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2014National Programs Multi-Year Strategic Roadmap
Publication Date: June 30, 2014
CONFIDENTIAL REPORT
This Report is proprietary and confidential and is for internal Licensee and BCBSA use only. The information contained in this report is confidential and is intended only for the use of the addressee. It is the property of the Blue Cross and Blue Shield Association. Unauthorized use, disclosure or copying of this report or any part thereof is strictly prohibited.
National Programs
Table of ContentsExecutive Summary 4
Roadmap Overview 4
Blue System Strategic Priorities and National Programs Development Initiatives 4
2014 Priorities 5
Emerging Priorities 5
2014 National Programs Strategic Roadmap Document on BlueWeb 6
Updates to Information in This Document 6
National Programs Online Multi-Year Business and Technical Roadmap 6
National Programs Initiatives 8
Networks 81. Blue Distinction® Specialty Care Program 92. Blue Distinction® Total Care 12
3. National Programs Care Management 14
Cost 181. PlanConnexion® Collaborative Services 19
2. Risk Adjustment 23
Products 25
1. Consumer Transparency: National Consumer Cost Transparency 26
2. Reference-Based Benefits 28
3. Health Information Technology (HIT) Strategy 30
4. BlueCard For Public Exchange Products 33
5. Office of Personnel Management (OPM) Multi-State Plan Program 35
6. Transfer Program 38
Service 40
1. Inter-Plan Data Solutions (IPDS) Business Intelligence Development 412. Provider Data Improvement 44
3. Policy Review 47
Regulatory 49
1. ICD-10 50
2. Administrative Simplification 52
National Programs Technology 54
Technology: Platform Release Planning 54
1. Inter-Plan Teleprocessing Services (ITS) 552. BlueSquared® (Blue2) 57
3. Inter-Plan Data Solutions (IPDS) Extract 594. BlueExchange® (BX) 61
5. Licensee Desk Level Audit (LDLA) 636. BlueGuest® 64
7. National Consumer Cost Transparency (NCCT) Technical Infrastructure 65
8. Inter-Plan Operational Reporting (IPOR) 67
9. Inter-Plan Data Exchange (IPDEX) 69
10. Datanet Lite (DNL) 71
11. Value-Based Programs Care Delivery Platform 73
Technology: Ongoing Maintenance 75
1. Provider Data Format (PDF) 76
2. Licensee Desk Level Audit (LDLA) Extracts 77
3. Performance Tracking System (PTS) Extracts 78
4. National Consumer Cost Transparency (NCCT)Data Submission to BCBSA 79
5. Physician and Hospital Quality Measurement 80
6. Blue Physician Recognition (BPR) Program 82
7. Patient Experience 83
Technology: Software Standards 84
National Programs Timelines 85Initiative and Technology Timelines 85
National Programs Initiatives: Association Key Milestones Timelines 86
National Programs Technology Platform Releases:Association Key Milestones Timelines 91
Appendix 1: Technology Implementation Plan 101
Appendix 2: Technology Platform Matrix 146
Index 148
Executive Summary
Roadmap OverviewThe National Programs Multi-Year Roadmap is a rolling three-year blueprint for the future. The document provides Plans with the information to plan, prioritize and implement upcoming National Programs initiatives. First published in 2007, the Roadmap is published annually to help Plans prepare for upcoming initiatives.
Association Publishes 2014 National Programs Roadmap
Plans Use 2014 National Programs Roadmap to prioritize future initiatives
June 30, 2014
Our goal in publishing this Roadmap is to provide you with the strategic framework for our future national initiatives and a specific business plan for implementing these initiatives. As you review this document, in part or as a whole, please contact us with any questions.
For a discussion of our overall National Programs initiatives and their connection to Blue System- wide priorities, please contact Kari Hedges ([email protected]; 312-297-5648) or Rich Cullen ([email protected]; 312-297-5987).
Blue System Strategic Priorities and National Programs Development InitiativesBCBSA’s mission statement—“To enable the success of Blue Plans collectively and individually in order to benefit those they serve”—emphasizes that the first and foremost focus is to enable Plan success.
Our 2014 National Development priorities are framed by BCBSA’s mission statement, the Board- approved strategic plan, as well as Health Care Reform (HCR) and market developments. These strategic priorities are designed to ensure collective success in meeting national and local Plan requirements in several areas.
At its February 2014 meeting, the Inter-Plan Programs Committee approved the 2014 strategic priorities, which focus on retaining members, supporting the national account market and preparing for a transition to a retail environment.
