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Payer Adoption Matrix - Implementation and Validation Status
Revision: 2011-05-02
OneHealthPort is serving as a lead organization to help implement SB 5346 and to coordinate a standard implementation of the HIPAA transactions.
One of OneHealthPort's responsibilities is to report on the rate of voluntary adoption by health plans and providers.
Each payer is asked to indicate whether they are complying with the BPRs.
The charts below share the reported level of adoption by various health plans.
Adoption Charts by Subject Area
Click on the BPR title below to open a detailed adoption table. Click on the link again to close the table. Each table is alphabetically sortable by column by left clicking the head of the column. Right clicking the head of the column will let you remove any columns you do not wish to view/print. Legend of terms is listed below all table chart links.
Validating Health Plan Capabilities
Validation is a structured and objective process for assessing how closely a health plan's implementation of their web site and/or HIPAA transactions matches the associated Best Practice Recommendation (BPR).
Click on the following link to access the validation materials developed by the workgroups. These materials can be used by health plans for self-assessment of their capabilities and by groups for providers for their assessment - in accordance with the structured methodology.
Web BPR: Requesting and Receiving Coverage Information for Eligibility and Benefits
See Adoption Matrix |
| Health Plan
| Adoption Level
| Validation: Either a link to supporting policy or a rating (depending on BPR)
| Health Plan Comment (click link to see)
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| Aetna |
Adopt at CORE level |
Acceptable (Self) |
Comments |
| Asuris |
Fully Adopt |
Complete (self) |
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| CHPW |
To Be Determined |
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Comments |
| Cigna |
Adopt at CORE level, late 2011 |
Revalidation Pending 1Q2012 - Improvements Underway |
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| CUP |
Fully Adopt |
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Comments |
| FCHA |
Fully Adopt |
Acceptable (Self) |
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| GHC |
Fully Adopt |
Complete (Providers) |
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| Kaiser |
To Be Determined |
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| KPS |
Fully Adopt |
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| Lifewise |
Fully Adopt |
Complete (Self) |
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| LNI |
Not Applicable |
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Comments |
| Medicaid |
Fully Adopt, date TBD |
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| Molina |
Fully Adopt, as of 01/2013 |
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| PacificCare |
To Be Determined |
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| Premera |
Fully Adopt |
Complete (Providers) |
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| Regence |
Fully Adopt |
Complete (Self) |
Comments |
| United |
Partially Adopt |
Complete (Self) |
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HIPAA Transaction BPR: Requesting and Receiving Coverage Information for Eligibility and Benefits
See Adoption Matrix |
| Health Plan
| Adoption Level
| Validation: Either a link to supporting policy or a rating (depending on BPR)
| Health Plan Comment (click link to see)
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| Aetna |
Adopt at CORE level |
Acceptable (Self) |
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| Asuris |
Fully Adopt |
Acceptable (Providers) |
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| CHPW |
Fully Adopt |
Acceptable (Self) |
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| Cigna |
Adopt at CORE level, late 2011 |
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| CUP |
To be determined |
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| FCHA |
Fully Adopt |
Acceptable (Self) |
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| GHC |
Fully Adopt |
Complete (Providers) |
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| Kaiser |
Fully Adopt as of 01/2014 |
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Comments |
| KPS |
Fully Adopt as of 06/2011 |
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| Lifewise |
Fully Adopt |
Complete (Self) |
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| LNI |
Not Applicable |
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Comments |
| Medicaid |
Fully Adopt |
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| Molina |
Fully Adopt, as of 01/2013 |
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| PacificCare |
Fully Adopt, as of 12/2011 |
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| Premera |
Fully Adopt |
Acceptable (Providers) |
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| Regence |
Fully Adopt |
Acceptable (Providers) |
Comments |
| United |
Fully Adopt |
Complete (Self) |
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Web BPR: Browser Capabilities for Pre-Authorization and Admission Notification
See Adoption Matrix |
| Health Plan | Service
| Validation Findings
| Health Plan Comment (click link to see)
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| Aetna |
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| Asuris |
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| CHPW |
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| Cigna |
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| CUP |
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| FCHA |
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| GHC |
Medical |
Latest Validation: August 2012 BPR: Version 7.7
Currently Required Capabilities: The web site supports all except for the following:
A. Pre-Authorization
1. Clinical Review Criteria for medications that fall under a patient's medical benefit is not currently linked to the One Stop Shop page for Prior Authorization requirements. (Services that fall under a patient's pharmacy benefits are outside the scope of this BPR) Action to be taken: By 12/31/2012, Group Health will add a link to the Pharmacy clinical review criteria that will be accessible for providers through the One Stop Shop page.
