Data...