2014 Priorities• Networks: Blue Distinction Evolution, Care Management Enhancements
o Create a differentiated advantage in provider-coordinated care management (Blue Distinction Total Care) through the continued transformation of Blue Distinction into a total value proposition
• Exchange Business: BlueCard for Exchanges, Office of Personnel Management (OPM)Multi-State Plan Program, Risk Adjustmento Adapt BlueCard for continued success in the expanding individual/retail market♣ Implement solutions to support BlueCard for Exchange products
♣ Negotiate and manage an OPM Multi-State Plan Program contract
♣ Implement a national approach to enable Plans to manage risk adjustment
processes, including implementing a medical record retrieval record solution, provider outreach, Plan outreach and analytics
• Consumer Engagement: Transparency Tools and Consumer Operationso Enhance members’ access to standardized healthcare cost and quality information,
including cost estimates, provider quality information and access to patient reviews• PlanConnexion: Hosting Capabilities, Shared Services, Collaboration Tools, Data Access
o Foster voluntary Blue shared services to drive cost efficiencies and Blue market leadership
• Operational Excellence and Service Performanceo Ensure operational excellence and improve service performanceo Strengthen compliance and improve Plan performanceo Promote operational best practices
• Regulatory Compliance: the International Classification of Diseases, Tenth Revision (ICD- 10), Health Information Technology (HIT), Administrative Simplificationo Ensure regulatory complianceo Support System-wide implementation of HCR (Affordable Care Act), including:
♣ Administrative simplification (health plan identifiers, eligibility and claims status
transactions)♣ Quality reporting
♣ Transparency standards
o Support System-wide implementation of ICD-10
Emerging Priorities• Next Generation Transfer Program: Identify options for the next iteration of the Transfer
Program, taking into account new rules and regulations of the Affordable Care Act to promote the retention of Blue members in the group-to-individual market•
• National Programs Scenario Planning and Multi-Year Development Plan: Create a multi-year development plan by understanding how healthcare market shifts and changes in Blues’ operating environment may impact current National Programs in the next 3 to 5 years
• Data Strategy: Support implementation of Board-approved recommendations to ensure that the Blue System has a broader, aggregated data asset as a foundation to drive value and enable future competitiveness; this strategy includes improving existing data assets to win in the National Account market and keep members Blue
• Network Access: Develop a national network strategy, based on the evolution of Plans’ local network strategies and anticipated market demand, including recommendations regarding the Inter-Plan Programs network criteria for national account and individual market lines of business
• Telemedicine: Complete a market and economic analysis of the emerging telemedicine field to determine the legal and operational impacts, and develop corresponding recommendations to address impacts
• Medicaid: Due to increased Plan expansion into Medicaid business, review the application of existing Inter-Plan Program policies and propose an approach to support Plans’ needs to service these products when enrollees travel outside a Plan’s service area
Please note: This 2014 Roadmap is a snapshot in time, and Plans should expect changes as a result of Health Care Reform and continued refinement of the Blue Strategic Priorities.
2014 National Programs Strategic Roadmap Document on BlueWebPlans can access the Roadmap by clicking on the BlueWeb link below (or by searching for “2014 National Programs Strategic Roadmap”): http://bluewebportal.bcbs.com/article?id=6813168.
Updates to Information in This DocumentInformation in this document is current as of June 30, 2014, the publication date. This 2014 Roadmap document is a snapshot in time, and Plans should expect changes as a result of Health Care Reform. Users of the document should always check BlueWeb for the most up-to-date information on each strategic initiative. The Roadmap includes links to the specific BlueWeb pages: in the table for the initiative, see the section called “More Info.”
National Programs Online Multi-Year Business and Technical Roadmap
An online companion document to the Roadmap is available on the National Programs Release Central BlueWeb page. In addition to describing the strategic initiatives, the online Roadmap includes all of the tactical, technical and regulatory initiatives that Plans must implement. The online
Roadmap is updated bi-monthly and is in an Excel format that includes filters that you can use to drill down for more specific information. The online Roadmap can be useful for budget and resource planning purposes.
National Programs Initiatives
NetworksProvider networks are a fundamental asset of the Blue Cross and Blue Shield System. Plans’ provider relations are evolving in response to the increasing cost of healthcare, new technology, new organizational and payment models, and Health Care Reform (HCR) legislation.
Plans are working closely with their providers to improve quality and control costs and, as a result, bring value to accounts and members. National Programs will support Plans’ network development initiatives and develop ways to deliver these advantages to National Account members and individual travelers.
Future network development priorities will build upon existing Blue assets to meet quality and affordability requirements. Network value will evolve over time, with discounts, quality incentives and alternative payments all critical to success.
This section provides details about our Network initiatives:
1. Blue Distinction® Specialty Care Program2. Blue Distinction® Total Care
3. National Programs Care Management
For a visual summary of Network initiative key milestones, please see the Initiative Timelines in the Timeline Section of the Roadmap.
1. Blue Distinction® Specialty Care Program
Overview Blue Distinction Centers® are part of a national designation program that recognizes facilities that demonstrate expertise in delivering quality specialty care safely and effectively. An additional, more selective designation, Blue Distinction Centers+, was implemented to distinguish facilities that demonstrate that they provide this quality care cost efficiently. Quality is key: only those facilities that first meet Blue Distinction Centers’ nationally established, objective quality measures will be considered for designation as a Blue Distinction Center+. The goal of the Blue Distinction Centers program is to help consumers find both quality and value for their specialty care needs, on a consistent basis, while encouraging healthcare professionals to improve the overall quality and delivery of care nationwide.
The basics of each designation are as follows:• Blue Distinction Centers: Meet quality-focused criteria that emphasize
patient safety and outcomes• Blue Distinction Centers+: Meet the same quality-focused criteria that
emphasize patient safety and outcomes and meet cost of care criteria
Six specialty care areas are included in this program: Spine Surgery, Knee and Hip Replacement, Cardiac Care, Transplants, Bariatric Surgery, and Complex and Rare Cancers. These specialty care areas were chosen because they involve high risk and/or high cost procedures that, together, account for more than 30 percent of inpatient expenditures. Blue Distinction Center+ designations are currently in place for Spine Surgery, Knee and Hip Replacement, and Cardiac Care. Blue Distinction Center+ is expected to be added to Transplant in mid-2014.
Facilities must reapply for the Blue Distinction designation on a regular basis, to help maintain consistent national quality. These reevaluation cycles include reassessment of quality criteria and thresholds, and include input from the medical community to stay current with medical and measurement advancements. Cost of care evaluation is based on Blue Plan data and is measured against a national threshold. Blue Plan claims data will continue to be utilized for cost evaluation, and non–Blue Health Intelligence (BHI) Plans will be asked to supply this information annually to enable these refreshes.
