ACA Theme: Enrolling members in health plans
State based Health Insurance Exchange
(HIX) with interoperable services to the
federal HUB and MAGI determination for
financial assistance / Medicaid / CHIP
Interoperability Showcase
In collaboration with IHE
Use Case 13
Theme: Affordable Care Act (ACA)
Use Case 3 : State based Health Insurance Exchange (HIX) with interoperable services to the federal HUB
and rules based MAGI determination for financial assistance / Medicaid / CHIP
This Scenario demonstrates a simple yet extensible state based HIX. Complete with a UX2014 inspired user
experience, MAGI rules for determining the availability of financial assistance, and Medicaid/CHIP enrollment.
Primary Goal: To support the enrollment of members into health plans and to determine if an enrollee meets the MAGI
rules that would allow that member’s participation in Medicaid/CHIP or would allow premium tax credits to be made
available for the purchase of a qualified health plan.
Affordable Care Act relevance:
This scenario is responsive to the ACA in the enrollment of members in health care plans with a particular focus on the
modified adjusted gross income (MAGI) to determine availability of Medicaid/CHIP or premium tax credits
Key Points:
• Demonstrate an extensible solution that can meet the short timelines required by the ACA and provide
the foundation for a comprehensive solution through the addition of MITA aligned modules in a SOA
architecture.
• Provide a compelling, business rules based user experience (UX) that will allow members to navigate
the complexities of health plan enrollment and MAGI determination.
• Integration with federal HUB services and state data repositories for verification of attested data.
• Identity proofing (i.e., Is this applicant who they claim to be?)
• Web analytics allowing continuous tuning of the UX to meet the changing Internet.
Flow Chart:
ICD-10 End-to-End
To study the impact of ICD-9 to ICD-10 mappings and also to track the
behavior of the payers in adjudicating them.
The patient’s chart is documented
using NextGen
837 is run through NextGen for auto
suggested diagnosis codes
Use Case Scenario:
1. The clinical patient encounter is documented in NextGen’s Practice Management system.
2. The 837 file is run through NextGen’s ICD-9 / ICD-10 Comparison Tool for auto suggested
diagnosis codes. ICD-10 codes for the documented ICD-9 codes are translated via GEMs
and two 837 files are created for claims testing and/or processing.
3. Then Optum’s Claims Manager performs clinical editing of both ICD-9 and ICD-10 claims.
4. The claim files are submitted to the payer for adjudication or for testing.
5. The payer will adjudicate these files and send the corresponding 835 files.
6. NextGen then imports the 835 files for analysis to explain the differences in payment
between ICD-9 & ICD-10 codes.
Clinical
Supporting
GEMs
Multiple ICD-10s
No Match
?
GEMs
Exact
Match
Biller using the EPM creates 837
claim files; One with ICD-9 codes and
another with ICD-10 Codes
Optum performs clinical editing
837 files are submitted to the payer
837 Files
$
Documents
Payer
Payer processes and sends the 835
file for both the 837 files
835 Files
NextGen imports 835 files for analysis
ICD-10 Use Case
Claims Manager
NextGen™ Practice Management
HIMSS Interoperability Showcase Healthcare Financial Network Of the Future Use Cases developed by the HIMSS G7
Point of Service Payment Processing End-to-End
To provide patient convenience and accelerate revenue cycle.
Flow
Chart:
Use Case Scenario:
1.
Patient presents themselves at provider’s office or hospital front desk and staff completes
need for eligibility verification using NextGen Practice Management.
2.
NextGen submits 270 request to Optum Intelligent EDI and receives 271 response back.
3.
Optum Intelligent EDI provides benefit levels and patient responsibility at time of service.
With this information, the provider charges the patient copay.
4.
NextGen obtains balance from Optum prior to insurance (copay, deductible, and
percentage not covered). Front desk collects and processes payment through NextGen.
5.
Citibank’s payment portal, Money2 for Health, then imports patient responsibility data from
NextGen and from patient’s health plan.
6.
Patient is alerted that their bill is ready and can pay providers through Money2 from any
funding source, including Flex Spending & Health Savings Accounts.