2. When completing a pre-auth request form, the provider cannot specify the type of request being made, i.e. concurrent urgent or non-urgent. Specifying the type of request is necessary in order to establish the timeframe expectations in which the request will be processed. Action to be taken: Group Health will add the "type of request" to the web request system. Completion date TBD
3. No information is provided about requesting changes to a previously submitted request. Action to be taken: Group Health will develop, and post on the web site, instructions for providers on how to request a change to a previously submitted request. Completion date TBD
B. Admission Notification
Timeframes for notifying GHC about different conditions under which a notification is required are not included in the Admission Notification Policy. Action to be taken: Group Health will update the policy to reflect this information. Completion date TBD.
Jan 1, 2013 Required Capabilities: The web site support all except for the following:
The site does not identify the specific documentation that must be sent to support the medical necessity, e.g. clinical notes, path report, etc.
Usability Score: 3.5 on a 5 point scale
Note: Services requiring pre-authorization are grouped and listed by functional category, rather than by CPT code or Description.
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| Kaiser |
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| KPS |
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| Lifewise |
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| LNI |
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| Medicaid |
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| Molina |
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| PacificCare |
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| Premera |
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| Regence |
Medical |
Latest Validation: August 2012 BPR: Version 7.7
Currently Required Capabilities: The web site supports all except for the following:
1. The web site does not clarify when a pre-authorization IS NOT required for a service.
2. The web site does not identify the process that will be followed in evaluating changes to existing requests and notifying the provider. (The Request Form does allow for requesting changes to an existing request).
Action to be Taken: No action at this time. TBD
Jan 1, 2013 Required Capabilities: The web site support all except for the following:
1. No reference number is provided when a request form is submitted electronically.
2. Status information about a request is not available on the web site.
Usability Score: 4.0 on a 5 point scale
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| Advanced Imaging |
Latest Validation: August 2012 BPR: Version 7.7
General: With one exception, all of the current and Jan 1, 2013 BPR capabilities related to Prospective Review are substantially supported. The only exception is the absence, on the web site, of information about requesting changes to a previously submitted request. Action to be Taken: Nothing to report.
Notes:
1. The AIM site does not ask you to indicate the type of request, e.g. urgent pre-service, concurrent urgent, or non-urgent. All request are handled within the urgent timeframe.
2. If you choose to print a version of the web interaction, all of the questions and answers are printed. However, any additional clinical information that you may have entered is not on the printed form but it conveyed to AIM.
3. Order numbers are provided when a request has been authorized. If a request is not authorized, it can be reviewed online for the selected patient. AIM will make a follow-up call on these requests, usually within the same day.
Usability Score: 3.5 on a 5 point scale
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United |
Medical |
Latest Validation: June 2012 BPR: Version 7.7
General: Most of the current and Jan 1 2013 BPR capabilities are supported. The browser can be used to submit notification/prior authorizations requests and to access status information about submitted request. Most of the information needed by providers about advance notifications/prior authorizations/admit notification is available on-line, though navigating the web site and finding the information can be challenging due to the volume of information on the web site. Also, it is not always clear which web site function(s) apply to which product/member.
Usability Score: 3 on a 5 point scale
Specific Cautions:
1.It is difficult for determine whether or not a pre-auth is required for a service. Reviewing the Admin Guide is cumbersome and the submission process allows for requesting services that do not require prior authorization, which results in extra work for the provider and for United. Action to be taken: The Notification/Prior Authorization Required Inquiry will have this information once implemented for all products. ETA for project and deployment: TBD
2.The ‘Service Descriptions’ (Emergency, Scheduled, Urgent) on the submission form do not align with the BPR’s Request Types (Urgent Pre-Service Requests, Concurrent-Urgent Request, Non-Urgent Requests) making it difficult to know the notification and timeframe expectations associated with any given request.
3.It is difficult to find instructions for how to request changes to a submitted request.