2014 and Beyond• Expand Blue Distinction Center+ designations for
o Transplants (mid-2014)o Bariatric Surgery (early 2015)
• Update New Submission Formats (SF) Message Codes to support inter- Plan claims processing for the Bariatric Surgery designations as part of Inter-Plan Teleprocessing Services (ITS) release 14.5
• Create new Blue Distinction Specialty Care - Facility Performance Reports and make them available to Plans in mid-2014. These reports include more detailed information regarding cost and quality performance for facilities that applied and were deemed eligible for a Blue Distinction Specialty Care designation. The goal of the reports is to empower local Blue Plans to
leverage local and national data to tailor benefit designs to meet theirAccounts’ cost and quality objectives.
• Implement enhancements to the program management tool, BD Linksm, to support users with workflow, reporting and navigation
• Identify new specialty care categories, in addition to the current six specialty areas, in mid-2014 for future implementation and then implement new SF Message Codes to support inter-Plan claim processing for the new care categories
• Collect claims and administrative data from Plans that do not participate in BHI during the third and/or fourth quarter of 2014 to enable upcoming re- evaluation cycles for existing designations and for new care categories that are identified
As the Blue Distinction Specialty Care objectives and activities evolve during planning and implementation, existing workgroups will provide direction and feedback based on their scope. These workgroups include the Inter-Plan Programs Committee (IPPC) Implementation Sub-Committee, the National Programs Products and Services Workgroup, the National Council of Physician & Pharmacist Executives (NCPE) and the Network Executives Council, as well as other appropriate governance committees as needed.
Key Info Stage of Development:• Implementation
Key Milestones and Dates:• Make available Blue Distinction Specialty
Care - Facility Performance Reports for existing designations: Mid- 2014
• Launch Blue Distinction Centers+ for Transplants: Mid-2014
• BD Link enhancement release 5.4:August 2014
• Launch Blue Distinction Centers+ for Bariatric Surgery: Early 2015
• BD Link enhancement release 5.5: Late 2014/early 2015
• Appx. Size of Plan Work Effort:• Small/medium
• • Platform(s):• ITS• PDR• Other: BD Link• Other: NCCT
Audience(s):• Accounts/employer groups• Consultants/brokers• Providers• Consumers/members• Plans
• Workgroup(s) Supporting This Effort:• Blue Distinction Plan User Group
More Info Contact:Rhonda McGivney Managing Director [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=302 5140
Business DriversHealthcare delivery is rapidly changing, and a renewed focus on delivering value—a combination of quality and cost—is critical to employers and their employees. Through an expansion of the Blue Distinction Centers program, we offer a suite of flexible national solutions that makes it simple to identify high-value providers and design benefits tailored to employers’ specific objectives.
Research* confirms that, overall, patients treated at Blue Distinction Centers and Blue Distinction Centers+ have better results, including fewer complications and, in the case of Spine Surgery and Knee and Hip Replacement, lower readmission rates. Blue Distinction Centers+ for Spine Surgery, Knee and
Hip Replacement, and Cardiac Care, are also more than 20 percent more cost-efficient than non-designated hospitals.
Many employers have chosen to use benefit differentials for use with the Blue Distinction Centers program to encourage employees to select quality specialty care and, at Blue Distinction Centers+, more cost-efficient specialty care. Blue Distinction Centers and Blue Distinction Centers+ are located nationwide, making them easy to find wherever employees live, work or travel.
The current Blue Distinction Specialty Care Program demonstrates the Blue System’s ability to support account cost management strategies and proves the Blue Plans’ ability to evolve with the market and demonstrate a nationally consistent response to meet market demands. This program also demonstrates the Blues’ absolute commitment to providing members with access to the highest quality, most affordable care.
As always, each of the foregoing processes recognizes that each Blue Plan acts as a separate, independent entity that makes its own decisions on all matters, including benefits, coverage and claims.*Research referenced in the Blue Distinction® Specialty Care Toolkit: Supporting Facts and Figures
2. Blue Distinction® Total Care
Overview As Plans develop and implement alternative payment models and network arrangements, it is critical to
• Understand Plan approaches and strategies• Define national requirements for Blue Distinction Total Care value-based
programs• Enhance System-wide capabilities to support National Programs delivery for
BlueCard and National Accounts
New payment models are essential to support more coordinated, efficient and quality-driven healthcare.
High-performing delivery systems can be supported by payment models that reward physicians for ensuring a high value of delivered care, improving quality, encouraging coordination and optimizing services to control cost. Coordination among providers can be supported by aligning provider incentives and by bundling payment for clinically related services. The optimal payment model and pathway to implementation will vary across the delivery system due to differing market characteristics. Network management strategies can be used with new payment approaches to further align provider incentives.
Blue Distinction Total Care is a designation program that identifies the programs that meet specific criteria for patient-centered, value-based care. The Blue Distinction Total Care program will leverage the Blues’ strength in care delivery innovations and deep provider relationships.
New operating models have been developed, and policies have been approved by the Board of Directors to support a consistent national delivery of these programs for effective dates January 1, 2015, and beyond. A new data exchange solution is available and is being tested with Plans in 2014. This solution provides the supporting operational platform for the Blue Distinction Total Care initiative and national delivery of value-based programs.
Key elements of the program are data exchange for claims, membership, attribution pre-authorization/discharge and care management/disease management notifications. Policy modifications and enhancements, revisions to disclosure language, and financial settlement processes support the initiative.
Staff members have worked with Plans to develop the standards and policies to support the national delivery platform. Ongoing work continues to assist Plans in meeting the milestones of this initiative. Examples of this assistance include Plan- specific implementation project plans and Plan visits to consider business and technical requirements.
All Plans will implement the data exchange platform for 2015 and make available all Par/Host Plan local programs that meet policy criteria. For Control/Home Plan national accounts, 2015 implementation will be transitional because there is some flexibility for account participation until 2016.
