State Sponsored Business

1. State Sponsored Business California Round Table Core Administration Redesign Systems Business Change Impacts Presenters: Lisa Lambert, Director Change Management Traci Earle, Manager, Network Data June 22, 2010 Version: 6/11/10

2. Background: States Impacted by CARS Scenario 1: Seeing the Member. When a provider calls to verify the member’s eligibility, several systems come in play to record the call and pull member, provider, and benefit information. CallCare Browser (CCB) WGS (Membership) eWPD and EPDS2 (Benefits) EPDS (Providers) Scenario 2: Submitting the Claim. When a provider submits a claim, our systems perform claim editing and processing. SSB also submits our information to the states to get reimbursed. ClaimsXten Claims Premium Billing Encounters Provider & Member Impacts Implementation Dates Communication Dates Training Topics to be Covered

3. The states below are impacted by CARS. See map legend for SSB states on other systems and exited states. ANTHEM PLANS Anthem Blue Cross Blue Shield of Indiana Hoosier HealthWise Package A, B Medicaid Package C CHIP Healthy Indiana Plan (HIP) Other Blue Cross Blue Shield of South Carolina BlueChoice Health Plan of SC Medicaid UNICARE PLANS UniCare of Kansas HealthWave 19 Medicaid HealthWave 21 CHIP UniCare of Texas STAR Medicaid CHIP CHIP UniCare of West Virginia WV Medicaid Managed Care Medicaid Massachusetts Children’s Medical Security Program Other Healthy Start ProgramOther States Impacted by CARS MA NY NV OH VA IN WV CA KS SC TX ACTIVE D950 STATES UniCare plans – “Green” states Anthem plans – “Blue” states NON-D950 STATES EXITED D950 STATES

4. OUR SCENARIO — FROM THE CUSTOMER PERSPECTIVE Emergency Room physician, Dr. Wilma Point, sees patient Erlinda Garcia who is running a high temperature and is having trouble breathing. Using the information on the Erlinda’s member card, the ER staff calls the customer care center to verify eligibility and benefits. An IVR (Interactive Voice Response) takes the initial information to route the call properly. A Customer Service Representative (CSR) verifies the ER staff can receive the member’s PHI (Protected Health Information – HIPAA). The CSR relays the requested information to the ER staff member and documents the call. Scenario 1: Seeing the Member

5. OUR SCENARIO — FROM THE SYSTEM PERSPECTIVE The CSR is using CCB (CallCare Browser) which pulls information from WGS. With CCB, the CSR will be able to document Dr. Pointe’s call and, if needed, view member, provider, claim, and payment information. Erlinda’s demographics (date of birth, address, phone number), eligibility status, and plan information are contained within WGS Membership Data. WGS, in turn, may pull data from ancillary systems such as: eWPD (Enterprise WellPoint Product Database) for benefits information. EPDS (Enterprise Provider Database System) for provider information. CCB WGS Membership eWPD EPDS Scenario 1: Seeing the Member

6. CallCare Browser CCB WGS Membership eWPD EPDS Scenario 1: Seeing the Member

7. Calls Inquiries • Once the call is routed from the IVR to a Customer Service Representative (CSR), the CSR will use CCB to document the call and ask several questions to verify that the caller can have access to Erlinda’s PHI. • The CSR will do this by comparing the caller’s information with the member and provider date viewable in CCB. • CallCare Browser (CCB) is a browser-based application that uses features such as point-and-click tabs, links, drop-down menus, and radio buttons. • CCB also interfaces with WGS Inquiry Tracking to route calls that require further action, such as for member data maintenance or adjustment of a claim. WGS Inquiry Tracking uses the WGS claims queuing and routing function to route these transactions to the appropriate unit for handling. • Inquiry Tracking produces call center, correspondence, internet, and grievance reporting.

