Transcript ICD-10 Processes

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Copyright © 2014 TriZetto Corporation
NetworX Best Practices
and Techniques
Carolyn Keadle, Sr Product Designer
Lori Tadolini, Sr Tech Analyst
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Agenda
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Maintaining NetworX Properties / ICD-10 Processing
Rate Sheet/Medical Agreement processing
Fee Schedules and Industry Codes
Facets versus Stand Alone differences
Customer Exchange/TriWiki – Important NetworX
locations
 NetworX Pricing Training
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Maintaining NetworX
Properties / ICD-10
Processing
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Why Properties are Important
 Properties drive various processes
 Same Pricing arrangement can return various results based on
Properties
 Contract Term Dates
 ICD-10 Processing Dates
 ICD-9/ICD-10 Translation
 Stand Alone Pricer and Modeler properties and Facets Pricer
Properties are not all the same
 SA/Modeler - Contract Dates – determine claim dates used to
determine which terms to select
 Facets NetworX Pricer – Disallow properties determine how
Pricer will handle various disallow values submitted
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Qualify on ICD-10 Date
 Property Name: (Stand Alone Pricer and Modeler General.QualifyOnICD-10_Date with valid values “Yes” or “No”)
 Property Name: (Facets NetworX Pricer - Qualify on ICD-10 Date
with valid values “Y” or “N”)
 When processing a claim with Qualifier Group containing ICD
qualifiers, claim qualifies based on the claim code(s) for the ICD10 date (Yes) or the submitted code (No)
Stand Alone Pricer and Modeler:
Facets NetworX Pricer:
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ICD-10 Processes
 Check Qualifier Groups
 Based on ICD-10 Date
 Qualifier Group with ICD-9 contain corresponding ICD-10?
 Returns report with groups with 9’s w/o corresponding 10’s
 Does not validate codes
 Claim Pricing
 ICD-10 Date (property set to “Y”/”Yes”)
 Claim date on/after ICD-10 date use ICD-10 to qualify on
appropriate qualifier groups
 Claim date before ICD-10 date use ICD-9 to qualify on
appropriate qualifier group
 ICD-10 Date (property set to “N”/”No”)
 Process based on submitted ICD-9/ICD-10 code regardless
of date
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Disallow/Manual Override Properties
 Facets NetworX Pricer Only
 WebSphere Custom NetworX Properties determine
how NetworX reacts to disallowed lines
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Eligibility
Duplicate charges
Clinical editing
Utilization management
 Property processes are system wide
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Disallow/Manual Override Properties cont.
 WebSphere NetworX Custom Properties
 Property not set (not included or value set to “0”)
 Line is marked as excluded and complete; does not process
through NetworX engine
 Property set (value set to “1”)
 Line is processed through engine, allowing grouping/rolling of
charges
 Line’s pricing set to “0” at end of process
 Properties
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Property Name: DISALL_AX
Property Name: DISALL_CDMD
Property Name: DISALL_CDML
Property Name: MANUAL_OVR
 Additional logic to include an override explanation code - enter “E###
(### = Explanation Code)
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Disallow Properties Logic
 DISALL_AX, DISALL_CDMD, DISALL_CDML – Inactive
 Disallow equal to line charge – line is total disallow
 Line marked “Excluded” and “Complete” by NetworX prior to engine
processing
 Line ignored in processing
 DISALL_AX, DISALL_CDMD, DISALL_CDML – Active
 Disallow equal to line charge – line is total disallow
 Line is not marked “Excluded” and ‘Complete” by NetworX prior to
engine processing
 Line used for processing in NetworX, including charges being rolled to
the line and grouping
 Prior to passing pricing back, disallow line allowable set to $0.00.
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Manual Override Properties Logic
 MANUAL_OVR property - Inactive
 Line marked as “Excluded” and “Complete” by NetworX Prior to engine
processing.
 Line not considered in NetworX pricing.
 Manual override amount returned as allowed.
 MANUAL_OVR property - Active when the property is set
to “1” (active):
 Line is not marked “Excluded” and ‘Complete” by NetworX prior to
engine processing
 Line used for processing in NetworX, including charges being rolled to
the line and grouping
 Manual override amount returned as allowed
 If property contains Explanation Code matching override code, manual
override treated as inactive.