Key Info Stage of Development:• In development to
implementation**Varies based on initiative
Key Milestones and Dates:• Test data exchange: Q3-Q4 2014• Launch program: 1/01/2015
• Appx. Size of Plan Work Effort:• Large
• • Platform(s):• ITS• BlueSquared• PDR• Plan software• Other: CBF• Other: I-Hub• Other: IPDS• Other: NDW• Other: Value-Based Program
Database• Other: Value-Based Programs
Delivery Platform
Audience(s):• Accounts/employer groups• Consultants/brokers• Providers• Consumers/members• Plans• Office of Personnel Management
• Workgroup(s) Supporting This Effort:• Blue Distinction Plan Advisory Group
More Info Contact:Cindy Pearson [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=303 6738
Business DriversInnovative provider payment and network models are essential to supporting more coordinated, efficient and quality-driven healthcare. This development is driven by primarily market demand for products/networks that slow the rate of growth in healthcare costs. In addition, Health Care Reform and changes in Medicare payment are expected to lead to changes in the commercial business.
Plans are exploring and developing new approaches that change providers’ financial incentives,
focusing on outcomes and quality. These approaches, many of which are being piloted now, must be made available for national delivery to support National Accounts.
3. National Programs Care Management
Overview National Accounts and key local accounts are demanding superior care management as a critical lever to reduce costs and improve employee health. In addition, the emergence of new payment models requires the Blues to reevaluate how care management is delivered nationally. Improving care management perception is critical to National Account retention and new business growth.
The Inter-Plan Programs Committee (IPPC) and the National Council of Physician& Pharmacist Executives (NCPE) identified Electronic Provider Access and Provider Financial Responsibility as key initiatives for setting a foundation for an effective care management model.
Due to Health Care Reform and other competing Plan priorities, the BCBSA Board of Directors delayed the implementation of these two initiatives until 2014 and is allowing Plans with approved exceptions to implement the initiatives throughout 2015.
Enhancements to Address Traditional Care Management
Current National Programs initiatives focus on opportunities to support traditional care management capabilities and meet critical market demands by addressing issues/gaps in National Programs coordination for out-of-area members.
Specifically, engaging providers by requiring them to be responsible for pre- certification and pre-authorization for inpatient facility services and providing them with the appropriate tools to be successful are key initiatives underway in 2014 and beyond.
Provider Financial Responsibility (PFR) for Pre-service Review
Issue
Members are currently at financial risk and exposure when receiving out-of-area care. The current delivery model creates member confusion as well as member and account dissatisfaction. In addition, holding members responsible for meeting pre- service review (commonly referred to as pre-notification, pre-certification, pre- authorization and prior approval) isn’t aligned with payment innovation models.
Providers are looking for consistent and more transparent care management processes. However, current utilization management and utilization review processes for local and BlueCard members often conflict. The current processes negatively impact both provider administrative costs and provider/member satisfaction. Maintaining provider satisfaction is critical to Plan strategies for network development in support of National Account members.
Solution
An important component of achieving the provider engagement aspect of the care management vision is shifting financial responsibility for pre-service review to the provider. If pre-service review is not obtained for inpatient facility services, the participating provider becomes financially responsible for the provider sanction
amount in its contract with the local Blue Plan. Holding providers accountable for obtaining pre-service review for inpatient facility services for out-of-area members is a major change to the fundamentals of the BlueCard Program but necessary to achieve a successful National Programs Care Management delivery model.
Electronic Provider Access (EPA)
Background
Electronic access to pre-service review is currently available to many local providers. Currently, out-of-area providers are prohibited from direct electronic connections to Control/Home Plans and are limited to the Medical Policy Router, which routes out-of-area providers, via alpha prefix, from their Par/Host Plan portal to a public page on the Control/Home Plan portal for read-only access to medical policy and general pre-certification requirements.
Typically, out-of-area providers who want to conduct pre-service review call the Control/Home Plan directly for authorization or use the 1-800-676-BLUE number. A small portion of providers use facsimile, and less than 2 percent use BlueExchange. While BlueExchange provides the capability for providers to request pre-service review for a member, Control/Home Plans generally respond with a request that the provider call the Control/Home Plan due to the interactive nature of pre-service review.
Issue
Calling and faxing Control/Home Plans for pre-service review is inefficient and costly for Plans and providers and impacts overall provider satisfaction with the Blues. Providers cannot use their office-based electronic processes for BlueCard out-of-area members, and calls to Control/Home Plans frequently are put on hold or transferred several times. Based on provider feedback, 60 percent had problems reaching the correct person, 46 percent had issues with timely responses, and 45 percent had issues with claims denied after obtaining pre-service.
From a Control/Home Plan’s perspective, fielding calls is more costly than using the electronic process in place for local providers. In addition, Plans have invested in auto-authorizations that cannot be leveraged through requests by phone or fax. The Plans in the EPA Workgroup estimated that between 45 and 95 percent of out-of- area pre-service reviews currently received by phone could be auto-authorized.
Based on Plan responses, the majority (81 percent) of Plans offer some pre-service review functions electronically for their local providers. Only seven Plans have no immediate plans to offer providers electronic pre-service review through their portals.
Solution
The EPA initiative was implemented by the majority of Plans on January 1, 2014, and other Plans will implement at various dates in 2014, based on approved exception requests and action Plans. EPA enables out-of-area providers to access Control/Home Plan portals through Par/Host Plan portals to conduct electronic pre- service review. Only authenticated providers that have been authorized by the Par/Host Plan are allowed to access Control/Home Plan pre-service review portals. Utilization and tracking reports are available.
The routing of providers from Par/Host Portal to Control/Home Portal is supported by Security Assertion Markup Language (SAML) version 2.0. BCBSA acts as the SAML broker, and Plans have SAML connections with only BCBSA instead of with each individual Plan. This set-up reduces the monetary and resource costs for Plans.