8. SCREENSHOTS: By indicating this is a provider call in the first drop-down box, fill-in boxes for the provider and member appear. Clicking OK opens up a Log Event to document the call. CCB is a browser-based application that uses features such as point-and-click tabs, links, drop-down menus, and radio buttons. NEW/CHANGES TO CCB TO ACCOMMODATE SSB BUSINESS: HCID field (member identifier) has been expanded to accept up to 20 alphanumeric characters in order to accommodate D950 states. New fields created to pull additional provider and claims data. CallCare Browser

9. WGS Membership CCB WGS Membership eWPD EPDS Scenario 1: Seeing the Member

10. Membership Membership Files • Enrollment files are received from various external sources; e.g., Maximus (an enrollment vendor used by some states). • Membership files will be pulled from either EDI or proprietary files and extracted using Business Objects • All data will be stored in the SSB data warehouse for CA and all the migrated states • Eligibility records are then processed for membership eligibility, reporting and other business functions in the form of claims processing, capitation, premium billing, extracts, crosswalks, reference database, and PCP assignment. • Membership information will now process against 20 bytes HCID instead of 9 bytes

11. FROM THE ENROLLMENT FILES: A PCP Choice is assigned when a PCP choice is indicated on the file. The PCP choice must pass all enrollment rules.* An existing PCP is retained when no PCP choice is indicated on the file of if the PCP choice fails enrollment rules. Existing PCP must have an active contract and be a PCP at the time of assignment. A PCP whom other family members see is assigned when the existing PCP has an invalid contract or is no longer a PCP. The member must pass the enrollment rules for the family PCP. A PCP is auto-assigned when the family PCP fails or there are no family PCPs. Members will be auto-assigned using a new PICK process that considers both member (home address) and provider information (member address to provider, language spoken, specialty/type, and ranking). * Provider enrollment rules cover the type of patients a provider will see (age, gender, new or existing patients) and how many members the provider will see (enrollment capacity by line of business) AUTO ASSIGN PCP ASSIGN FAMILY PCP RETAIN PCP ASSIGN NEW PCP PCP Assignment States indicate that each member for our HMO programs have Primary Care Provider assigned to them. Massachusetts is an exception as this is an ASO program (MA does not have PCPs assigned to either CMSP or HSP program).

12. Notification of a membership update for IN, SC, WV, TX, KS, & MA is received by SSB membership via internal sources (fax, email, reports) or external sources (fax, email, extranet). ID Card Triggers Changes in Membership status can trigger the issuance of a new ID card; for example: Member adds, changes, and address changes PCP assignment change PCP address change Change in age category, group, county, or contract code (benefit package) Eligibility effective date change Reinstates, depending on state Update Membership

13. NEW TO MEMBERSHIP SCREENS TO ACCOMMODATE D950 BUSINESS: Subscriber/Dependent Membership Information ID Screen Responsible Party Eligible Information WGS Membership Information in red indicates changes to WGS. NEW : SUBSCRIBER/DEPENDENT

14. WGS Membership – Member Information Screen NEW: MEMBER INFORMATION SCREEN • Fields may or may not be available for data entry depending on state requirements. • For example, • PRESMP ELIG FLAG (Presumptive Eligibility) is only available for Indiana. • NEWBORN FLAG is only available for West Virginia and Texas • Information on these screens may cause other fields on other screens to be populated. See next slide for examples.

15. Claims will look at the following member information: Demographics Plan / Contractual information Eligibility Authorizations Prior Claim history Key data elements utilized or captured by Claims include: Health Care ID (HCID) Contract Code and effective dates. Member Network Data Claims route code Effective and term date Limited Liability Data/Coordination of Benefits (COB) Funding Type Code: Used for WGS EOB/Check Write Used to drive edits & claims processing Used to generate the full Line of Business for General Ledger WGS Membership – Impact to Claims

16. Enterprise WellPoint Product Database (eWPD) CCB WGS Membership eWPD EPDS Scenario 1: Seeing the Member

17. eWPD — Viewing ER Benefits in WGS • Similar to the layout in eWPD, benefits are listed in Major Categories: • General benefits. Examples: calendar year or benefit year or if co-pays apply. • General provisions. Example: whether IRS rules apply and any exclusions or limitations. NOTE: SCREENSHOT SHOWS COMMERCIAL INFO

