BCBSNC Realtime Claims Program

1. BCBSNC Realtime Claims Program National Plan Automation Group Presented by: Morgan Tackett Director Electronic Solutions September 24, 2007

2. Presentation Overview • Realtime Claims History • Lessons Learned • Current Approach • NC Status • Value Points • New Lessons/Next Steps

3. About BCBSNC • 3.2 Million Members • 4,400 Employees • 36,000 Network Providers • 30,000 use online services • 32 million claims processed per year • 117,500 per day • 16,800 telephone calls per day • 12 million electronic eligibility inquiries per year • 90% Internet based

4. Realtime Claims History

5. 1999 Realtime Claims Goals • Build relationships with contracted providers • Claim error reduction • Expense reduction • Assist providers to overcome technology hurdles • LPF v. NSF Format • HIPAA Compliance • Systems Issues • Increase electronic claim submission rates • 63% Professional Electronic Claims 1999 • Lead competition in use of innovative technology

6. Local Marketplace Issues • Multiple vendors offering single functionalities • BCBSNC Solution = Blue e • No “one-stop-shopping” option available • Connectivity constraints • Provider cost consciousness

7. Solution = RealMed • Indianapolis-based health IT Company • Integrates with large Blue plans, national payers, and governmental payers • HCSC Illinois/Texas • CareFirst • WellPoint Indiana/Kentucky/Ohio • Total revenue cycle solution, automating the entire payment process, including eligibility, claims editing, claims submission and management, online adjudication, claims status, remittance advice, and reporting • Facilitates workflow and realtime adjudication of professional claims

8. RealMed Developmental Timeline Charter Technical Integration Pilot POC Production January 2001 May 2003

9. Integration Steps • Technical integration to major Provider and BCBSNC claims systems to enable real-time claims • Provider Point of Service Claim Entry • Route validated claims based on member ID • Map in scope claims to processing system for direct key to claims screens for realtime adjudication • Message claims status back to provider with “EOB like” statement of service • Verification of provider acceptance and value of real-time claim resolution capability • Provider fees offset by replacement clearinghouse fees, higher first pass adjudication rates, reduction in re-work, and related efficiencies

10. Lessons Learned – Phase 1

11. Phase 1 Lessons Learned • POS claim entry • Adopted fast batch approach • Eliminated statement of services provision • Replaced PMS interfaces with translators • Functionality • Secondary Claims • Connectivity Issues • High speed availability v. high speed adoption • Provider cost of use • BCBSNC only extended to Universal EDI by RealMed • Internal Competition • Blue e v. RealMed? (or Free v. Fee?)

12. Current Approach

13. RealMed Workflow and Design

14. Program Modules • Tier I - Core • Integrates to PMS for file creation and claim transfer to RM in batch mode • Edits claims pre-submission • Routes for realtime entry and adjudication • Non-realtime claims batch for nightly 837P submission • Enables workflow platform for claims management through receipt and posting • Tier 2 - Print Exchange • Same functions, targets smaller providers

15. RealMed Functionality Automated Eligibility • Provides a single source for real-time eligibility verification to over 300 payers • Substantially decreases phone calls to payers and multiple visits to multiple websites • Allows providers the ability to correct eligibility information prior to patient’s appointment q

16. RealMed Functionality Claims Editing & Population • Provides rigorous edits, including CCI and LMRP • Dramatically reduces the number of claims returned due to eligibility errors by automatically populating the claim header information with the exact data from the payer’s eligibility file

17. RealMed Functionality Claim Submission & Management • Provides a single source for submitting claims online (EDI) to over 1,500 BCBS, government and commercial payers • More timely and productive follow-up and resubmission of rejected claims through a simple-to-use online claims management screen

18. RealMed Functionality Online Adjudication & Claim Status • Claims can instantly adjudicate and be paid during the next scheduled payment cycle • Provides a single source for quickly and efficiently tracking current claim status

19. RealMed Functionality Remittance Advice • For payers that are available, RealMed returns an 835 Electronic Remittance Advice • This ERA details payments made in the practice, includes reports for secondary filing and gives practices one source for viewing payment information

20. RealMed Functionality Reports • RealMed offers a robust set of customizable reports that allow practices to track all of their RealMed transactions

21. NC Program Status

22. North Carolina User Base • 363 Total Provider Groups • 5,664 Providers • 550,000 Average Monthly Claims • 60% Realtime • 21% Total BCBSNC Professional Claims Volume

23. Value Points

24. Value Points to BCBSNC • Electronic Claims Penetration • Paper Reduction • Secondary Claims • Throughput • Suspends • Adjustments • Denials • Inquiries • Remit Posting

25. Value Points to Providers • Universality • Error reduction • “Forced” claims status • End to end workflow • Cash flow enhancement • HIPAA compliance • HIPAA transaction adoption

26. Electronic Claims 92% Professional Electronic Claims!!!!

27. Throughput Legacy 70 to 78% - Power 78% to 91% !!

28. Suspends Legacy 24 to 18% - Power 18 to 7%

29. Denials 10% to 8%

30. Inquiries 21,000 Telephone Calls!

31. Next Steps

32. Next Steps • Short Term • Target Tier 3 Providers • Drive electronic submission rates to 95% • Long Term • True end-to-end with EFT • Institutional batch claims • Attachments and secure communication

33. THANK YOU! An independent licensee of the Blue Cross and Blue Shield Association. ® Marks of the Blue Cross and Blue Shield Association. SM Mark of Blue Cross and Blue Shield of North Carolina