Healthcare Data Interchange Group (HDIG)

More than four years ago, M2 Systems formed a strategic partnership with The Healthcare Data Interchange Group (HDIG) to focus specifically on providing highly reliable and economical HIPAA transaction solutions for payers and clearinghouses. HDIG is a consortium of several Blue Cross Blue Shield Plans including:

• Blue Cross and Blue Shield of Kansas (Administrative Service of Kansas - ASK, Inc.)
• Blue Cross and Blue Shield of North Dakota (Noridian)
• Blue Cross and Blue Shield of Rochester, Syracuse and Utica (Excellus)
• Blue Cross and Blue Shield of Wisconsin (Cobalt)

The mission of the association is:

• To reduce cost for receiving and sending Electronic Data Interchange (EDI)
• To standardize the implementation and maintenance on members' EDI platforms
• To reduce cost and gain efficiencies and time by jointly developing, testing, and maintaining standard sets of EDI applications
• To influence vendors with regard to design and development of current and future core product offerings to meet the needs and expectations of the members of the Association
• To share the knowledge and resources of each other's plan
• To be proactive in influencing the national standards and implementations in the industry

This partnership has enabled the members and M2 Systems to designate best practice process flows, business rules, payer specific edits and trading partner practices that are being utilized at the member organizations and have been incorporated into their common technology infrastructure, M2 Systems' ENGIN. By acting as a group with a common goal and standardizing on ENGIN, they have been able to recognize great economies of scale. The consortium's input has also been strategically evaluated by M2 Systems' development team and key functionality has been incorporated into standard release functionality of ENGIN.

This approach has also paid significant dividends for each of the members HIPAA deployments. By agreeing on a common technology framework and working together to agree on a best practices approach, the members have been able to move quickly through the HIPAA implementation, testing and production environment. Of great significance was the announcement in August of 2002 by Noridian Administrative Services that they were the first Medicare intermediary in the country to put the HIPAA-compliant X12.837 Institutional Format into production with live trading partners. For more details see the Noridian Press Release. In addition, members of HDIG have begun to leverage their success by processing healthcare transactions on behalf of other Blue Cross Blue Shield organizations across the country. Organizations seeking to leverage HDIG's innovative approach should contact:

Ann Schlosser - VP ProPar Services Inc, Affiliate of BCBS Nebraska
Email: Ann.Schlosser@bcbsne.com
Phone: 402.390.1858

Mona Speranza - IT Manager - Clearinghouse Services, Excellus Corp.
Email: Mona.Speranza@excellus.com
Phone: 585.238.4422

Patsie Robinett - Asst. Manager - Unix/EDI Systems Support, BCBS of Kansas
Email: Patsie.Robinett@bcbsks.com
Phone: 785.291.7146

Jeff Harmon - Medicare Services Operations Manager, Noridian Administrative Services, LLC
Email: Jeff.Harmon@noridian.com
Phone: 701.282.1261

Chuck Schuele - Director of Technology Support Services, Cobalt, BCBS of Wisconsin
Email: Chuck.Schuele@cobalt-corp.com
Phone: 262.523.4795

HIPAA Solution

Communications Managers - M2 Systems' ENGIN-based i24Payor provides a complete message queuing environment to manage the process and workflows of claims and other HIPAA compliant transactions while under its control. The communications managers provide interfaces to other systems, applications, files and databases. Protocols supported include Asynchronous, X.25, SNA TCP/IP, MQ Series and others.

Real Time / Batch Capability - M2 Systems' Solution provides both real-time and batch capability. This allows organizations to handle both the submission of large batches of claims and other transactions in a periodic or scheduled manner while simultaneously supporting real-time eligibility, claim status and other administrative transactions. This also allows payers and clearinghouses to migrate from batch to real-time using one integrated solution rather than requiring the costly integration of two disparate technologies.

Authentication - Authentication is the first component of ENGIN's Trading Partner Services (TPS) capability. Every trading partner has a unique trading partner profile that stores identifying information and the nature of their relationship with the payer or clearinghouse. Authentication challenges every user for their ID and password, and admits or rejects them based on the accuracy of the response.

Authorization - Once authentication has occurred, the trading partner profile is queried to determine additional detail about the trading partner. At this point in the process the trading partner is authorized to perform certain functions within the system such as submit claims, receive acknowledgements, inquire about claim status, etc.

Structure Validation - HIPAA compliance requires that all transactions conform to a specific format and structure. The WEDI/SNIP organization has issued a series of guidelines that detail seven levels of testing to ensure full HIPAA compliance. ENGIN has been certified in conjunction with M2 Systems' customers at all seven levels. This granularity of HIPAA compliant testing allows ENGIN to quickly eliminate duplicate and ineligible claims, a common problem for payers. Rejections can be applied at the most granular levels including batch, file, claim, by Provider, by Subscriber, by Patient, etc.

Routing - Once the structure of the incoming transactions has been validated, ENGIN applies TPS-derived business rules to determine the final destination (by claim, by eligibility, by referral, etc.) of each transaction within a batch and groups them accordingly for further processing. Since routing is configuration and profile driven, processing is rapid and efficient. This capability is an integrated component of the solution and requires no custom coding to implement.

Payer Specific Edits - Once grouped according to routing destination, payer specific edits are applied according to the parameters contained in the trading partner profile. The M2 Systems HIPAA Solution ships with pre-built sets of payer specific edits that meet the HIPAA guidelines. Additional rules for new trading partners can be easily configured using intuitive GUI tools rather than high cost - high maintenance custom coding.

Translation - M2 Systems provides powerful, single pass translation. This translates into high throughput and enhanced productivity for users. As a part of the solution, pre-defined mapping and translations from and to X.12 837 4010 (Institutional, Professional and Dental), NSF, UB92 and proprietary formats help speed the implementation, testing and production process.

Rebatching / Distribution - Once the transactions have been fully routed, edited and translated they are re-batched or grouped according to the final intended destination. Re-batching can be based on multiple, complex criteria and distribution can occur instantaneously or delivered to other systems according to pre-determined delivery instructions.

HIPAA Compliance and HIPAA Productivity - The difference between a HIPAA compliant system and a HIPAA productive system is significant. HIPAA compliance certifies that a system can receive and validate any or all of the ten designated HIPAA transactions. Compliance testing and certification can also be at any one of seven levels as well. For example, a solution can be certified as "HIPAA-compliant" if it passes the first 3 levels of testing (EDI Syntax, HIPAA guideline testing and Balancing of fields). However, the formats of the transactions received (Medicare claim) may require that levels 4 - 7 (situational, external code sets, product types or line of services, trading partner specific) be tested as they relate to certain segments in certain positions containing certain values as they pertain to certain trading partners. Additionally, a solution can be certified as HIPAA compliant if it takes in X.12 4010 transactions, validates them and passes them through as X.12 4010. While these scenarios may be HIPAA compliant, they are not HIPAA productive.

M2 Systems has worked closely with HDIG (a group of 7 BCBS plans) to establish a set of best practices that encapsulate HIPAA certifiable administrative transactions that are being used in real-world environments. These best practices consist of pre-defined workflows, trading partner profiles, mapping and translations, business rules and custom edits that are specifically designed to streamline an organization's HIPAA implementation, provide rapid certification and go into production on time and within budget.This approach has been highly successful and the HDIG members have been able to meet their deadlines with minimal business interruption.