David Tucker EDI Strategic Planning Director David.Tucker@Anthem.com 1 One of the largest US health benefits companies ◦ ~ 67 million individuals served through its affiliated companies ◦ > 36 million members enrolled in our affiliated health plans 1 in 9 Americans receives medical coverage through a WellPoint company NY 2 Supports the 270/271 and 276/277 transactions CORE Seal for CAQH Phase I and II Supports HIPAA X12 TR3, CAQH CORE and BCBSA requirements Supports Real Time and Batch transactions from Trading Partners, Direct Connects and Web Portal (Availity) transactions Available 24h/6 days (Monday – Saturday) per week 3 1
Abortion Health Benefit Plan Coverage* MH Provider Facility – Inpatient Psychiatric - Inpatient Ambulatory Serv Center Facility Home Health Care MH Provider Fac – Outpatient Psychiatric - Outpatient Anesthesia Hospice MRI/CAT Scan Psychotherapy Cardiac Rehabilitation Hospital Newborn Care Radiation Therapy Chemotherapy Hospital - Ambulatory Surgical Obstetrical Routine Physical Chiropractic Hospital - Emergency Accident Obstetrical/Gynecological Screening Laboratory Dental Care Hospital - Emergency Medical Occupational Therapy Screening X-ray Diagnostic Lab Hospital – Inpatient Oral Surgery Second Surgical Opinion Diagnostic Medical Hospital – Outpatient Pediatric Skilled Nursing Care Diagnostic X-Ray Immunizations Pharmacy Speech Therapy Dialysis Infertility Physical Medicine Substance Abuse Durable Med Equipment (DME) In-vitro Fertilization Physical Therapy Substance Abuse Fac – Inpatient DME Purchase Mammogram, HR Patient Physician Visit – Office: Sick Substance Abuse Fac – Outpat DME Rental Mammogram, LR Patient Physician Visit – Office: Well Surgical Emergency Services Maternity Podiatry Surgical Assistance Family Planning Medical Prof (Physician) Visit - Home Urgent Care Flu Vaccination Mental Health (MH) Prof (Physician) Visit - Inpatient Vision (Optometry) General Benefits Health Benefit Plan Coverage Prof of (Physician) Visit – Office** Well Baby Care Gynecological MH Provider – Inpatient Prof (Physician) Visit – Outpatient MH Provider – Outpatient *accounts for 86%, **accounts for 2% 4 Returns Patient Liability Co-insurance Out of Pocket ◦ ◦ Copayments Benefit Limitations and ◦ ◦ Deductible Maximums ◦ Remaining Amounts ◦ Certification Indicator ◦ UM contact information PCP (Primary Care Physician) Other Payer Information 5 270/271Volumes ◦ 1.5 million per day ◦ 86% are general benefit (STC 30) ◦ 2% are office visit (STC 98) ◦ All other STC account for less than 1% 276/277 Volumes ◦ Over 300,000 per day 6 2
Meet with Trading Partners and Providers to discuss resolve 27x concerns and future enhancements (bi-weekly, monthly, quarterly) Wisconsin Providers Include: • Luther Hospital • University Wisconsin Medical Foundation (UWMF) Clearinghouse/Vendor Includes: • Passport 7 Grea eate ter Deta tail/G il/Gra ranula lari rity ty within in 277 Claim im Statu tus ◦ Requesting Medical Records ◦ Investigating Other Insurance ◦ Aligning with the 835 CARC/RARC 2014 Enhancem emen ents ts for 271 Eligibi ibility lity Respo ponse se ◦ Patient’s actual cancel date when patient is inactive for date of service being requested ◦ Health Insurance Exchange (HIX) patient’s grace period information ◦ Patient’s HRA amount/remaining 8 Governance ◦ Launching a robust Governance process to ensure greater consistency and granularity across all Plans Industry Participation and Collaboration ◦ Soliciting additional input and feedback in case any other entity would like to engage in collaborative discussions 9 3
Increase adoption and expand Provider usage of 27x Electronic Transactions. Enhance transaction detail, availability and quality towards minimization of Provider abrasion and unnecessary phone calls 10 11 4
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