278 Notification Transaction

1
278 Notification Transaction

• April 2008

2
UHC Notification Program

• UnitedHealthcare 24 hour notice of inpatient
  admission
• Looking to get notice of inpatient admission 7
  days per week
• Looking to improve patient outcomes through care
  coordination
• Working with hospitals, vendors, clearinghouses
  to create path for automated notification to
  replace cumbersome phone and fax solutions

3
Notification Program Approach

• Approach to notification automation
• Create direct connectivity capability for real
  time and batch Connectivity Director
• Coordinate development with EDI vendors through
  Ingenix EDI Solutions (UHGs clearinghouse)
• Pilot transaction capability with selected
  hospitals in April-May 2008
• Expand availability of transaction in Q4 2008

4
Issues for choice of Notification EDI

• What is the impact of HIPAA?
• What standard to use, if any?
• What is the impact on facilities and vendors?

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What is the impact of HIPAA?
HIPAA Compliance
HIPAA Rules for 278 Referral and
Authorization

• HIPAA Transaction concerns
• Covered Entity health plans, providers,
  clearinghouses and their business associates
• Covered Business Events
• Usage of HIPAA transactions rules and
  limitations

Subpart MReferral Certification
and Authorization 162.1301 Referral
certification and authorization transaction. The
referral certification and authorization
transaction is any of the following
transmissions (a) A request for the review of
health care to obtain an authorization for
the health care. (b) A request to obtain
authorization for referring an individual to
another health care provider. (c) A response to a
request described in paragraph (a) or paragraph
(b) of this section. 162.1302 Standard for
referral certification and authorization. The
Secretary adopts the ASC X12N 278Health Care
Services Review Request for Review and
Response, Version 4010, May 2000,
Washington Publishing Company, 004010X094 as the
standard for the referral certification and
authorization transaction. The implementation
specification is available at the addresses
specified in 162.920(a)(1).
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HIPAA EDI conclusions

• UHC is a covered entity
• Notification is not a business event listed under
  HIPAA
• A separate X12 Format is available for
  Notifications
• Conclusion The HIPAA transaction rules and
  constraints do not govern this business event

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What standard to use, if any?

• Business Requirements for inpatient notification
  are similar to pre-certification/pre-authorization
  transaction under HIPAA
• X12 has multiple Implementation Guides for 278
  transaction
• Proprietary transactions have been created by
  other health plans and entities for this event
• Conclusion There are multiple formats that could
  be used for this event

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Choice of 278s

• Multiple versions of 278 exist
• 278 Healthcare Services Review and Response
• This was chosen by HIPAA to cover HIPAA business
  events only
• Authorization (including Pre-Certification) and
  Referral only
• This version currently being used to accommodate
  UHC inpatient notifications for pilot program
• 278 Healthcare Services Review Notification and
  Acknowledgement
• This is a separate non-HIPAA-mandated
  Implementation Guide available for Notifications
• Designed by X12 specifically for notification
  events not covered under HIPAA
• This version recommended by X12 to CMS for
  adoption by HIPAA in future
• This version will be long term format planned for
  Q4 2008
• 278 Healthcare Services Review Inquiry/Response
• A separate non-HIPAA-mandated version available
  for status information
• Used to inquire as to the status of a previously
  submitted notification referral, or authorizations

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What is the impact on facilities and vendors?

• The 278 HIPAA transaction is not widely adopted
  as yet
• Few clearinghouse vendors report significant
  volume for this transaction
• The few vendors and health plans using the 278
  use the HIPAA version Healthcare Services
  Request for Review and Response (004010x094a1)
• Proprietary transactions are expensive to build,
  and generally work only for one trading partner
  relationship
• Conclusion Use the HIPAA format for pilot sites
  to possibly utilize what is in place for vendors
  and facilities today.

