HealthCare eCommerce: Claims and Payment/ERA

1. HealthCare eCommerce: Claims and Payment/ERA Redix International, Inc DISA 10/2001 Redix

2. Agenda • HealthCare eCommerce • HealthCare eCommerce Architecture • HealthCare Pipeline Components • Demonstration Redix

3. Why Is Medical Billing Different From Commercial Billing? • Claims are NOT invoices • Third party payers • Secondary, third, … multiple payers • Third party payees Redix

4. Provider 837 835 837 835 Primary Payer Adjudication 837 835 Secondary Payer 837 835 Third Payer Healthcare Claims/Payment/COBCOB: Coordination of Benefits Redix

5. HealthCare Payment/ERA (835) Information Flows Payer Payee ERA EFT & ERA Debit Auth. Debit Notice Payer DFI EFT & ERA Payee DFI Credit Notice Debit EFT DFI: Depository Financial Institution Payer: Actual payer and any third party agents Redix ERA: Electronic Remittance Advice Payee: Actual providers and/or their agents

6. HealthCare Payment (835) Claim Balancing • Transaction Balancing • the sum of all claim payments minus the sum of all provider level adjustments equals the total payment amount • BPR02 = CLP04 -  PLB/04/06/08/10/12/14 • Claim Balancing • submitted changes for the claim minus the sum of all monetary adjustments equals the claim paid amount • CLP04 = CLP03 -  CAS03/06/09/12/15 • Service Line Balancing • related to specific line items from the original submitted claim • SVC03 = SVC02 -  CAS03/06/09/12/15 Redix

7. HealthCare Processing Pipelines Order Processing Pipelines Format Conversion Commerce Interchange Pipeline Cryption Claims Pipeline Product Pipeline Digital Signature Transmit Pipeline eCommerce Components Storage ERA Pipeline Plan Pipeline Receive Pipeline Dictionary SimpleList OBI Pipeline Enrollment Pipeline OrderForm DBStorage Promotion Audit/Tracking HealthCare eCommerce Architecture HealthCare Applications Oracle, SQL Server, Legacy, ERP, Access, or ODBC/OLE-DB databases Redix

8. Component Component Component Component Component Component HealthCare eCommerce - Why Pipeline? • A framework for modeling business processes • that can be broken into steps or stages • where at each stage component(s) can be plugged in to do work • Dynamically define InterProcess Communications • Easily configured • one business process/one pipeline • one transaction/one pipeline Pipeline Stage Stage Redix Stage

9. HealthCare eCommerce ORG A ORG B Data Stores Data Stores Non TX MTS DB MTS DB Non TX HealthCare Transactions Receive Pipeline: Decrypt, Unsign, Receipt, Map, audit, App Int HealthCare Transactions Transmit Pipeline: Map, Sign, Encrypt, Audit, Transmit HIPAA, XML HIPAA, XML INTERNET HTTP SMTP Business Application Processing Pipeline HIPAA, XML Web Server HIPAA, XML HealthCare Transactions Receive Pipeline: Decrypt, Unsign, Receipt, Map, audit, App Int HealthCare Transactions Transmit Pipeline: Map, Sign, Encrypt, Audit, Transmit Browser App Client Business Application Internet Client (Consumer) Redix

10. Claims Processing Legacy Document Management Database Claims Entry Claims Receive Pipeline Decrypt, Unsign, Receipt, Map, audit, App Int 997 Claims Ack Transmit Pipeline Map, Sign, Encrypt, Audit, Transmit Internet Processing Pipeline ASP Claims Receive Pipeline Decrypt, Unsign, Receipt, Map, audit, App Int HIPAA 837 Claims Transmit Pipeline Map, Sign, Encrypt, Audit, Transmit Claims Web Client OfficeClient HealthCare Claims eCommerce Processing - Example Payer Provider Redix

11. Billing Processing Legacy Document Management Database ERA Entry Claims Receive Pipeline Decrypt, Unsign, Receipt, Map, audit, App Int 997 ERA Ack Transmit Pipeline Map, Sign, Encrypt, Audit, Transmit Internet Processing Pipeline ASP ERA Receive Pipeline Decrypt, Unsign, Receipt, Map, audit, App Int HIPAA 835/ERA Payment/ERA Transmit Pipeline Map, Sign, Encrypt, Audit, Transmit Payment Web Client OfficeClient HealthCare Payment eCommerce Processing - Example Provider Payer Redix

12. HealthCare eCommerce Transmit Architecture Healthcare eCommerce Interchange Transmit Pipeline Map NSF -> HIPAA, FF->HIPAA, FF->FF, DB->HIPAA, etc Add Header ISA, Internet MIME, etc. Digitally Sign Digital Signature, RSA, PGP, etc. Encrypt DES, triple DES, RC2 Audit Database Audit Transport HTTP, SMTP, FTP, etc Redix

13. HealthCare eCommerce Receive Architecture HealthCare eCommerce Interchange Receive Pipeline Decrypt RC2, DES, etc. Verify Signature Digital Signature, RSA, etc. Open Header ISA, MIME, etc. Receive Transport Connector 997, Internet, etc. Generate Receipt Map HIPAA->FF, HIPAA->DB, etc. Audit Database Audit Application Integration Redix

14. HealthCare eCommerce Pipeline Components • Format Conversion (NSF, UB, HIPAA, X12, DB, Flat Files, XML, etc) • PKCS7 and SMIME • Digital Signature, Verify Digital Signature, EncryptPKCS • DecryptPKCS, EncryptSMIME, DecryptSMIME • Tracking and Audit Trails • Credit Card Payment (Verisign, Cybercash) • Application Integration • LOB (Line of Business), ERP • DB • Legacy Redix

15. HealthCare Claims Pipeline (NSF->HIPAA->Payer) Redix

16. HealthCare ERA/835 Pipeline (HIPAA->AP) Redix

17. HealthCare Open Buying on the Internet (OBI) Pipeline Redix

18. Internet Transmit Pipeline using XML Redix

19. Demonstrations • HIPAA Transaction Sets • Generic Maps of UB92 <--> HIPAA 837 Institutional • Generic Maps of NSF <--> HIPAA 837 Professional • HIPAA 835 and Balance Checking • Oracle ERP’s POO (Purchase Order Outbound) to OBI Redix

20. Generic Map: NSF 2.0 to HIPAA 837 Professional

21. Generic Map: UB92 Version 4.1 to HIPAA 837 Institutional