4.For commercial plans, the need to submit supporting documentation is identified in a “pop up” window during the submission process for a number of services. However, for other services, providers may be contacted by a UHC person requesting supporting documentation. For non-commercial plans, the need for supporting documentation is not identified in a “pop-up” during the submission process for any services. Providers will be contacted by a UHC person as necessary. (Browser based notification of the need for supporting documentation is not a required BPR capability until Jan 1, 2013)
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| United Healthcare West |
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- Notes: Only implementation of Phase I capabilities is required by 12-31-10
- Acceptable - Implementation of Phase I capabilities
- Complete - Implementation of Phase I & II capabilities
Policy BPR: Extenuating Circumstances around Pre-Authorization and Admission Notification
See Adoption Matrix |
Policy BPR: Standard Notification Timeframes for Pre-Authorization Requests
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HIPAA Transaction BPR: Processing and Reporting Remittance Information (HIPAA 835)
See Adoption Matrix |
| Health Plan
| Validation Findings
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| Aetna |
Latest Validation: April 2013 BPR: Version 3.0 Worksheet Version: 112812a
High Impact Best Practices: 16 of 17 are met. 1 under review.
835s received by providers may be different those sent by Aetna. Example - An 835 was received with an OA 23 adjustment, even though the associated claim was processed by Aetna as primary. Aetna did not report an OA 23 adjustment on the 835. Action to be taken: Provider and Aetna are researching and verifying what was sent and received at each step between Aetna and provider.
Medium Impact Best Practices: 10 of 11 are met. 1 is not met.
The Group Code 'PI' is used with CARC 18 and 'PI 18' is used to deny line items on a corrected claim that were previously submitted on the original claim. CARC 18 should only be used with Group Code 'OA' and OA 18 should only be used in one of the following cases;
- The claim is an exact duplicate of another claim that was previously submitted.
- A service on a claim is an exact duplicate of another service on that same claim.
Action to be taken: A change in underway so that CARC 18 will only be used with Group Code 'OA'. This change is to be completed by June 30, 2013. Corrected claims (137) correctly submitted with the payer-assigned claim Id in 2300:REF*F8, will be processed as a reversal of the previous claim and a correction, both on the same remittance advice. Expected completion date is TBD.
Note: The date reported in the Claim Received Date field (DTM*50) is the most recent date that documentation required to adjudicate the claim was received by the Aetna. It is not the date that the submitted claim was received by the health plan
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| Asuris |
Latest Validation: June 2012 BPR: Version 2.5 Worksheet Version: 041612a
High Impact Best Practices:
Medium Impact Best Practices:
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| CHPW |
Latest Validation: January 2013 BPR: Version 2.9 Worksheet Version: 091312a
Fatal Issue: Privacy Concern
The 835 occasionally contains claims submitted by a provider organization with an NPI/Tax ID that is different than the NPI/Tax ID of the provider who received the 835. Action to be Taken: Feb 2013- Research in progress.
High Impact Best Practices: 13 of 17 are met. 4 are not met.
- Inactive CARC/RARC are being used, e.g. CO A2, CO123 Action to be Taken:
Mapping of codes is being reviewed. Remapping should be completed by March 31, 2013. Remapping to be completed June 30, 2013
- Some CARCs are not accompanied by required RARCs, e.g. 96. Action to be Taken:
Mapping of codes is being reviewed. Remapping should be completed by March 31, 2013. Remapping to be completed June 30, 2013
- When processing the 835 as a secondary payer, the 835 does not appropriately report the financial impact of the previous payer(s) using OA23 and their financial impact using a CO/PI 45. Instead, CO/PI 45 is used with overstated charges. Action to be Taken:
Feb 2013 - Drafting requirements with providers that should be completed in March. Target implementation will be set when requirements completed. Correct processing as the secondary payer to be completed June 30, 2013
- In some cases (related to institutional providers) the CLP section contains claims without the total charge amount. This creates an out-of-balance condition at the claim level. Action to be Taken: Feb 2013- Research in progress
Medium Impact Best Practices: 9 of 11 are met. 2 are not met.
- Line item control numbers are not always reported. Action to be Taken: Feb 2013- Research in progress
- The contract that applies to the claim is not reported Action to be Taken: Feb 2013- Research in progress
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| Cigna |
Cigna and Cigna Great West
Latest Validation: Sept 2012 BPR: Version 2.7 Worksheet Version: 071212a
High Impact Best Practices:
Cigna: 13 of 14 are met. 1 not met
Reversals are displayed after the correction rather than prior to the correction. Action to be Taken: None at this time.