EPA is available for any pre-service reviews that are needed (e.g., inpatient care, outpatient surgeries, radiology).
Key Info Stage of Development:• In development
Key Milestones and Dates:PFR• Implement PFR requirements: 7/01/14• Control/Home Plans with approved
account exception requests modify account contracts by the account renewal date: Q3 2014-Q4 2015
EPA• Plans with approved exception requests
and action Plans implement EPA: 2014 and Q1 2015
• Appx. Size of Plan Work Effort:PFR• Medium**$500,000 to $1 million
EPA• Medium**$200,000 for initial set-up and$20,000 for annual maintenance
Platform(s):• ITS• Plan software
Audience(s):• Accounts/employer groups• Consultants/brokers• Consumers/members• Plans• Providers
• Workgroup(s) Supporting This Effort:• National Programs Operations Workgroup• National Programs Products and Services Workgroup• National Programs Business Applications Workgroup
More Info Contact:Sharon Haft Managing Director [email protected]
BlueWeb Page:PFRhttp://bluewebportal.bcbs.com/article?id=325 0456EPAhttp://bluewebportal.bcbs.com/article?id=301 6171
Business DriversAccording to market intelligence, Plans lack strength in the Integrated Health Management arena. Accounts have voiced dissatisfaction with Blue care management programs and have cited the Blue System as disjointed and unable to provide seamless, integrated care management for out-of-area members.
With a continued focus on decreasing administrative costs and improving quality, accounts expect the Blue System to respond to their concerns by developing a seamless Integrated Health Management program for all business segments. Improved performance in this area is critical to account retention and new business growth.
CostCost pressures on Plans have never been greater. National and local accounts are demanding reduced administrative costs and direct healthcare expenditure. Additionally, in a Health Care Reform (HCR) environment, Plans will need to control costs to ensure that they have products and services that can be priced competitively and meet the medical loss ratio requirements.
As Plans look for solutions to reduce both administrative and medical costs, it is important to identify cost-effective solutions that Plans can leverage to meet national, local and HCR demands.
This section provides details about the Cost initiatives:
1. PlanConnexion® Collaborative Services (Voluntary)
2. Risk Adjustment
For a visual summary of Cost initiative key milestones, please see the Initiative Timelines in the Timeline Section of the Roadmap.
1. PlanConnexion® Collaborative Services
Overview PlanConnexion facilitates Plan collaboration and innovation by enabling Plan-driven data, information and technology shared solutions. PlanConnexion is a voluntary offering available to all Blue Plans. It provides a channel for shared solution acquisition, a developer portal for data integration, consulting services and an environment for collaboration.
Specifically, PlanConnexion in its current state provides the following capabilities:• PlanConnexion Solutions (https://www.pxcsm.com): PlanConnexion
provides access to Association-developed PlanConnexion shared solutions as well as vendor co-developed and vendor standalone shared solutions. Shared solutions include hosting services, solutions in coordination with National Programs mandates (i.e., Payment Innovation) and a variety of software products to support common Plan needs. More detail on these services can be found below.
• PlanConnexion Developer Portal APIs (https://developer.pxcsm.com): The Developer Portal is a data integration and exchange platform focused on providing access to Association-housed Blue data and third-party data through secure Web services. The Developer Portal also serves as a sandbox for application development. A list of APIs can be found below.
• PlanConnexion Consulting (https://www.pxcsm.com): PlanConnexion offers consulting focused on technology evaluation, implementation and training.
• PlanConnexion Collaborative Services Marketplace (PxCSM) Collaboration (https://www.pxcsm.com): The PxCSM site is a secure, moderated online portal for collaborations initiated by either Plans or the Association around any topic in support of sharing best practices, exchanging information, forming ideas and developing shared solutions.
Hosting Services
Through PlanConnexion hosting services, common and custom software components, databases and applications are installed and maintained on a shared mainframe platform. Client Plans continue to operate their own core systems and access common and/or custom components and databases through current BCBS system interfaces. Software and services hosted by PlanConnexion include
• Inter-Plan Teleprocessing Services (ITS) software• BlueSquared (B2) applications• Custom Plan components• Full mainframe elimination
There are 15 engagements supporting 12 Plans and 2 Plan vendors. Potential future offerings include APIs, Payment Innovation (pre-service, admission and discharge, or PAD) and Mobile Lab.
PlanConnexion Solutions
This service focuses on the development and ongoing support of software products to provide a more cost-effective solution that can be shared with Plans facing similar business needs. PlanConnexion application solutions are licensed to Plans on an elective
basis. The scope of the products is not limited to National Programs processes. Shared applications may be deployed by the Plan or hosted by the Association and used through PlanConnexion. Solutions include
• ALIM Plan interface component (APIC)• APIC 2 (ITS integration software for Facets)• APIC 3 (ITS integration software for other adjudication systems)• PMax (self-service tool to support test and production functions)• Conflict of Interest (tracking/reporting tool)• Change Data Capture (data mirroring tool)• DataNet 3 Hosting (under development)• Payment Innovation Solutions (under review)
PlanConnexion Developer Portal APIs
The Developer Portal is a data integration and exchange platform focused on providing access to Association-housed Blue data and third-party data through secure Web services.
