Transcript Optum ™ with NetworX ™ - What’s in it for you?

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Copyright © 2014 TriZetto Corporation
What’s New with the
Optum/NetworX Interface?
Optum: Heather Johnson
TriZetto: Tonia Burns, Dir Product Management
Carolyn Keadle, Sr Product Design
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What is it? What’s new?
Why Use Optum ™ with NetworX ™?
How it Works/Today’s Offerings
Recent Additions
Upcoming changes/additions
Updates and Troubleshooting Tips
Summary
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Optum ™ with NetworX ™ - What’s in it
for you?
 Contracts using Medicare and/or Medicare-like methodologies
 Medicare processes are complicated
 Pricing methods could be created in NetworX™, however
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No editing in NetworX ™ (editing from other source)
Editing rules for Medicare and “Medicare-like” rules created in other source
Pricing based on specific providers
Regulatory changes would require coding modifications
 Interface to Optum™ puts the complexity outside NetworX™
 Provides easy way to process based on numerous Prospective
Payment Systems (PPS), including
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Inpatient: Acute Care, LTCH, IPF, and CAH
Outpatient: HOPD, ASC, ESRD, and CAH
Sub-Acute: SNF, IRF, and HHA
Physician
 Non-Medicare PPSs are also available, including:
 TRICARE Inpatient and Outpatient
 Some State Medicaid Inpatient and Outpatient (NY, NJ, MI, TX)
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Advantages – Medicare/Medicaid
 Optum ™ provides:
 Appropriate Medicare/Medicaid edits and validation, including:
 CCI Edits (Correct Coding Initiative)
 OCE Edits (Outpatient Code Edits)
 MUE Edits (Medically Unlikely Edits)
 MCE Edits (Medicare Code Edits)
 POA/HAC Edits (Present on Admission/Hospital Acquired Condition Edits)
 Grouping, including:
 MS-DRG
 AP-DRG
 APR-DRG
 TRICARE DRG
 APC
 EAPG
 Pricing
 Based on what is wrong with the patient, what services are performed, and
where those services are performed
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The Advantages – Commercial Business
 Contracts based on Medicare and/or Medicaid
 Same processes for Editing and Grouping as
Medicare and available Medicaid
 NetworX™ has ability to group the appropriate DRG
 Set Pricing rules using standard NetworX™ calculations
 Use allowance returned as basis for Commercial
Allowable
 Apply Percentage of Allowable returned
 Use different DRG Versions
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How it works
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How it works – (simply)
Claim Submitted To NetworX™
Claim qualifies for term for Optum™
Process
NetworX™ send claim data to Optum™ for
processing
Claim processed in Optum
Processed claim returned to NetworX with
appropriate edits, grouping and pricing
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What the process does –NetworX™ to
Optum™
 Claim received by NetworX™
 User-defined terms indicate qualifier (what is on the claim to
drive it to pricing) as well as which pricing methodology
 Claim Qualifies for NetworX ™/Optum ™ term
 NetworX ™ “calls” appropriate Optum ™ service
 Passes Claim data (Diagnoses, procedures, patient age, etc.)
 Passes appropriate calculation information (source type, which
service to invoke, etc.)
 Optum ™ processes the claim
 Edits Applied
 Grouping Performed
 Pricing Determined
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What the process does – Optum™ to
NetworX™
 Optum™ Passes claim data back to NetworX™
 Includes appropriate Editing, Grouping, and Pricing Information
 Includes additional data stored with claim
 NetworX ™ receives the claim information
 Claim information is retained/passed to appropriate system
 In Stand Alone products, Repricing data is populated in NetworX
database
 In Facets, data is passed back to Facets to be saved with the
claim
Note - Claim pricing may be altered by additional NetworX™
calculations
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Prospective Payment
System (PPS)
currently available
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Inpatient Methodology – Edit/Group Only
 Edit/Group Only DRG
 Medicare (MS-DRG)
 Inpatient Rehab Facility (IRF) (separate term)
 Use to determine the appropriate code for the claim;
pricing rules to be set in other terms in NetworX™
pricing
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Inpatient Methodology
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Edit, Group and Price
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Medicare Acute Care (MS-DRG)
Medicare Inpatient Psychiatric Facility (IPF)
Medicare Inpatient Rehabilitation Facility (IRF) Group/Price (separate term)
Medicare Critical Access Hospital (CAH)
Medicare Long Term Care Hospital (LTCH)
New Jersey Medicaid
Ohio Medicaid (APR-DRG)
New York Medicaid (APR-DRG)
See Customer Exchange for complete list of PPS supported https://cx.trizetto.com/sitelogic.cfm?id=3701
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Outpatient Methodologies
 Edit, Group and Price
 Perform Outpatient Facility Edit/Group/Price
 Options for return values
 Option to Group/Price only **NEW**
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Outpatient Facility Options
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Medicare Ambulatory Surgical Center (ASC)
Medicare End Stage Renal Disease (ESRD)
Medicare Critical Access Hospital (CAH)
Medicare Home Health Agency (HHA)
NY Medicaid Enhanced Ambulatory Patient Group (EAPG)
MI Medicaid Outpatient
 See Customer Exchange for complete list of PPS supported https://cx.trizetto.com/sitelogic.cfm?id=3701
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Other Methodologies – Skilled Nursing
 Medicare Skilled Nursing Facility (SNF) – Part A and
Part B
 Used for both inpatient and outpatient claims
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Other Methodologies – Physician Pricing
 Apply Medicare pricing for physician claims, including
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Ambulance
Clinical Lab
DME
Anesthesia
 Option to apply/not apply Physician Editor edits
 User determination of level of errors to be returned
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Returned Pricing Information
 NetworX™ provides information on edits, grouping and pricing
from data returned by Optum™
 In Repricing Details, Supporting data returns information about
the Optum™ data used for the claim
 Actual data provides information on how claim was priced
(DRG, APC, Edits, and Pricing Information - based on the
calculation utilized)
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Other Information Provided
