Transcript PPt template - BMC HealthNet Plan 12.11.13

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Confidential | Copyright © 2014 TriZetto Corporation
Facets
Rules Automation – Workflow,
BPA and Customizing Rules
Led by: Keith Herbert, TriZetto, and
Karla Chavez, HealthNet Plan
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Confidential | Copyright © 2014 TriZetto Corporation
About BMC HealthNet Plan
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Boston Medical Center founded Boston Medical Center Health Plan, Inc. in 1997 as a non-profit managed care
organization doing business in Massachusetts as BMC HealthNet Plan.
BMC HealthNet Plan is the managed care organization with the largest number of MassHealth and
Commonwealth Care members in Massachusetts
BMC HealthNet Plan is ranked in the top 10 among Medicaid plans in the nation according to the National
Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Rankings 2013-2014. BMC HealthNet
Plan also continues to maintain Excellent Accreditation from NCQA as a Medicaid health maintenance
organization. In addition, BMCHP’s QHP program has been awarded Accredited status from NCQA, the highest
accreditation level available at this time.
In New Hampshire, the business name is Well Sense Health Plan.
Well Sense Health Plan was one of three managed care organizations selected by the New Hampshire
Department of Health and Human Services to provide health care coverage to New Hampshire’s Medicaid
recipients.
Well Sense Health Plan is the largest Medicaid managed care organization in New Hampshire.
Total membership as of 5/6/2014:
– Massachusetts (BMC HealthNet Plan) – 312,414
New Hampshire (Well Sense Health Plan) – 48,711
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Business Process Automation
TriZetto recommended that clients use a set of
applications introduced in Facets release 4.81 for
creating rules for service code conversions as they
relate to ICD-10 implementation. These applications
are found in the Medical Plan application group, and
appear online in this order:
• Supplemental Conversion Qualifier Group
• Supplemental Procedure Conversion Rules
• Supplemental Revenue Conversion Rules
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Using BPAs for ICD-10 configuration
• Supplemental Conversion Rules
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Supplemental Conversion Tables used ‘heavily’
Diagnosis Code Ranges dominated
124 Qualifiers
680 rules
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Using BPAs beyond ICD-10 configuration
• BMCHP expanded coverage services into the
state of New Hampshire in 2012.
• Benefit configuration was needed to be setup
“from the ground up” which presented an
opportunity to utilize new applications for nonICD10 related rules.
• Rules created included Coverage determination,
Clinical Policies, Vendor arrangements.
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Using BPAs beyond ICD-10 configuration
• 425 Qualifiers
• 485 Rules
• Original configuration was setup to apply all
rules to all types of services and use the
qualifiers to restrict processing
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BPA issues Release 5.10.002
• (Tracking Number: 00497595)
• Trizetto introduced a modification to address the
processing performance of the Supplemental
Conversion Rules. The Section Header table
(SHDR) data was introduced into the application
so that the qualification process of supplemental
conversion rules can be done in a more efficient
manner.
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Benefits of using “BPA”
• BPA tables streamline configuration by building
the business rules in one qualifier group and
applying it to many services.
• Business rules contained in Qualifier Groups are
easy to read and can be audited by business
owners.
• Maintenance is easier and quicker. Change is
made once and applied across services rather
than making the configuration change multiple
times.
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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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Confidential
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Copyright © 2014 TriZetto Corporation
Thank You!
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Confidential
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Copyright © 2014 TriZetto Corporation