Great West: 14 of 14 are met.
Medium Impact Best Practices:
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| CUP |
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| FCHA |
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| GHC |
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| Kaiser |
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| KPS |
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| Lifewise |
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| LNI |
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| Medicaid |
Latest Validation: April 2012 BPR: Version 2.5
High Impact Best Practices: 12 of 15 are met. 3 are not met.
- CO/PI 45 and OA23 are not always used appropriately
- A Claim Status Code of 4 may be inappropriately used
- Zero values are used in CAS03
Medium Impact Best Practices: 7 of 11 are met. 4 are not met
- CARC 18 is used even when the claim is not an exact duplicate
- In the PLB, the Claim Number and the Patient Control Number are not always sent
- The Claim Received Date is not reported (DTM segment of Loop 2100)
- The Adjustment Group and Reason Codes reported on a reversal are not always the same as reported on the original adjudication
Action: WA Medicaid does intend to align with the BPR. However, their pursuit of BPR compliance hinges on receiving funds appropriated specifically for the purpose of working towards compliance.
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| Molina |
Latest Validation: January 2013 BPR: Version 2.9 Worksheet Version: 091312a
High Impact Best Practices: 12 of 17 are met. 5 are not met.
- The order that HCPC codes that are reported on the 835 does not always reflect their order on the 837. Action to be Taken: Will change the process so that the 837 order is reflected on the 835. To be completed by
April May 2013.
- When information returned on 835 is not the same as what was submitted on the 837, the Corrected Name segment is not always sent. Action to be Taken: Will change the process to send the Corrected Name Segment in these situations. To be completed by July 2013.
- When reporting takebacks, (a) a Molina internal number is returned on the 835 rather than the patient control number, and (b) a PLB code AP is used rather than a WO or FB (AP is for accelerated payments). Action to be Taken: Will change the process to return the TRN02 of the original remittance advice instead of a Molina internal number and will use FB rather than AP. To be completed by July 2013.
- When reporting Reason Code 96, it is not always paired with a Remark Code. Action to be Taken: Will change the process to incorporate the appropriate Remark Codes when Reason Code 96 or A1 is used. To be completed by
TBD 4Q2013.
- A Claim Status Code of 4 is inappropriately used to reflect the denial of a claim. Action to be Taken: Will update the process so that Claim Status Code of 1 rather than 4 will be used in these situations. To be completed by July 2013.
Medium Impact Best Practices: 9 of 11 are met. 2 are not met.
- Line item control numbers are not always sent on professional claims that are adjusted or on institutional claims. Action to be Taken: Will change the process to always send the control numbers. To be completed by July 2013
- When Molina Medicare is primary and Molina Medicaid is secondary, MA18 is not used to reflect the crossover. Action to be Taken: Will change the process so that when Molina Medicare is primary and Molina Medicaid is secondary, then MA18 will be reported. To be completed by July 2013.
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| Premera |
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| Regence |
Latest Validation: June 2012 BPR: Version 2.5 Worksheet Version: 041612a
High Impact Best Practices:
Facets System: All 14 are met.
Note: Claim Status Code of 4 is used appropriately to indicate that the patient/ subscriber was not recognized by the health plan. However, the description for the code is confusing. The description indicates that the Number and Name Don’t Match when the patient is not even a Regence member. Action to be taken: System is being updated so that claims for non-Regence members will not be accepted for adjudication.
Legacy System: 13 of 14 are met. 1 is not met
Group and Reason Codes reported on the reversal are not always the same as the Group and Reason Codes reported on the original adjudication. Action to be taken: No changes will be made to Legacy system
Medium Impact Best Practices:
Facets System: 8 of 11 are met. 3 are not met.
- Line item control numbers from the 837 are not always returned on the 835. Action to be taken: Scheduled to be fixed by August 1
- When Regence provides multiple coverage's for the same patient, no crossover information is contained on the 835 for the primary adjudication (NM1-01 of Loop 2100 is not = ‘TT’ and remark code MA18 is not added to the MIA/MOA segment). Action to be taken: None reported.
- The health plan’s EDI support number is not always put in PER3 of Loop 1000A. Action to be taken: None reported.