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Properties Information
 NetworX Pricer and Modeler:
 Customer Exchange
 Documentation ► NetworX Pricer ► TriWiki or Documents
by Release ►Choose Pricer Version ► System
Administration Guide ► Chapter Maintaining System
Properties
 TriWiki
 https://cx.trizetto.com/doc/wikiView.cfm?contFileID=40280822
 Facets NetworX Pricer:
 Customer Exchange
 Documentation► Facets ► TriWiki or Documents by
Release ►Choose Version ► Installation Guide ► Chapter
= Installing and Configuring NetworX Pricer
 TriWiki
 https://cx.trizetto.com/doc/wikiView.cfm?contFileID=40286012
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Rate Sheet /
Medical Agreement
Processing
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Review - Rate Sheet/Agreement Sections
 Sections (inpatient or outpatient, exception of pre and
post processing)
Pre-Processing – Provides specific non-pricing functionality
Exclusions – Process outside of rest of the claim
Case Rate – Claim Pricing
Per Diem – Allows for inclusive pricing, based on lines (claim pricing
also available)
 Services – Line/claim pricing
 Stoploss – Override or “in addition” to pricing in other pricing sections
 Post Processing – Provides means to set charge grouping, non-pricing
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 Claim follows same flow every time
 Unreliable results if claim qualify only for Exclusion or
Stop Loss
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Rate Sheet/Agreement Pricing Flow
Claim
Excluded lines are
temporarily subtracted
from the claim total
Exclusions
(Line by Line)
Case Rate
(Entire Claim)
Yes
Does case rate processing apply?
No
Per Diem
(Line or Claim)
Yes
Does Per Diem processing apply?
No
Services
(Line by Line)
Excluded lines are added
back to the claim
Stop Loss
(Entire Claim)
Reprice
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Configuration Tips
 Multiple Service Reduction should not be used in
Complex Qualifier Terms
 MSR will not be applied correctly
 Claim and line level pricing in same section
 Claim should follow line
 Claim level processing sets unpriced lines as grouped; lines
would be unavailable for pricing following claim pricing
 Use Matching line as group sparingly
 Use when needed to group like things for determining
appropriate price
 Example – Multiple Level Per Diem with multiple
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Code Group/Qualifier Group Tips
 “Exists” qualifiers should be used in conjunction
with other qualifier types
 Be mindful of any modification to “Room and Board”
Qualifier Group
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Fee Schedules and
Industry Codes
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Fee Schedule Types
 “Flat Fee Schedule”
 Schedules with procedures (with or without modifiers) with
allowed amount and/or percentages
 Exception Schedules
 Flat fee schedules, using a base table and table with outliers
 Schedule with Unit Max
 Flat fee schedule, with modifiers with Maximum Units for
procedure.
 Derived Fee Schedules
 Schedules that use data tables to derive an allowed amount.
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Fee Schedules Tips
 Schedule termination date should be evergreen
(12/31/9999).
 Use procedure values to modify allowable based on dates
 Fee Schedule calculations are date sensitive
 Schedule within term date range.
 Create Exception schedules for “one-offs”
 Reduces schedule creation
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Industry Codes for Pricing
 DRG, APC, ASC
 Effective/Term dates by code.
 Year Applied and Code Source Type
 Year Applied – Period of time (user defined) for codes
 Code Source Type –Two character User Defined value to
identify code grouping
 Define multiple sets of data.
 Import through application or back-end
 Effective date, Year Applied, Code Source Type
selected as part of the import process.
 Load in chronological order (oldest/newest)
 Load logic will terminate existing records based on
new record effective date.
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Some differences
between NetworX
(Stand Alone and
Integrated)
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Facets Pricer versus Stand Alone
Facets
Qualifiers and Qualifier
Groups
Contracts and Contract
Terms
APC Maintenance
ASA Maintenance
ASC Maintenance
DRG Maintenance
NDC Code Maintenance
NDC Pricing Maintenance
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Stand Alone
Comments
Qualifiers = Codes Naming Convention
Code Types and Code Groups
difference. Same
functionality.
Contract = Rate Sheet Naming Convention
Rate Sheet and Rate Sheet Terms difference. Same
functionality.
