Technical Consortium Meeting July 2014 Topics Cost Sharing

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Technical Consortium Meeting July 2014

Technical Consortium Meeting July 2014

Topics: • • • Cost Sharing (Copay) Updates Encounter Claims Data Exchange/Blind Spots Updates

Topics: • • • Cost Sharing (Copay) Updates Encounter Claims Data Exchange/Blind Spots Updates APR-DRG Project Updates ICD 10 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 2

Cost Sharing (Copays) • Additions and/or modifications under evaluation and planned for 1/1/2015: New

Cost Sharing (Copays) • Additions and/or modifications under evaluation and planned for 1/1/2015: 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 o Reaching across Arizona to provide comprehensive quality health care for those in need 3

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

Cost Sharing (Copays) (cont. ) • Review of “draft Copays Matrix” Reaching across Arizona to provide comprehensive quality health care for those in need 4

Encounter/Claims Data Exchange/Blind Spots o AHCCCS will manage an ongoing exchange of encounter and

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 1/4 ly report for January – March 2014 was run and distributed in April; and second 1/4 ly 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 5

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

Encounter/Claims Data Exchange/Blind Spots (cont. ) q q Planned additions to the Data Exchange include the integration of - Medicare Paid Claims Data (Part D; DSNP; Medicare FFS) – In progress Quarterly data extracts are based on Claims and Encounters adjudicated within the reporting 1/4 Reaching across Arizona to provide comprehensive quality health care for those in need 6

APR-DRG’s • On schedule for 10/1/2014 Implementation (based upon Dates of Discharge) • Technical

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/EDITechnical. Workgroups. aspx • 3 Key Forms of Project Documentation – AHCCCS Policy Document o AHCCCS Rule o AHCCCS DRG Calculator o Reaching across Arizona to provide comprehensive quality health care for those in need 7

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

APR-DRG’s (cont. ) • Finalized all Policy decisions and shared with all Contractors (as well as 3 M) as a component of the DRG Technical Workgroup; reviewing and responding to Contractor questions as submitted • AHCCCS is currently Testing the 3 M 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 Reaching across Arizona to provide comprehensive quality health care for those in need 8

APR-DRG’s (cont. ) • Current DRG Project Milestones: o o o Complete Requirements and

APR-DRG’s (cont. ) • Current DRG Project Milestones: o o o Complete Requirements and Design - Completed - March 2014 Complete Coding – Completed - May 2014 Internal Testing Begins – In Progress - May 2014 Internal Testing Ends - July 2014 External Testing Begins (all Contractors/providers/ATR): § ICD 9/DRG Integrated End to End – In Progress - June 2014 § ICD 10/DRG Integrated End to End – October 2014 o System Implementation - September 2014 Reaching across Arizona to provide comprehensive quality health care for those in need 9

ICD-10 • The AHCCCS ICD 10 Project was impacted by Federal Legislation; direction from

ICD-10 • The AHCCCS ICD 10 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 Reaching across Arizona to provide comprehensive quality health care for those in need 10

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

ICD-10 (cont. ) • Communication to Contractors – “It is AHCCCS’s intent, as previously communicated, to continue to pursue finalization of our ICD 10 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 ICD 10 project without first discussing revisions to your timelines with us. ” Reaching across Arizona to provide comprehensive quality health care for those in need 11

ICD-10 (cont. ) • “Revised” AHCCCS ICD 10 Project Milestones Complete Requirements and Design

ICD-10 (cont. ) • “Revised” AHCCCS ICD 10 Project Milestones Complete Requirements and Design – Reference Completed o Begin Coding – Reference o Completed Complete Requirements and Design – All other o Internal Testing Begins – Reference o Completed o Begin Coding – All other System Areas o Freeze Begins. . . System Implementation – Reference o Initial Reference Table Loads o Reaching across Arizona to provide comprehensive quality health care for those in need In Progress Completed 12

ICD-10 (cont. ) • Internal Testing Begins – System Areas In Progress • Internal

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 ICD 9/DRG Integrated End to End June 2014 o ICD 10/DRG Integrated End to End October 2015 o Ongoing external testing supported through 9/30/2015 Reaching across Arizona to provide comprehensive quality health care for those in need 13

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

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 ICD 10 Effective Date - October 1 2015 (OP Dates of Services or IP Dates of Discharge) Reaching across Arizona to provide comprehensive quality health care for those in need 14

ICD-10 (cont. ) o Ongoing Contractor Milestone Reporting and Tracking should continue until 10/1/15

ICD-10 (cont. ) o Ongoing Contractor Milestone Reporting and Tracking should continue until 10/1/15 Reaching across Arizona to provide comprehensive quality health care for those in need 15

FQHC/RHC Project • FQHC/RHC Payment Alignment o Contractor’s will need to pay FQHC/RHC unique

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 Targeted for a 1/1/2015 implementation o Provider registration letter and spreadsheet (In progress, due by 8/15/14) o Testing window for Contractors and providers (beginning in August 2014) o Reaching across Arizona to provide comprehensive quality health care for those in need 16

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

FQHC/RHC Project (cont. ) AHCCCS will establish a unique provider type for FQHCs and a unique provider type for RHCs; Provider types 29 and C 2 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 o Reaching across Arizona to provide comprehensive quality health care for those in need 17

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

FQHC/RHC Project (cont. ) FQHC and RHC claims will identify the unique NPI of the FQHC or RHC as the service/rendering provider o 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 o Reaching across Arizona to provide comprehensive quality health care for those in need 18

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

FQHC/RHC Project (cont. ) 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 (340 B) billing will remain as is under the Pharmacy provider type, etc. . . and will not be impacted by this change o Reaching across Arizona to provide comprehensive quality health care for those in need 19

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

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 Reaching across Arizona to provide comprehensive quality health care for those in need 20

PCP Rate Parity • AHCCCS will make quarterly cost-settlement payments to the Contractor based

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 • A 650/A 655 Edits targeted to be changed to external pends for no later than 9/1/2014 Reaching across Arizona to provide comprehensive quality health care for those in need 21

PCP Rate Parity (cont. ) • “Catch-up” cost-settlement report for qualified encounters adjudicated/approved between

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 1/4 ly 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 Reaching across Arizona to provide comprehensive quality health care for those in need 22

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

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 Reaching across Arizona to provide comprehensive quality health care for those in need 23

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

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 Reaching across Arizona to provide comprehensive quality health care for those in need 24

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

TPL Workgroup Updates • Refer to Webpage http: //www. azahcccs. gov/commercial/EDIresources/EDITec hnical. Workgroups. aspx Reaching across Arizona to provide comprehensive quality health care for those in need 25

Other Updates • Greater AZ ADHS RFP – Effective 10/1/2015 • GMH/SA Duals Alignment

Other Updates • Greater AZ ADHS RFP – Effective 10/1/2015 • GMH/SA Duals Alignment – Effective 10/1/2015 • Other? Reaching across Arizona to provide comprehensive quality health care for those in need 26

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

Questions? Reaching across Arizona to provide comprehensive quality health care for those in need 27

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

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

Thank You. Reaching across Arizona to provide comprehensive quality health care for those in

Thank You. Reaching across Arizona to provide comprehensive quality health care for those in need 29