• National Provider Data API: Enables high-performance search capability against data from our National Provider Directory repository, including a faceted search capability to enable user-facing applications to allow checkbox filtering of results on the fly
• BlueExchange Direct Connect API: Receives member benefit information from the Plans by performing 270/271 transactions with the Blue Exchange System
• National Consumer Cost Transparency (NCCT) API: Obtains cost estimates for specific medical treatments and services supported by the NCCT
• National Member Out-of-Pocket API: Acquires estimated of out-of-pocket costs for healthcare services supported by the NCCT
• Patient Review of Physicians API: Allows patients to read and write reviews for in-network physicians and providers
• Alpha Prefix Lookup API: Validates an alpha prefix code and provides the Control/Home Plan code for routing information
• Attribution Service API: Supports plans per the Blue Distinction® Total Care – Value-Based Programs initiative to enable Control/Home Plans’ need to send pre-service, admission and discharge (PAD) notification messages to Par/Host Plans for attributed members
• Additional third-party APIs: Healthline, MedFax
Customizations are available. Additional potential future offerings include wearables integration for wellness programs, third-party consumer transparency information and security APIs.
PlanConnexion Consulting
Because of the Association’s product knowledge and familiarity with Plan processes, PlanConnexion offers consulting services, guidance and expertise where Plans need them most. PlanConnexion consulting services are designed around three core principles: discreet in-house Blue expert product knowledge, high-value service delivery and alignment of best practices.
Consulting services include, but are not limited to,• Migration strategies and implementations• Real-time services• Installation and configuration services• Web service integration• Workflow consulting• Planning and testing of performance engineering capacity
Key Info Stage of Development:• In development to finalized**Varies based on initiative
Key Milestones and Dates:Hosting Services• Implement hosting services for additional
Plans: Ongoing• Go live: July and August 2014 Shared
Solutions• Implement common Web user interface:
Ongoing• Implement PMAX: Ongoing• Implement conflict of interest: Ongoing• Implement change data capture:
OngoingConsulting• Provide engagements: Ongoing
• Appx. Size of Plan Work Effort:VOLUNTARY
Platform(s):• ITS• BlueSquared• Other: Web services
Audience(s):• Plans
• Workgroup(s) Supporting This Effort:• PlanConnexion User Group• PlanConnexion Steering Committee
More Info Contact:Hosting, Consulting and SolutionsLaurie Condon Managing Director [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/programs/fee- for-serv-programs/planconnexion
Developer Portal Mark Tomlinson Product [email protected]
Business DriversPlanConnexion provides a platform that supports development of shared business and technology solutions focused on driving collaboration, innovation, interoperability, integration, efficiency and low cost.
The PlanConnexion value proposition includes
• Enabling more timely, cost-effective and efficient deployment of new technological capabilities for BCBSA and all Plans
• Supporting Plan efforts to consolidate systems
• Reducing Plans’ need for local resources to support mainframes, data integration and other capabilities that make sense as shared solutions
• Providing Plans with expertise on strategies and implementation support
The APIs available via the PlanConnexion Developer Portal provide specific value:
• Faster speed to market due to simple, immediate access to test data services, simple migration to production, and the elimination of components needed to manage back-end databases
• Reduction in cost due to shared cost, less development work for individual Plans, and lower
maintenance and support costs• Easy integration of multiple sources of disparate data and services into the Plan’s own
branded applications• Data management left to the Web service, which enables the Plan to focus on its core
business and customer• Portability to plug and play the data with any Plan or vendor application requiring BCBSA-
managed information• Conformity with National Programs data compliance guidelines• The most up-to-date source of national data
•
2. Risk Adjustment
Overview Risk adjustment is a process for redistributing premiums to carriers that attract a member population with less-than-average health. Carriers must participate in risk adjustment for insured individual business and small group market business, both on and off public exchanges. Effective management of risk adjustment for the individual, small group and Medicare Advantage segments is expected to significantly impact the margin for these lines of business.
All health plans have faced challenges in implementing and managing the processes necessary to support risk adjustment. Processes include assuring accurate provider coding and documentation, identifying and retrieving member charts, and conducting claims analysis to quantify membership risk. Blue Plans face additional challenges for out-of-area members because providers are located in another Plan’s service area.
Throughout 2014, Association staff will work with Plans to monitor regulations and enable Plans to manage risk adjustment processes, including the following solutions.
Medical Record Retrieval Vendor Solution• Provide ongoing support for Plans• Monitor record requests to set pricing level for 2015• Continue ongoing monitoring of service level agreements
Provider Outreach• Plan best practices updates• Offer available continuing medical education (CME) and continuing education
(CE) vendor courses on the PlanConnexion marketplace• Have Plans continue to include provider contract provisions to support chart
reviews
Plan Outreach• Help Plans learn more about the risk adjustment program, operations and
market implications• Explore provider incentive programs and discuss experiences and pilot
programs already under way• Make independent audit vendor solutions available.
Analytics• Collaborate with Blue Health Intelligence (BHI) to improve on the solution to
help Plans identify and target less healthy members under permanent risk adjustment
Key Info Stage of Development:• Design• Implementation• Operational
Key Milestones and Dates:• Monitor medical record retrieval vendor
process: Q3-Q4 2014• Offer CME and CE courses on
PlanConnexion: Q3 2014• Offer independent audit solutions on
PlanConnexion: Q4 2014• Review the medical record request
volume to determine 2015 pricing: Q4 2014
•Appx. Size of Plan Work Effort:• Low to medium
• • Platform(s):• ITS• Policies• Other: HHS systems• Other: Plan website and FTP
system• Other: Vendor system and
website
Audience(s):• Blue Plans• Providers• Consumers/members• Vendor• Health and Human Services (HHS)
• Workgroup(s) Supporting This Effort:• Risk Adjustment Workgroup
More Info Contact:Amy RogalaBusiness Design Manager [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=327 9653
Business DriversSuccessfully managing risk adjustment processes is critical to Plans’ success in the individual and small group markets under the Affordable Care Act (ACA).
Identifying and documenting the risks of enrollees is necessary to engage them in care management and address gaps in care, which can improve their health and control future care costs.
Documenting the risk of the Plans’ members will enable Plans to receive the fair share of funds available through each state’s risk adjustment program.