Legacy System: 9 of 11 are met. 2 are not met
- Line item control numbers from the 837 are not always returned on the 835. Action to be taken: No changes will be made to Legacy system
- The Patient Control Number is not included with the health plan’s claim number in the PLB fields. Action to be taken: No changes will be made to Legacy system
| United Healthcare (Payer ID 87726) |
Latest Validation: October 2012 BPR: Version 2.8 Worksheet Version: 092912a
High Impact Best Practices: 17 of 17 are met.
Note: For some providers, it may appear as though reversals and corrections for a claim are not processed and reported correctly. However, research has indicated these situations are likely due to the provider's billing system rather than to United Healthcare's processing. For reversals and corrections to process correctly, the provider's claim number of the corrected claim needs to be the same as the provider's original claim number. Some Provider systems (such as Epic) increment the provider's claim number each time they send a corrected claim. United Healthcare's processing system treats this corrected claim as a new claim, since the two have different claim numbers
Medium Impact Best Practices: 11 of 11 are met.
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| United Healthcare (AARP) |
Latest Validation: January 2013 BPR: Version 2.9 Worksheet Version: 091312a
High Impact Best Practices: 12 of 17 are met. 5 are not met.
- For some claims, all lines submitted on an 837 are grouped into one line with one CPT code and processed. Action to be taken: Research underway to be completed in April 2013.
- For ASC charges, the 835 only reported one CPT codes and grouped total charges under that CPT code, rather than appropriately reporting Revenue Codes and/or HCPC codes. Action to be taken: Research underway to be completed in April 2013.
- Group Code OA rather than CO is used with CARC 45 & 9. Group Code OA rather than PR is used with CARC 3. Also, Group Code PR was not found on any line item level to reflect patient responsibility on either claim. Action to be taken: Research underway to be completed in April 2013.
- Claim was priced at the claim level, rather than service line level - only one CPT code was reported with all charges rolled into it. Action to be taken: Research underway to be completed in April 2013.
- Group Code CO rather than OA is used with CARC 23. Action to be taken: Research underway to be completed in April 2013
Medium Impact Best Practices: 10 of 11 are met. 1 is not met.
- Line item control numbers in the 837 were not always returned. I Research underway to be completed in April 2013.
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| United Healthcare West |
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HIPAA Transaction BPR: Electronic Processing of Corrections to Institutional Claims
See Adoption Matrix |
| Health Plan
| Adoption Level
| Validation: Either a link to supporting policy or a rating (depending on BPR)
| Health Plan Comment (click link to see)
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| Aetna |
Fully Adopt |
Complete (self) |
Comments |
| Asuris |
Fully Adopt |
Complete (Providers) |
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| CHPW |
To Be Determined |
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Comments |
| Cigna |
Fully Adopt |
Complete (self) |
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| CUP |
Fully Adopt |
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Comments |
| FCHA |
Fully Adopt |
Complete (self) |
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| GHC |
Fully Adopt |
Complete (Providers) |
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| Kaiser |
Fully Adopt |
Complete (self) |
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| KPS |
Fully Adopt |
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| Lifewise |
Fully Adopt |
Complete (self) |
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| LNI |
Fully Adopt |
Complete (Self) |
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| Medicaid |
Fully Adopt |
Complete (Providers) |
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| Molina |
Fully Adopt |
Complete (Self) |
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| PacificCare |
Fully Adopt |
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| Premera |
Fully Adopt |
Complete (Providers) |
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| Regence |
Fully Adopt |
Complete (Providers) |
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| United |
Fully Adopt |
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HIPAA Transaction BPR: Electronic Processing of Corrections to Professional Claims
See Adoption Matrix |
| Health Plan
| Adoption Level
| Validation: Either a link to supporting policy or a rating (depending on BPR)
| Health Plan Comment (click link to see)
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| Aetna |
Fully Adopt |
Complete (self) |
Comments |
| Asuris |
Fully Adopt |
Complete (self) |
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| CHPW |
To Be Determined |
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Comments |
| Cigna |
Fully Adopt |
Complete (self) |
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| CUP |
Fully Adopt |
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Comments |
| FCHA |
Fully Adopt |
Complete (self) |
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| GHC |
Fully Adopt |
Complete (self) |
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| Kaiser |
Fully Adopt |
Complete (self) |
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| KPS |
Fully Adopt |
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| Lifewise |
Fully Adopt |
Complete (self) |
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| LNI |
Fully Adopt |
Complete (Self) |
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| Medicaid |
Fully Adopt |
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| Molina |
Fully Adopt |
Complete (Self) |
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| PacificCare |
to be determined |
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| Premera |
Fully Adopt |
Complete (Providers) |
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| Regence |
Fully Adopt |
Complete (Self) |
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| United |
Fully Adopt |
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Policy BPR: Claim Coding Policy and Edits Standardization & Transparency
See Adoption Matrix |
Policy BPR: Reconsideration of a Health Plan's Policy Regarding Code Edits
See Adoption Matrix |
Web BPR: Requesting and Receiving Claim Status Information
See Adoption Matrix |
| Health Plan
| Validation Findings
| Health Plan Comment
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| Aetna |
Latest Validation: May 21, 2012 BPR: Version 1.4
High Impact Best Practices: 8 of 9 met 1 is not met.