Provider/Hospital Front desk
Deductible
& Copay
270
Payment
Portal
271
$
Patient presents
themselves at provider or
hospital front desk
EDI
Clearinghouse
NextGen submits 270
request to Optum
Optum provides benefit
levels
NextGen obtains
payment information from
Optum for front desk to
collect and process
Citibank imports patient
data from NextGen
Bank
Collected
$
Patient is alerted of bill
and pays remaining
balance via Money2 for
Health portal
Point of Service Payment Processing
Use Case
NextGen™ Practice Management
Intelligent EDI
Money2 for Health
HIMSS Interoperability Showcase Healthcare Financial Network of the Future Use Cases developed by the HIMSS G7
Patient Financial Experience with Money2 for Health
Flow
Chart:
Use Case Scenario:
1.
2.
3.
4.
5.
6.
Patient enrolls in Money2 for Health platform to review healthcare bills and make payments.
Citibank platform receives adjudicated claim info from consumer’s health plan (Aetna) and
may also receive patient responsibility data from provider’s practice management system
which then is matched to health plan data.
Patient receives alert from Money2 for Health that a medical transaction is ready for review
and payment.
Patient can reconcile all healthcare bills, view past payments, and schedule payments
through Money2 for Health portal using any funding source, including checking, credit card,
debit card, Flex Spending & Health Savings Accounts.
Patient uses Money2 for Health to pay all bills from single portal/app.
Provider receives electronic payment from patient through Money2 for Health and payment
posting file is exported to providers’ practice management system.
Consumer enrolls in
Patient Payment
Portal
Health Plan passes
post adjudication data
to patient payment
portal
Healthcare Provider
passes final patient
responsibility data to
patient payment portal
Consumer is alerted
healthcare
transactions are
ready to pay
Bank
Consumer makes
payment online or via
smart device
$ $
FSA
HSA
Checking
Credit
Citi aggregates
payments and passes
funds and data to
Provider electronically
Patient Financial Experience
Use Case
Money2 for Health
HIMSS Interoperability Showcase Healthcare Financial Network of the Future Use Cases developed by the HIMSS G7
Hub Payment Processing End-to-End
Flow
Chart:
To accelerate payment delivery, improve
reimbursement transparency, and optimize payment tracking.
NextGen generates 837 file
Use Case Scenario:
1. Through NextGen’s Practice Management system, the provider’s office generates and submits
the 837 claim file to the payment processor.
2. Optum Claims Manager performs clinical editing that replicates Medicare and emulates the
commercial adjudication process.
3. Using Optum Intelligent EDI, the 837 is routed to the payer, and the payer adjudicates the claim.
4. The 835 file is retrieved by Optum and forwarded to the provider.
5. The payer’s bank will initiate EFT payments to the individual provider’s bank.
6. The provider will retrieve the 835, then using NextGen Practice Management the file is
imported, processed, and a contract analysis is done for expected reimbursement.
7. Using NextGen Insight Reporting, the provider analyzes the 835 to compare productivity,
utilization, reimbursements for peers, and other analytics.
Provider
EDI Clearinghouse
837
835
835
Payer’s Bank
EFT
Optum does technical editing and
sends 837 to payer
835 is retrieved from Optum and
sent to provider
Payer’s bank initiates EFT
payments to provider’s bank
837
Provider’s Bank
Optum does clinical editing
EFT
Payer
$
Provider retrieves 835
NextGen imports, processes, and
analyses 835
Hub Payment Processing Use Case
Claims Manager
Intelligent EDI
NextGen™ Practice Management
Insight Reporting™
HIMSS Interoperability Showcase Healthcare Financial Network of the Future Use Cases developed by the HIMSS G7
HIMSS WEDI
ICD-10 National End-to-End Testing Pilot
Learn more about the ICD-10 program at www.himss.org and join us during
HIMSS 13 on March 6th from 7:30am – 9:30am
HIMSS ICD-10 Playbook will have ICD-10 test data for industry sharing
1st Phase of the Pilot is from April 2013 through July 2013
Increases interoperability across healthcare systems and processes
himss_wedi_ICD10NPPSupport@lottqagroup.com
Interoperability Through Collaboration
Point of Service Payment Processing End-to-End
To provide patient convenience and accelerate revenue cycle.
Flow
Chart:
Use Case Scenario:
1.
Patient presents themselves at provider’s office or hospital front desk and staff completes
need for eligibility verification using NextGen Practice Management.
2.