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Final Choice and Roadmap Step 1

• UHC Inpatient Notification project team has
  chosen to use the HIPAA version as the basis for
  the notification transaction meet the immediate
  need for a pilot Notification transaction
• Advantages
• HIPAA 278 Map already in use at UHC for HIPAA
  referrals and authorizations
• 278 format can supply 99 of the data needs for
  this one particular notification
• Same internal UHC systems already use the HIPAA
  278 for authorization

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Final Choice and Roadmap Step 2

• Migrate to the X12 Healthcare Services
  Notification and Acknowledgement (005010x216) for
  Q4 2008
• Advantages
• This transaction more flexible in long term for
  multiple notification events provides
  capability for two-way notification
• Likely to be chosen if/when HIPAA chooses to
  cover notification business event (already
  recommended by X12 to CMS)
• Promotes the use of standardization in healthcare
• Requires minimal mapping change from HIPAA
  version
• Provides a clearer option for the long term no
  confusion with HIPAA transaction

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Appendix

• X12 Committee Descriptions -Transaction Usage
  for X12 278 Transactions

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278 Authorization (Pre-certification) and Referral

• X12 278 Healthcare Services Request for Review
  and Response (taken from HIPAA-required version
  004010x094a1 Guide)
• 1.3 Business Use and Definition
• The 278 has the flexibility to accommodate the
  exchange of information between
• providers and review entities. This section
  introduces the business events and
• processes associated with the 278.
• 1.3.1 Business Events Supported in this Guide -
• Request and Response
• This implementation guide covers the following
  business events.
• ? admission certification review request and
  associated response
• ? referral review request and associated response
• ? health care services certification review
  request and associated response
• ? extend certification review request and
  associated response
• ? certification appeal review request and
  associated response
• (NOTE HIPAA defines certification as the event
  which authorizes healthcare services, when a
  health plan requires prior authorization for
  services)

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278 Notification (non-HIPAA)

• X12 278 Healthcare Services Notification and
  Acknowledgement (taken from current version 5010
  Guide)
• 1.4 Business Usage
• The 278 has the flexibility to accommodate the
  exchange of information between
• providers and review entities. This section
  introduces the business events and
• processes associated with the 278.
• 1.4.1 Business Events Supported in this Guide
• This implementation guide supports the following
  health care service review business
• events.
• 1.4.1.1 Notification
• The 278 can be used to send unsolicited
  information among providers, payers,
• delegated UMO entities and/or other providers.
  This information can take the
• form of copies of health service reviews or
  notification of scheduled, or the beginning
• and end of treatment. A participant who is the
  recipient of the information
• may acknowledge they received the data, or reject
  the data due to specific application
• layer processing, but may not respond with any
  review decision outcome.
• This implementation guide supports the following
  categories of notifications.
• Advance Notification for
• ? scheduled inpatient admissions

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General Process Flow
278 Referral Authorization With Notification data
Hospital System
UHC FTP
B2B Mercator ETL Translate Record
278 Notification
Needed to support Industry Standard 278
Notification
278 Notification Response
Real-time or Batch
single/multiple admits
UHG Clinical Systems
CCS
B2B Gateway
278 Notification Response
CareOne
Hospital Registrar
Look up Eligibility Look up Provider
Hospital sends notification to UHC EDI FTP UHC
Sends back a 278 Notification Response
Hospital ADT system creates EDI X.12 278
Notification Record
UHC B2B Translates the received record into our
internal format
Eligibility confirmed record routed to internal
Clinical system which provides a response
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UHC 278 Notification Companion Guide

• Differences from HIPAA Authorization 004010x094a1
  IG to UHC 278 Notification Companion Guide
• No violations of HIPAA 278 structure
• Some situational elements are required for
  inpatient event
• Patient Condition (when diagnosis is unavailable)
  is entered into the MSG segment
• Admission Time is optional, and can be entered in
  the MSG segment

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Companion Guide Notes

• Sample from Companion Guide

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Companion Guide Notes
Sample from Companion Guide
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Future 278 Considerations

• Review 278 Notification and Acknowledgement for
  usability since it is not widely used, there
  may be bugs or shortcomings that need to be
  reported to X12
• Become more involved in supporting 287
  Notification at X12 meetings
• Need to determine if Admission Time is critical
  to business need, and incorporate into
  transaction
• Review applicability of 278 Inquiry and Response
• Not designed for interaction with 278
  Notification?
• Status of a notification has not been clearly
  defined in the implementation guide
• Time is optional, and can be entered in the MSG
  segment
• Evaluate 278 Notification response transactions
  in light of WEDI whitepaper on acknowledgements

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Questions

• Questions?
• Feedback?
• Suggestions?
• ALL ARE WELCOME!