Plans failing to gain the appropriate funds may need to increase pricing relative to that of the competition, which could possibly result in a loss of favorable risk individuals and exacerbate the risk of adverse selection of Blue Plans by individuals with higher risk.
ProductsDue to the rapidly changing healthcare environment, Plans are faced with numerous requests to enhance products and services to meet their national, local and individual member needs. The product demands are diverse and touch upon a number of key areas, such as consumer transparency, analytics, health management, interaction with Exchanges, health information technology and government programs.
In addition, National Accounts are demanding more advanced consumer transparency capabilities from Blue Plans, to include meaningful, understandable views of cost and quality information in an integrated, consumer-friendly display. In response, BCBSA has partnered with Consortium Health Plans (CHP) and Blue Plans to accelerate delivery of planned transparency initiatives.
This section provides details about the Product initiatives:
1. Consumer Transparency: National Consumer Cost Transparency
2. Reference-Based Benefits
3. Health Information Technology (HIT) Strategy (Voluntary)
4. BlueCard for Public Exchange Products
5. Office of Personnel Management (OPM) Multi-State Plan Program
6. Transfer Program
For a visual summary of Product initiative key milestones, please see the Initiative Timelines in the Timeline Section of the Roadmap.
1. Consumer Transparency: National Consumer Cost Transparency
Overview The National Consumer Cost Transparency (NCCT) was developed to enable members to obtain Blue-negotiated cost estimates for specific medical treatments/services. More recently, NCCT data are used to support other programs, such as Referenced-Based Benefits (RBB) and Plan data quality analytics.
NCCT Treatment Categories
Currently, NCCT provides cost estimates for 1,632 treatment categories (TC), of which 402 are mandated for submission to BCBSA. All Plans are required to submit updated cost files bi-annually. For more information, also see the NCCT Data Submission to BCBSA initiative.
A voluntary expansion (VE), which was undertaken at Plan request, enables Plans to submit data on an additional 1,230 treatment categories to ensure that provider cost data is market competitive. In 2013, a total of eight Plans had participated and submitted data as part of the VE. During the spring 2014 refresh, three additional Plans participated and submitted cost data. Throughout the rest of 2014 and 2015, BCBSA will continue to work with the remaining Plans and encourage them to participate in the program.
NCCT Data Quality Reporting
With increasing interest in data quality, Plans should focus their efforts on improving the completeness and accuracy of their NCCT cost data submitted during each upcoming refresh cycle. Reporting tools were made available to Plans during the spring 2014 refresh period. These tools include automated geographic detailed and summary cost reports that could be used by reviewers to find gaps and outlier costs. Plans are also expected to reduce the number of “no cost providers” in their data submissions. In addition, the development of measurement criteria for completeness and accuracy is now underway to allow BCBSA to benchmark the quality of data submitted by each Plan. These criteria could range from measuring the percentage of mandated treatment categories with populated costs, to using a sample of current claims data to compare actual costs with previous cost estimates displayed to the member.
NCCT Web Service
The Web service accepts inquiries from Plans and then provides Plans with cost estimates and demographic data pertaining to treatment categories and providers. The providers for a given treatment category can be viewed by selecting a geographic search radius centered on a given ZIP code or city/state combination. NCCT supports two Web service versions at any given time. A major Web service release contains changes that will alter the way in which a Plan interfaces with the Web service.
For more information, also see the NCCT Technical Infrastructure initiative.
Key Info Stage of Development:• Ongoing/maintenance
Key Milestones and Dates:Plans Data Refreshes• See the NCCT Data Submission to BCBSA
initiativeData Quality Reporting• Make program guidelines available to
Plans: 10/01/2014Web Service Releases• See the NCCT Technical Infrastructure
initiative
Appx. Size of Plan Work Effort:• Large
• • Platform(s):• Other: Database• Other: Web service
Audience(s):• Plans
• Workgroup(s) Supporting This Effort:• National Programs Products and Services Workgroup
More Info Contact: BlueWeb Page:NCCT Business Owner http://bluewebportal.bcbs.com/article?id=300Karthik Subramanian 9376Business Design Manager
[email protected] Quality ReportingKen MatusakBusiness Design [email protected] Technical InfrastructureMike DowdBusiness Design Director
Business DriversAs individuals take increased responsibility for their healthcare expenses, it is critical that they have access to meaningful, credible information about providers. To meet these member (and account) transparency needs, the Blues® offer a suite of transparency offerings that provide standardized healthcare cost and quality information to members. These offerings enable providers to make smarter choices related to issues such as cost estimates, provider quality information and access to patient reviews. Data from Blue Cross and Blue Shield Plans are aggregated to display cost estimates for 402 treatment categories, with an ongoing expansion to more than 1,600 treatment categories.
2. Reference-Based Benefits
Overview Reference costs are service-specific benefit dollar limits, generally set to cover the costs at most, but not all, providers in a specific market or cost region. Reference- based benefits help members become more engaged with their healthcare choices by providing an incentive to comparison shop for specific services. A Plan offering reference-based benefits establishes a benefit limit for specific services and will pay up to that limit. Members are then responsible for expenses above the reference cost for those services.
Members must use consumer transparency tools, with data from the National Consumer Cost Transparency (NCCT) estimates, or must contact the provider directly to determine if a provider will deliver the service for less than the reference- based price. Because the amount above the reference price will be the member’s liability, a strong incentive exists for the member to select the best cost value for that specific service.
Once an account has decided to implement reference-based benefits, Plans and accounts must collaborate to
• Define the services covered• Define the covered cost amount for services by location• Create strategies to inform members about their benefits and the impact of
their healthcare choices• Offer consumer transparency tools to encourage member comparison
shopping for procedures
Reference-based benefits offer stakeholders additional value.• For the member, the benefit structure lowers costs and allows members to
take a more active role in their healthcare decisions.• For accounts, reference-based benefits lowers costs without higher cost
sharing.• For brokers/consultants, reference-based benefits is a new type of offering for
clients.