18. Enterprise Provider Database System (EPDS) CCB WGS Membership eWPD EPDS Scenario 1: Seeing the Member

19. EPDS I and EPDS II CARS has enabled the SSB lines of business to develop their own instance of the Enterprise Provider Database Solutions, more commonly referred to as EPDS. Currently there are 2 separate instances for EPDS: - EPDS I supporting the California based operations - Institutional implementation April 2006 - Professional implementation June 2010 - EPDS II supporting Indiana, Kansas, Massachusetts, South Carolina, Texas and West Virginia - Implementation scheduled for August 2010 EPDS I and EPDS II will house both the provider demographic and contractual information New fields to be passed to Provider to enhance matching process through EPDS I for CA and EPDS II for all migrated states • Billing and Rendering Taxonomy codes • Provider’s Facility Address and Zip Code • Bill Type

20. OUR SCENARIO — FROM THE CUSTOMER PERSPECTIVE Dr. Pointe submits a claim for Erlinda’s visit. The hospital uses a Clearinghouse which submits all the claims electronically. The claim was processed and paid. Encounter information on the claim was set to the state. The office billing staff called the customer care center with a question on payment amount. The Customer Care Representative relayed the information and documented the call. Scenario 2: Submitting the Claim

21. OUR SCENARIO — FROM THE SYSTEM PERSPECTIVE In addition to looking at the Membership data, eWPD, and EPDS, the claims system interface with: ClaimsXten (or CXT) - Web-based user interface that provides access to claims that were viewed and edited by claims editing logic in the rules engine and were tagged as having matched pre-defined editing criteria. CIA (Claim Interactive Analyzer) - CXT tool used for manual entry of information to determine what rules will fire for “mock” or “what if” claim scenarios or when combining multiple claims have been billed by the same provider on the same date of service or a global billing period. WMDS (WellPoint Medical Decision System) – Utilized by Medical Management to capture information such as case information and authorization. Scenario 2: Submitting the Claim

22. Front End Process Claims Front-End Processes: Claims are received from multiple sources, including: • EDI – Claims are received from EDI external trading partners. These claims are received at the WellPoint Enterprise Gateway where they are verified against the HIPAA Standards for electronic claims transmission (all required fields are present, fields have valid HIPAA compliant values). If a claim is not HIPAA compliant, it is rejected and sent back to the submitter of the claim. Valid electronic claims are converted to WellPoint common format and sent to WGS. EDI claims are also translated into a standard image and sent to an image repository (FileNet). • Paper Claims – SourceCorp receives mailed professional and institutional paper claims where they are scanned and assigned a Document Control Number (DCN), logged and entry of claims is completed or claim returned to provider, validated and routed to appropriate SSB departments. The claims are also sent to the image repository (FileNet). • ITS Claims (BlueCard) – SSB receives claims from other Blue Plans, which will be priced and sent to the member’s “Home” plan using the Inter-plan Teleprocessing System (ITS). Benefits are determined by the member’s plan. BLUE CARD

23. Validating Claims Data Once claims are received by WGS, a series of validations must occur before adjudication can take place. MEMBER VALIDATION: Is the member eligible for benefits as of the date of service? Does the member have other coverage? If needed, the claim or claim information is routed to the appropriate areas (Membership, Financial Operations) or denied. PROVIDER VALIDATION: Does the provider have a National Provider ID (NPI) and a valid contract for line of business and date of service? Does member’s age and gender match provider’s enrollment information? If provider is a specialist or non-par, do other validation criteria apply? Do other requirements prevail (benefit code, attestation, etc.)? If the provider is not found, the claim is routed to PCDA for an update. DATA VALIDATION: Are the procedure codes/diagnostic codes appropriate for the service/age/gender? Do co-pays apply? Do prior claims impact adjudication (for example, duplicate claims, benefit accumulators)? Has claim been reviewed by CXT? PRIOR AUTHORIZATION VALIDATION: Does the procedure require prior authorization? If a prior authorization is required and no authorization is found, the claim is sent to the Utilization Management for prior authorization. If no medical records are on file for the member, the claim is denied. BENEFITS AND PRICING VALIDATION: The final step is to validate pricing. If rates are not loaded, the claim is routed to either PCDA or Benefits Administration for update. If rates are present, a validation is done to ensure that the claim was filed within timely filing limits. APPROVE DENY Validating Claims Data

