|
|
AmeriHealth Contingency Planning
Background
Over the past several years, AmeriHealth has been diligently working towards compliance with the electronic transaction and code set standards adopted pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
AmeriHealth will be able to comply fully with the HIPAA transaction and code set regulations by October 16, 2003. However, in accordance with guidance published by CMS, AmeriHealth has developed a strategy to handle the receipt and processing of non-compliant electronic transactions received from health care providers and other covered entities (collectively referred to herein as "trading partners") after the October 16th HIPAA compliance date to ensure the smooth flow of payments.
Demonstrating Compliance
- AmeriHealth will be production ready and able to transact (i.e., accept and transmit) the X12 4010A-1 version of all electronic health care transactions on October 16, 2003.
- AmeriHealth will have completed testing and connectivity of all electronic health care transactions (270/271, 276/277, 278, 820, 834, 835, 837) with those trading partners who, prior to October 16, 2003 requested testing, and will continue to test with trading partners post-October 16, 2003 as these trading partners seek to become compliant with the electronic transaction and code set regulations.
Outreach
AmeriHealth, or AmeriHealth's delegate (e.g., NaviNet®/Highmark), will make reasonable and diligent efforts to facilitate compliance with the electronic transaction and code set regulations by all trading partners by employing the following actions:
- Contact each existing trading partner, provider and/or clearinghouse to remind them of the impending October 16, 2003 compliance date and AmeriHealth's intent regarding their compliance.
- Conduct regular conference calls with each existing trading partner to monitor status of trading partner testing, address issues and make changes, as required.
- Maintain dates and documentation of all trading partner contacts and meetings held to promote outreach and transaction testing.
AmeriHealth will also make reasonable and diligent efforts to assist providers using trading partners/clearinghouse to become compliant by October 16, 2003 by employing the following actions:
- Make testing opportunities available to the trading partners/clearinghouses identified by AmeriHealth's participating providers.
- Maintain dates and documentation of all contacts and meetings held with trading partners/clearinghouses identified by participating providers to promote outreach and transaction testing.
Testing
AmeriHealth or AmeriHealth's delegate will contact each existing trading partner to advise of our testing readiness and establish external testing tasks and timeframes for trading partner testing. AmeriHealth will also make testing opportunities available to those trading partners/clearinghouses identified by participating providers.
Facilitate Compliance of Trading Partners
- AmeriHealth will provide and distribute, or make available via the AmeriHealth website, companion guide documentation which describes AmeriHealth specific requirements for each electronic transaction in those instances where the Implementation Guides permit AmeriHealth to impose plan-specific requirements.
- AmeriHealth will provide a web accessible self-test facility for professional claim submission trading partners to submit transactions and receive responses regarding content and format compliance.
- AmeriHealth will be available for trading partner testing with clearinghouses and/or providers and those clearinghouses identified by providers in advance of 10/16.
- AmeriHealth will continue to test with trading partners post-October 16, 2003 as these trading partners seek to become compliant with the electronic transaction and code set regulations.
- AmeriHealth will periodically assess the readiness of the provider community leading up to the 10/16 compliance date to determine the need to implement contingency plans while continuing to work toward compliance.
Contingency Planning Process
In the event that all existing electronic trading partners have not converted to the compliant transactions prior to the October 16th deadline, AmeriHealth will employ contingencies in order to mitigate unintended adverse effects on (i) provider's cash flow and business operations during trading partners' transition to the standards and (ii) the availability and quality of patient care.
CMS Guidance allows the deployment of contingencies, in order to ensure the smooth flow of payments, provided the health plan has "made reasonable and diligent efforts to become compliant, and... to facilitate compliance of their trading partners." Specifically, as long as a health plan can demonstrate to CMS its active outreach and testing efforts, it can continue processing payments to providers.
AmeriHealth contingencies will include:
- Continued acceptance of legacy, proprietary or nonstandard electronic transaction formats (NSF, UB92), until February 29, 2004, from existing trading partners that are undertaking and demonstrating efforts to achieve compliance (e.g., testing with AmeriHealth).
- Acceptance of X12 4010A-1 electronic formats from trading partners that may not be data content compliant, until February 29, 2004, while working with the trading partner to achieve compliance. There are certain data elements required on the compliant transactions that were not previously required for proprietary electronic submissions. Because some of this data is not used in AmeriHealth's adjudication process, its unavailability as of October 16th will have no impact on AmeriHealth's ability to pay claims. However providers, vendors and clearinghouses must continue their efforts to collect and transmit the new data elements in order to meet the requirements for full compliance.
- The CMS Guidance states that "in determining whether a good faith effort has been made, CMS will place strong emphasis on sustained actions and demonstrable progress, with particular focus on the actions that occurred prior to October 16th." In keeping with the spirit of this enforcement approach, AmeriHealth 's contingency plan to accept non-compliant transactions will be employed only when AmeriHealth believes its trading partners are undertaking good faith efforts to come into compliance with the electronic transaction and code set regulations.
|
