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Executing Your Plan for QicLink™ 5.0

Presented by: Ron Gripon, Rodney DeClerk and Stephen Weir

Why 5.0 ?



Compliance



Efficiency



Compatibility



Future Considerations



Services 3

Compliance



ICD-10 Code sets



Full 5010 Transaction integration



CAQH/CORE Transactions

   X12-270/271, X12-276/277 X12-835 EFT transactions

ICD-10 Setup Checklist



ICCLOAD – Load ICD Code Sets



ICMSM – Establish Mapping Set ID



ICMLOAD – Load Code Mappings



MM/MMCAT – Update/Add CBX Categories



ICMM – Establish/Maintain Code Mappings



SN-3 – Add ICD-10 Date and Mapping Set ID

 

PlanBuilder – Mapping Set to Override SN-3

 Optional

CEPM routing controls 5

Load & Manage ICD Codes / Mappings New ICD Programs



ICD Code Load (ICCLOAD)

 Load both ICD-9 and ICD-10 Diagnosis and Procedure codes 

ICD Mapping Set Maintenance (ICMSM)

 Establish and maintain mapping set IDs 

ICD Code Mapping Load (ICMLOAD)

 Load mappings of  ICD-9 codes to ICD-10 codes  ICD-10 codes to ICD-9 codes 

ICD Code Mapping Maintenance (ICMM)

 Establish and maintain code mappings 

ICD Code Translation (ICT)

 Inquiry of mappings

ICD Code Mappings



No industry standard crosswalk map



CMS adopted GEMS

  QicLink used GEMS for crosswalk solution testing 95% of codes mapped 

Bi-directional mappings

  From ICD-9 to ICD-10 From ICD-10 to ICD-9 

Includes one to one, one to many, and many to one mappings 7

Efficiency



ICD-10 setup, load, and mapping programs



Full 5010 Transaction integration

  835 segment conformity with EFT re-association compliance CAGC, CARC and RARC code set mapping and integration 

Real-time incoming 270 and 276 transactions



Real-time response 271 and 277 transactions 8

Efficiency



Performance enhancements 5.0

 Check cycles     Load programs, pmload, emload Reporting programs Web Customer Service Module Normalization of QicLink data 

Current and future Microsoft products/platforms

   Windows 2008 and SQL2012 .Net framework 4.0 and Fujitsu Cobol 4.1

Windows Connection Foundation (WCF) transport layer

CAQH CORE

What is CAQH CORE?

 

The Council for Affordable Quality Healthcare (CAQH) is an American non-profit organization that collaborates with healthcare providers, trade associations, and insurers. The organization is based in Washington, DC The Committee on Operating Rules for Information Exchange (CORE) is a multi-stakeholder membership group organized and facilitated by CAQH.

Types of CAQH CORE Transactions

Phase I and II



270/271 – Eligibility (real time)



276/277 – Claim (real time) Phase III



Electronic Funds Transfer (EFT)



835 Remittance Advice (ERA)



QicLink™ 5.X supports Phase I, II and III transactions. 12

Types of CAQH CORE Transactions

Requests/Inquiries



QicLink™

  Without HIPAA Gateway With HIPAA Gateway 

Web Service (Real time or Batch)

  Without HIPAA Gateway With HIPAA Gateway

CAQH_CORE Web Requests

Compliance Checker

In 270/276 Out 271/277 14

835 Processing



Executing HIP835C



HIP835C will continue to do what it does today for both Gateway and non-Gateway



New with CAQH CORE

 Whether you are Gateway or Non-Gateway a new table called QL835Trans will also house the transaction data  (

ETL) extract, transform, and load process

 A SQL job moves the 835 records to the CAQH CORE DB.  This ETL process also moves the claims and eligibility data for 270 and 276 requests.

270 / 276 Web Request



Submitted via HTTP/Soap request to QCC Services



Elements needed by QCC Services

   Correct Login Correct Password Correct File Layout 

QCC Services replies with an 271 / 277 16

Repository Inquiry Tool

Inquiry tool: Criteria screen

Inquiry tool: Display results

Compatibility

   

QicLink™ 5.0 is the platform for future functionality enhancements and Regulatory requirement enhancements 3 rd party software

 Maintain compatibility of current versions

Trading Partner Compatibility

  Minimize step-up/step-down issues Current data file formats for data exchanges (ECISF, 834)

QicLink 4.20 Core enhancement and performance enhancements limited 21

Compliancy

Future Considerations?

Resources

 

Centers for Medicare & Medicaid Services

http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ic d10   2014 ICD-10-CM and GEMS 2014 ICD-10 PCS and GEMS

Customer Exchange

 How to Corner:  https://cx.trizetto.com/sitelogic.cfm?id=1179 QicLink™ e2 Corner  Did You Know?

  ICD-10 Corner 835 setup  QicLink 5.00 Documentation

Services



TriZetto Services

     QicLink™ 5.X Technical Consulting Project Management Automation / Operational Reviews ICD-10 Implementation 835 Implementation   CAQH CORE Implementation Custom Development

Workshop Survey We would like to extend you an opportunity to provide candid feedback.

During the workshop you should have received an e-mail notification for you to take an on-line survey.

If you could take a few minutes to complete at this time , we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately.

Document

Transcript Document

Executing Your Plan for QicLink™ 5.0

Presented by: Ron Gripon, Rodney DeClerk and Stephen Weir

Why 5.0 ?

Compliance

ICD-10 Setup Checklist

Load & Manage ICD Codes / Mappings New ICD Programs

ICD Code Mappings

Efficiency

Efficiency

CAQH CORE

What is CAQH CORE?

Types of CAQH CORE Transactions

Types of CAQH CORE Transactions

CAQH_CORE Web Requests

835 Processing

270 / 276 Web Request

Repository Inquiry Tool

Inquiry tool: Criteria screen

Inquiry tool: Display results

Compatibility

Compatibility

Compliancy

Future Considerations?

Resources

Services

Workshop Survey We would like to extend you an opportunity to provide candid feedback.

Thank You!

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