24. ClaimXten (CXT) Scenario 2: Submitting the Claim

25. ClaimXten (CXT) will replace ClaimCheck and/or McKesson Bundling in SSB’s processing systems. SCREENSHOT: (Claim Interactive Analyzer) CIA main page screen for CXT. Associate will type in system ID and DCN in the Claim ID field. CXT LOG-IN SCREEN

26. The claim detail screen shows all the information sent from WGS to CXT. It also shows which lines were denied and history DCN (if applicable) and why. If an associate needs additional information on the denial reason, they can click on the Rule Acronym to get a pop up with edit rational. CXT CLAIM DETAIL SCREEN

27. This is the claim in WGS. Note in the bottom left corner of the claim, there is a CX edit, indicating CXT pop-up information is available by clicking on the CX pop-up indicator. This CX pop-up shows that CXT reviewed this claim with a $0 payment for claim line 2. CXT

28. WGS Claims Scenario 2: Submitting the Claim

29. Claims Screens — PAC View 1 • WGS claims information are presented on several screens. • PAC VIEW 1 contains: • Member information • Provider information (pulled from EPDS) • Diagnosis codes • Claims codes • Using the function keys, you can navigate to additional screens.

30. Claims Screens — PAC View 2 • PAC VIEW 2 contains: • Procedure codes • Payment, line-by-line • Using the function keys, you can navigate to additional screens.

31. Pricing Configuration Pricing and Configuration Information • External : State fee schedules • Internal: Areas such as Non-Standards Contracts with Providers, Medical Management, Central Support. CA Pricing / Configuration Functionality Utilized by D950 Migrated States • Rate Sheets - Contract Codes - Contractual Pricing Pricing Methodology • There are different pricing methods. Appropriate pricing method depends on the provider’s contract and claim type • Professional claims and some institutional outpatient claims are priced using fee schedule and negotiated contract rate. • Institutional outpatient claims can be priced using a percentage of billed charges. • Institutional inpatient claims are priced per diem, percentage of billed charges, or as a whole claim (one payment amount regardless of number of individual procedures) using DRGs (diagnosis related groups).

32. Adjudication and Adjustment Claims Adjudication and Finalization • All claims are validated • If the claim is deemed non payable, a denial code is sent back to the system and a EOB/RA is sent to the provider along with a reject letter to the member. • If the claim is deemed payable, pricing is applied with a payable reason code. Then an appropriate paid code is applied to ensure correct notification. This could be an Electronic Remittance Advice (ERA), Electronic Fund Transfer (EFT), Explanation of Benefits (EOB), or Remittance Advice (RA). • The claim is submitted for the daily check run (CheckWrite). Overpayment Claims Adjustment • The Finance Ops team researches and validates overpayment requests from providers or from SSB functional areas (Customer Care Center, Claims, and Grievance and Appeals). If the case is determined not to be valid, the case is closed. • If the overpayment is determined to be valid, the claim is corrected and notes are entered on the claim, including an adjustment reason code. When the claim is adjusted in WGS, the retraction is set up and notification is sent to the provider.

33. Claims Payment • WGS interfaces with financial/cash disbursement systems that produce the Explanation of Benefits (EOB), remittance advices (RA), and checks for finalized claims. • These systems are: WGS 2.0 accounting, EOB, and Check Write. • The provider has the ability to select the method under which they will receive payment • Physical check they will deposit themselves • Electronic Funds Transfer (EFT) where the funds are deposited in their account for them • Providers may also select the methods under which they will receive their remittance advice (RA): • Physical remittance advice mailed to them • Electronic transaction, the HIPAA 835, that will be transmitted to them through Enterprise EDI.