 To help troubleshoot, additional information is
available and is saved with the claim
 Third Party Details returns Additional Information
from claim’s processing and is retained in the
database
 Facets Users (with Related Information)
 Stand Alone Users:
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Optum Additional Information
Additional information based
on the type of processing
done
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Recent Modifications
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Recent additions for PPS’s
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TriCare (Inpatient and Outpatient)
Georgia Inpatient
Illinois Inpatient
Michigan Inpatient
Texas Inpatient (APR-DRG effective 9/1/2012)
Washington (state) Inpatient
Pennsylvania Inpatient (APR-DRG)
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Supported Optum™ Services
Inpatient –Optum™ Version 1303
Outpatient –Optum™ Version 1303
Skilled Nursing Facility –Optum™ Version 1303
Inpatient Rehabilitation Facility –Optum™ Version
1303
 Physician –Optum™ Version 1303
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Newer Functionality with 1303
 Support for ICD-10, including the new Code Class input field
 Support for 64-bit
 Ability to update Optum™ rate files without performing an IIS
reset
 New NY Medicaid APR-DRG and Medicare ESRD pricing
worksheets
 New external data file for Return Code labels and other labels
(outpatient only)
 New input fields for inpatient claims only, including:
 Line-level National Drug Code (NDC)
 Used for Medicare Acute Care claims new technology reimbursement
 Admission Date
 Used to calculate claim length of stay taking into consideration the new
72 hour rule for billing outpatient services on an inpatient claim
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On the Horizon
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But First…..
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Optum Upgrade Plans
 Upgrade Physician Pricer to Optum™ Version 1405
 Upgrade Inpatient Service to Version to version 1405
 Upgrade Inpatient Rehab Facility (IRF) to version
1311
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Updates and
Troubleshooting Tips
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Customer Exchange – Validated Version?
 Customer Exchange provides information on
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Web Service/Version of Optum™
Facets™ and NetworX™ Versions first supporting web service
NetworX™ Calculations
Prospective Payment Systems
 To access, go to
 Customer Exchange/Support/How-To Section/NetworX™ HowTo Section
 then select “Ingenix (HSS) Interface”
Links
 Web Service versions - https://cx.trizetto.com/sitelogic.cfm?id=3700
 Calculations - https://cx.trizetto.com/sitelogic.cfm?id=3701
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Optum™ Releases – Two Main Types
 Regulatory with no modifications to input and/or
output structures – no changes to NetworX™
 Code updates
 Annual Grouper updates
 Pricing and/or editing updates
 Updates requiring input and/or output structures
changes
 New claim field inputs like Code Class
 New data values not currently mapped
Note - TriZetto™ and Optum™ work closely together to
determine what (if any) changes are required
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Troubleshooting - Connectivity
 Is NetworX™ calling the appropriate Optum™ service?
 Verify correct WSDL URL/Property values (see documentation
for information on properties)
In Stand Alone Product, Check System Properties
In Facets, Check Websphere Properties
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If you receive errors….
 Optimizer/System Error
 Be sure to restart the server if new data files were loaded
 Web service may need to be reloaded
 Refer to the EASYGroup™ Technical Reference Guide for more
information
 Contact your Optum™ Representative
 Grouper and/or Rate is incorrect
 Use the Optum™ Tester
 Input claim data exactly from the incorrect results claim
 Test in Web.Strat™ if Tester results still incorrect
 Contact your Optum™ Representative
 Results incorrect in NetworX™ and correct in Tester
 Submit an incident to TriZetto for review
 Capture logcntl.txt file and send to Optum™
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Use the Optum™ Testers
 Inpatient, Outpatient, SNF, IRF, and Physician
Testers with various services
 Test various Groupers/Pricers; good troubleshooting
tool
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If available, use Web.Strat™
 Validate data files are correct
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Common Problems
 Installation of components
 Not installed
 Not installed in correct directory
 Updates not installed
 Rate Manager
 Incorrect Rate Manager data
 Incorrect Rate Manager file transfer procedures
 Incomplete host system configuration settings
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Common Data Problems
 Inpatient
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Invalid Diagnosis or Procedure Codes submitted
Incorrect coding practice for Principal Diagnosis
Missing or invalid Discharge Status
Newborn claims – Birthweight invalid or missing
 Outpatient
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Invalid Diagnosis or Procedure Codes submitted
Missing or invalid line Procedure Codes (where applicable)
Missing or invalid line Procedure Modifiers
Wrong Bill Type
Ambulance claims – Missing Zip Code reported with Value Code
A0
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…and in conclusion
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Summary
 Why use Optum™ and NetworX™
 Easy to set up and use
 Edit/Group/Price to required allowances
 Medicare, Medicaid and Commercial Business
 What’s Available
 Facility PPSs for inpatient, outpatient, SNF, and IRF services
 Physician PPS
 What’s Coming
 Additional state pricing methods, as requested/required
 Troubleshooting and Assistance
 Regulatory updates
 Various tips and tools available for troubleshooting
 Knowledgeable Support Teams
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Web Links for Additional Information
 Home Page Links
www.Optum.com
www.TriZetto.com
 TriZetto Customer Exchange
http://cx.trizetto.com/
 Optum Prospective Payment Solutions
http://www.optum.com/health-plans/operations/paymentintegrity/pre-payment/prospective-paymentsolutions.html
 Optum Client Portal
http://optum.force.com/CustomerPortal
(Contact [email protected] to set up a User
Name)
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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.
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Thank You!
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