Search, Maintain APC
Codes Tab, Code Types APC
Weights and CPTAPCX
Weights and CPTAPCX
Codes
Search, Maintain ASA
Codes Tab, Code Type CPT4ASAX (American Society of
Anesthesiologist) codes
Search, Maintain
Codes Tab, Amb Surg Grp Codes Ambulatory Surgery
Codes
Search, Maintain
Codes Tab, DRG Weights
DRG/DRG Weight data
Search, Maintain NDC
Codes Tab, NDC Codes
Codes
Search, Maintain pricing
parameters for NDC
Pricing Tab, NDC Pricing
processing
Facets Pricer versus Stand Alone
Facets
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Stand Alone
Fee Schedule Export
Data Transfer/Export to
file/Schedule and all
associated records
Fee Schedule Import
Data Transfer/Import to
Database
Transfer - Qualifier Groups
Data Transfer/Code Groups
Transfer - Contracts
Data Transfer/Rate Sheets
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Comments
Export Schedules (Fee
Schedule, Fee Schedule with
Exception, Fee Schedule with
Modifiers, Fee Schedule with
Exception with Modifiers) from
system to a .csv file
Import Schedules (Fee
Schedule, Fee Schedule with
Exception, Fee Schedule with
Modifiers, Fee Schedule with
Exception with Modifiers) from a
.csv file into the system. Note:
file must be in the appropriate
format
Data Transfer for Facets is a
separate utility (outside the
system). Users must be sure to
configure to point to the system.
Data Transfer for Facets is a
separate utility (outside the
system). Users must be sure to
configure to point to the system.
Facets Pricer
 Broadcasting - can only be a subscriber
 Pay Percent through iCES, ClaimCheck, etc. – do not
use Percent of Allowed for modifier pricing
modifications
 Modifications will be made twice; Pay Percent is post-NetworX
processing
 System properties are maintained within WebSphere
 Can have an explanation code and/or a user warning
message applied to a term
 Can maintain Source Types/Codes via the UI
 Manual Pricing calculations - A’ddl NetworX data
field
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Stand Alone
 Broadcasting can be a publisher or subscriber of
rate sheets, code groups, fee schedules and industry
codes
 Provides locking functionality for rate sheets, code
groups, fee schedules and industry codes for
broadcasting
 Can disable rate sheet terms
 System properties are maintained through the
application UI
 Can add Source Types/Codes via the UI, however
maintenance is via the back-end
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Customer Exchange /
TriWiki – Important
NetworX locations
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NetworX Optum (HSS) Interface Information
 NetworX “How To” on Customer Exchange
 Optum Web Services Versions
 Spreadsheet with Optum Web Service version information
supported by NetworX
 Optum (HSS) Calculation Information
 Spreadsheet with information on NetworX Calculations and
using Optum services
https://cx.trizetto.com/sitelogic.cfm?id=3699
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NetworX Change Package Review Group
 Date and times of Client Engagement Reviews
 Provides Draft Readme files (past and upcoming)
 Past Client Engagement Review Presentations
https://cx.trizetto.com/community/usergroup/groupportal/index.cfm?g=44
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NetworX Solution News
 Product Announcements and Support Bulletins
 Change Package Planned Content
https://cx.trizetto.com/support/dspProductNews.cfm?p=49
 RSS feed available
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“My Account” set to get NetworX info?
 Are you signed to see and receive NetworX News?
 To check navigate to My Account and scroll to Update Your
Contact Types to ensure the NetworX CP Review View, NetworX
PBA Product News, and NetworX Product News are checked.
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NetworX Pricing
Training
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What is NetworX Pricing Training?
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Developed by TriZetto NetworX Experts
Covers 32 types of NetworX pricing/calculations
Wide range of qualifier types
Hands-on, instructor led
Develop knowledge in pricing methodologies
Understand the logic behind commonly used
methods
 Learn how to effectively automate complex pricing
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What will I get out of this course?
 Learn how to turn the contract into pricing rules
 How the steps in the building process
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Analyze the contract
Build the qualifiers
Build the terms
Hierarchy
 Learn how to test (what makes a good vs bad test)
 Learn how to troubleshoot configuration issue
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Video
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Some prerequisites
 Some experience in working with NetworX or
 Completed NetworX Pricer Foundations
 Recommend
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Healthcare 101, or equivalent experience
Healthcare Industry experience
NetworX Pricer Project experience
AHM
 We will provide job aids
 How to enter claims
 Calculation job aids
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Need more information?
 If you are interested in purchasing this training,
please contact your Account Executive, or contact
Aaron Preston [email protected] in
Learning Services for more details
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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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Questions?
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Carolyn Keadle, Product Designer Sr
(630) 428-5158
[email protected]
Lori Tadolini, Tech Analyst Sr
(303) 495-7099
[email protected]
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Thank You!
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