34. Premium Billing and Encounters Scenario 2: Submitting the Claim

35. Premium Billing – Rate Screens • Premium Billing refers to the the monthly amount we expect to be paid by the state for a particular member. Premium is paid monthly. • Each state assigns a rate that can be based on gender, age, and geographic location. • Before the premium received from the state is finalized, Finance and Membership review and reconcile any discrepancies between the amount paid by the state and the amount expected based on the member in WGS. GNBSRTEI WELLPOINT GROUP SYSTEM 2 12/07/09 08:44:33 1 WASKIDR VTC00009 SSB RATES INQUIRY VERSION 000 CASE 186100 GRP/SUF 1861000001 186100 1861000001 GRP NAME: KS STANDARD TITLE 19 GEO-CD: SE MBU: SKS PRODUCT LINE: SC GENDER AGE-FRM AGE-TO RATE RT-TYP RETRO EFF-DT TRM-DT CNT-TERM ------ ------- ------ -------- ------ ----- -------- -------- -------- B 0.00 0.99 522.57 REG N 07012009 00000000 06302010 B 1.00 5.99 106.5 REG N 07012009 00000000 06302010 B 6.00 14.99 98.25 REG N 07012009 00000000 06302010 F 15.00 21.99 188.74 REG N 07012009 00000000 06302010 M 15.00 21.99 105.99 REG N 07012009 0000000 06302010 F 22.00 29.99 291.73 REG N 07012009 00000000 06302010 F 30.00 34.99 378.19 REG N 07012009 00000000 06302010 M 22.00 34.99 192.38 REG N 07012009 00000000 06302010 B 35.0 150.00 469.78 REG N 07012009 00000000 06302010 F 0.00 29.99 368.49 PREG N 07012009 00000000 06302010 PF01=HELP PF02=MENU PF03=RETURN PF04=RTRRTE PF05=NXTRGN PF06=CURRTE PF07=PREV PF08=NEXT PF10=BILSRC PF11=NMSBTX PF12=CLEAR

36. Encounters Encounters (Health Care Services Received by Our Members) • Encounter data requirements differ by state. For example, most but not all states require reporting NPI. State-specific encounter data extracts are created from claims, membership, and provider information. Encounter data may also come from our vendors for pharmacy, dental, vision, transportation, and behavioral health. • Once the extracts are created, they are validated for accuracy and any errors are corrected. An 837 or proprietary file is created and submitted to the appropriate state. From the 837/proprietary file, internal reports are generated, including performance reports for capitated groups, cross-functional reporting, and various other reports. • When the state receives the encounter file, a validation is run on the data submitted. If SSB receives notice that the encounter file sent did not pass validation, the errors are reviewed, analyzed, and corrected. A corrected 837/proprietary file is sent back to the state. If SSB is notified that the encounter file did pass validation, encounter scorecards and reports are generated for internal use.

37. Using Business Objects for Encounter Reporting • Encounters will pull reports through Business Objects, a browser-based application where report templates or user-defined reports can be created.

38. Provider & Member Impacts

39. Provider & Member Impacts

40. Provider & Member Impacts

41. Implementation Dates

42. Communications

43. Provider DomainCA Field Staff Training Impacts: ID Cards (HF site code only), Eligibility rosters, Capitation reports, Enhancement of the Authorization indicator, WGS screen updates Impact training will last approximately 2-3 hours, to review the above changes • CXTen: August 18, 2010, role out October 4, 2010 • Prerequisites: • A Day in the Life

44. Provider DomainCA Provider Training • Provider Training • Duration: 2.5 hours (possible multiple sessions required) • Field staff will facilitate all training to providers • Material to be created by CARS training team • Training: CXTen, New CAP report format, New eligibility report format , New Site code information, WGS screen updates

45. Questions