The Patient Control Number is not included as a field in the list of patients that match the search criteria that is entered. Having this number in the list is important so that providers can quickly select the specific claim that they want to see without having to go back and forth to the detail screen. Patient Control Number is in the detail Claim information once a claim in selected. Action to be taken: Aetna has no current plans to include Patient Control Number in the Search Results list
Medium Impact Best Practices: 2 of 2 met
Usability Score: 3.2 on a 5.0 scale
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| Asuris |
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| CHPW |
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| Cigna |
Latest Validation: August 2012 BPR: Version 1.4
High Impact Best Practices: 8 of 9 are always met (1 is sometimes not met).
In some but not all cases, an explanatory remark code is provided on the web site without an accompanying description. Extra work, e.g. call to customer service, is required if the provider doesn't know the meaning of the remark code.
Action to be Taken: Cigna is working on a fix to be completed 1Q2013
Medium Impact Best Practices: 2 of 2 met
Usability Score: 4.0 on a 5.0 scale
Notes:
1. In some but not all cases, searching by Patient Control Number does not return the corresponding claim(s). Action to be Taken: Cigna is working on a fix. Completion date TBD
2. When claim payment/reimbursement is identified as member responsibility and payment is made from a member's Reimbursement Account (Health Saving's Account (HSA) or Health Reimbursement Account (HRA), the web site indicates claim processed AND a paid date is noted. This is a correct display of status information, though confusion can result as this is different from the more common situation when the status information is EITHER claim processed (meaning claim has been adjudicated and no reimbursement from member's benefit) OR a paid date (meaning claim has been adjudicated and payment made.)
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| CUP |
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| FCHA |
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| GHC |
Latest Validation: August 2012 BPR: Version 1.4
High Impact Best Practices: 7 of 9 are met (2 not met).
1. The reason for a claim denial is not provided on the web site.
2. There is inconsistency between the web site and customer services as the reason for a claim denial was available from customer service. (Differences between web site information and customer service reinforce the practice of making phone calls.)
Action to be Taken: GHC recognizes these gaps, which will be corrected when we move to our new claims processing system's Web portal (implementation date TBD).
Medium Impact Best Practices: 2 of 2 met
Usability Score: 3.9 on a 5.0 scale
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| Kaiser |
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| KPS |
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| Lifewise |
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| LNI |
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| Medicaid |
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| Molina |
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| PacificCare |
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| Premera |
Latest Validation: June 27, 2012 BPR: Version 1.4 (Amended Dec 17, 2012)
High Impact Best Practices: 7 of 9 are met (2 not met).
- The Patient Control Number and the Health Plan Claim Number are not included as fields in the summary list of patients that match the search criteria that is entered. Having these numbers in the list is important so that providers can quickly select the specific claim that they want to see without having to go back and forth to the detail screen. Patient Control Number and Health Plan Claim Number are in the detail Claim information once a claim is selected. Action to be Taken: This is being considered as a future web site enhancement.
- For some zero payment claims and some denied claims, the status information may not always contain sufficient level of detail. Phone calls may be required to get up to date information. Action to be Taken: This is being considered as a future web site enhancement.
Medium Impact Best Practices: 1 of 2 met (1 not met)
Usability Score: 4.2 on a 5.0 scale
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| Regence |
Latest Validation: June 26, 2012 BPR: Version 1.4
High Impact Best Practices: 8 of 9 are met (1 not met).