NextGen submits 270 request to Optum Intelligent EDI and receives 271 response back.
3.
Optum Intelligent EDI provides benefit levels and patient responsibility at time of service.
With this information, the provider charges the patient copay.
4.
NextGen obtains balance from Optum prior to insurance (copay, deductible, and
percentage not covered). Front desk collects and processes payment through NextGen.
5.
Citibank’s payment portal, Money2 for Health, then imports patient responsibility data from
NextGen and from patient’s health plan.
6.
Patient is alerted that their bill is ready and can pay providers through Money2 from any
funding source, including Flex Spending & Health Savings Accounts.
Provider/Hospital Front desk
Deductible
& Copay
270
Payment
Portal
271
$
Patient presents
themselves at provider or
hospital front desk
EDI
Clearinghouse
NextGen submits 270
request to Optum
Optum provides benefit
levels
NextGen obtains
payment information from
Optum for front desk to
collect and process
Citibank imports patient
data from NextGen
Bank
Collected
$
Patient is alerted of bill
and pays remaining
balance via Money2 for
Health portal
Point of Service Payment Processing
Use Case
NextGen™ Practice Management
Intelligent EDI
Money2 for Health
HIMSS Interoperability Showcase Healthcare Financial Network of the Future Use Cases developed by the HIMSS G7
Patient Financial Experience with Money2 for Health
Flow
Chart:
Use Case Scenario:
1.
2.
3.
4.
5.
6.
Patient enrolls in Money2 for Health platform to review healthcare bills and make payments.
Citibank platform receives adjudicated claim info from consumer’s health plan (Aetna) and
may also receive patient responsibility data from provider’s practice management system
which then is matched to health plan data.
Patient receives alert from Money2 for Health that a medical transaction is ready for review
and payment.
Patient can reconcile all healthcare bills, view past payments, and schedule payments
through Money2 for Health portal using any funding source, including checking, credit card,
debit card, Flex Spending & Health Savings Accounts.
Patient uses Money2 for Health to pay all bills from single portal/app.
Provider receives electronic payment from patient through Money2 for Health and payment
posting file is exported to providers’ practice management system.
Consumer enrolls in
Patient Payment
Portal
Health Plan passes
post adjudication data
to patient payment
portal
Healthcare Provider
passes final patient
responsibility data to
patient payment portal
Consumer is alerted
healthcare
transactions are
ready to pay
Bank
Consumer makes
payment online or via
smart device
$ $
FSA
HSA
Checking
Credit
Citi aggregates
payments and passes
funds and data to
Provider electronically
Patient Financial Experience
Use Case
Money2 for Health
HIMSS Interoperability Showcase Healthcare Financial Network of the Future Cases developed by the HIMSS G7
Payment Hub End-to-End
To optimize payment tracking, improve
reimbursement transparency, and accelerate payment delivery.
Flow Chart:
837 sent to payment hub by healthcare
provider
Hub acknowledges and sends 837
to payer
Use Case Scenario:
1. Through NextGen Practice Management System, the provider’s office will
generate and submit the 837 claim file to the payment hub
2. The Hub receives and acknowleges claim EDI, the 837 is routed to the payer,
and the payer adjudicates the claim.
Payer adjudicates claim and remits 835
to hub
3. The 835 file is sent to the hub in standard EFT/ERA format
4. Hub parses the file into Financial portion for bank and supporting claim data
Hub parses payment data from health
data into SWIFT File Act
5. A NACHA format file will be sent to the payer's bank on behalf of payer via
SWIFT FileAct
6. The payer’s bank will initiate debits to payer account and credit to the providers
accounts via SWIFT FileAct in NACHA
7. Providers bank will send complete achtjnl to hub for forward to provider
8. The 835 file data and achtjnl is sent to provider for load into NextGen PMS
Hub workflow is
updated for web
portal viewing by all
counterparties
File is sent to payer bank for processing
9. A contract analysis is done for expected reimbursement.
All workflow history is updated at each step into the hub for web portal tracking
by all counterparties
Provider
837
Payment Hub
835
Payer
837
835
Payment is reconciled to the provider’s
bank
Payment with claim data is returned in
one file to Provider
Provider receives and matches to
patient accounting
Provider’s
Bank
Payment
Data
EFT
NACHA
Payer’s Bank
Claim Info

835
Denial management