The Patient Control Number is not included as a field in the list of patients that match the search criteria that is entered. Having this number in the list is important so that providers can quickly select the specific claim that they want to see without having to go back and forth to the detail screen. Patient Control Number is in the detail Claim information once a claim in selected. Action to be taken: None at this time.
Note - When a claim is adjusted, there may be a delay before the web site (Provider Center) is updated. Adjustments are made manually to the claims processing system before the claim is manually released to the Provider Center. Until the adjusted claim is manually released, Customer Service will have access to more up to date status information.
Medium Impact Best Practices: All met
Usability Score: 4.3 on a 5.0 scale
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| United Healthcare (Payer ID 87726) |
Latest Validation: October 2012 BPR: Version 2.8 Worksheet Version: 092912a
High Impact Best Practices: 17 of 17 are met.
Note: For some providers, it may appear as though reversals and corrections for a claim are not processed and reported correctly. However, research has indicated these situations are likely due to the provider's billing system rather than to United Healthcare's processing. For reversals and corrections to process correctly, the provider's claim number of the corrected claim needs to be the same as the provider's original claim number. Some Provider systems (such as Epic) increment the provider's claim number each time they send a corrected claim. United Healthcare's processing system treats this corrected claim as a new claim, since the two have different claim numbers
Medium Impact Best Practices: 11 of 11 are met.
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| United Healthcare West |
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Credentialing Record Pick-up and Outreach
SB 5346: Health Plan Participation - who's waiting to use your records
Click to See Readiness Results | | |
| Health Plan
| Participating
| Retrieving Records Now
| Provider Communications Plan
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| Aetna |
Yes |
Yes |
TBD |
| Asuris |
Yes |
Yes |
TBD |
| CHPW |
Yes |
Yes |
TBD |
| Cigna |
Yes |
Yes |
No |
| CUP |
Yes |
No |
TBD |
| DLI |
Yes |
Yes |
Yes |
| DSHS |
No |
No |
No |
| FCHA |
Yes |
Yes |
Yes |
| GHC |
Yes |
No |
no |
| KPS |
Yes |
No |
Yes |
| Lifewise |
Yes |
Yes |
Yes |
| Molina |
Yes |
Yes |
TBD |
| Premera |
Yes |
Yes |
Yes |
| Puget Sound Health Partners |
Yes |
TBD |
TBD |
| Regence |
Yes |
Yes |
TBD |
| United |
No |
No |
No |
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Legend:
1. Adopt BPR at CORE Level - CORE is a national collaborative that encourages standard operating practices. The Washington State BPR's address a broader set of operating practices than does CORE and at a more rigorous level. Adopt at Core indicates that the health plan reported that they will adopt a subset of the BPR practices that corresponds to CORE's recommended practices.
2. Partially Adopt BPR - indicates that the health plan reported that they will adopt a subset of the BPR practices. Some health plans provided more information in their comments about which practices they adopt/don't adopt.
3. Validation: Either a link to supporting policy or a rating (depending upon the BPR): For some BPRs, a method of validating the health plan's implementation of the BPR has been defined.
a. In some cases, that validation method calls for a health plan to post, on their website, their policy that corresponds to the BPR. In these cases, health plans were asked to provide the link to their web site policy.
b. In other cases, a structured validation methodology has been developed that results in a rating of the level of implementation -- Unacceptable, Acceptable, Complete. In these cases, health plans were asked to use that methodology to validate their implementation of the BPR and report their rating. These ratings are indicated by '(Self)'. Depending upon interest, a group of providers may be convened to use the methodology to validate a health plan's implementation. These ratings are indicated by '(Provider)'
c. In the case of the BPR- Browser Capabilities for Pre-Authorization and Admission Notification, health plans were asked to provide web links / instructions for how providers should request a prospective review and for how providers should notify them about an admission. This information is put in one place on the OHP web site, and is referred to as 'One-Stop-Shop Content'. If the health plan provided this information, 'One-Stop-Shop Content' is included in this column along with their Validation Rating.
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FREE CMS ICD-10 Implementation Handbooks Click here to find out more.
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Credentialing and Privileging Data Collection - videos.
To view the training videos on Provider Attestation and Browser Second Factor Provisioning
click here
WPA Field Mapping Guide NOW Available to assist in mapping your provider data to the new ProviderSource application.
click here
Health Information Exchange Project Updated.
Read the latest on the Washington State HIE:
click here
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