To implement a national solution for reference-based benefits, the Association and Blue Plans have established a process to
• Establish the accounts’ reference cost point• Determine a national grid of cost regions• Develop a consistent national communication strategy that informs and
educates both members and providers about reference-based benefits and the potential impact of their choices
The Association has established a granular national cost region grid to more closely represent member purchasing patterns. This cost region grid is defined as the first three digits of a United States Postal Service ZIP code. Plans have identified 168 services (treatment categories) to offer for reference-based benefits.
Key Info Stage of Development:• Ongoing/maintenance
Key Milestones and Dates:• Calculate and publish reference costs
using spring 2014 data: Q3 2014• Calculate and publish reference costs
using fall 2014 data: Q1 2015
• Appx. Size of Plan Work Effort:• Small
• • Platform(s):• Other: NCCT
Audience(s):• Accounts/employer groups• Consultants/brokers• Consumers/members• Accounts• Providers
• Workgroup(s) Supporting This Effort:• Reference-Based Benefits Workgroup
More Info Contact(s): BlueWeb Page:Richard Stephenson http://bluewebportal.bcbs.com/article?id=327Manager, National Delivery [email protected]
Nickolas ClevelandSenior Business [email protected]
Business Drivers
National employers and their consultants have clearly communicated their desire to gain control of and reduce the overall healthcare cost of their employees. In response to this desire, the major brokerage/consulting agents have developed a suite of consumer transparency objectives that is designed to inform members of the actual cost of healthcare services and actively engage members to take a more hands-on approach to making their healthcare decisions. Incorporation of reference- based benefits into benefit programs is one of those objectives.
In response to this market demand, in January 2013, three Blue Plans began to offer a consistent national approach for setting and communicating a reference pricing strategy to National Accounts. The unique strategy currently being used allows Plans to tailor an approach to each account’s needs while offering a benefit design that is unique to the Blues in the marketplace.
3. Health Information Technology (HIT) Strategy
Overview HIT allows comprehensive management of medical information and its secure electronic exchange among healthcare consumers, providers, health plans and others. Broad use of HIT will improve healthcare quality, prevent medical errors, reduce healthcare costs, increase efficiencies and expand access to affordable care. HIT can also help ensure the availability of accurate and timely patient information at the point of care.
National Programs is working to establish a consistent approach to empowering consumers and providers through availability of health information. National Programs is also working to enable interoperability of HIT systems by defining Blue principles that ensure consistency, establishing Blue standards that reduce variability, and enabling provider education and outreach. The following initiatives are offered to address this strategy.
Greater HIT Adoption
Goal: Establish the Blues as leaders in improving quality and efficiency of care through greater adoption of HIT
Given the dramatic changes in the healthcare environment in the past several years, the Industry Standards and eHealth team is conducting a follow-up HIT provider survey. The environmental and industry changes include the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Drug Enforcement Agency’s rule allowing e-prescribing of controlled substances, and Health Care Reform, which includes Health Information Exchanges (HIEs). This survey will address each of these topics and their implications for practices as well as Plan HIT programs and initiatives. Meaningful Use Stage 1 has been in effect since 2011/2012, and in 2014, eligible providers can begin to attest to meeting Stage 2.
Throughout 2014, staff will continue working with Plans and within BCBSA to develop strategies for exchanging data with non-Blue entities (e.g., Health Information Organizations (HIOs), Electronic Health Record (EHR) vendors) and identify potential impacts to Plans’ value propositions.
Health Records and Data Availability
Goal: Empower consumers and providers through availability of health information By
providing and encouraging the use of Personal Health Records (PHRs), theAssociation and Plans empower consumers to participate as partners in theirhealthcare and make informed healthcare decisions.
The Association will continue to advocate the use of PHRs by consumers and providers.
Knowledge Sharing
Goal: Maximize Blue assets to continue alignment with vision and mission Federal
efforts to support HIEs are increasing, and HIEs continue to becomefinancially sustainable. Therefore, Plans’ business models are evolving to include participation with these organizations. The Association will continue to engage Plan stakeholders as the industry gains experience in HIEs.
Key Info Stage of Development:• In development
Key Milestones and Dates:Greater HIT Adoption• Conduct and publish Plan HIT Survey:
Q2-Q4 2014Appx. Size of Plan Work Effort:VOLUNTARY
Platform(s):• Plan software• Other: Vendors
Audience(s):• Accounts/employer groups• Consultants/brokers• Providers• Consumers/members
• Workgroup(s) Supporting This Effort:• National Programs Workgroups as needed
More Info Contact:Matt Schuller [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=297 2071
Business DriversThe Blue System is committed to improving the quality, safety and efficiency of healthcare. By promoting greater quality and cost transparency, Blue Plans are helping consumers to participate as partners in their care and to make informed healthcare decisions based on quality and cost. Blue Plans also are advancing HIT initiatives within their communities.
HIT stakeholder value propositions include the following.
Plans• Reduction in medical errors and greater application of evidence-based medicine• Cost savings through increased efficiency and greater formulary compliance• Improved care management and wellness programs through coordination of care• Improved provider relations•
National Accounts• Control of spiraling healthcare costs
• Higher-quality wellness and care management programs, which are expected to improve employee productivity
Consumers• Improved safety and quality of care
• Cost savings from less duplication of testing and from greater physician adherence to formularies
• Greater access to complete medical records
• Potential for patient reminders about prescription refills, lab work and physician appointments
Providers• Improved safety and quality of care• Cost savings from less paperwork and increased efficiency• Greater access to complete medical records• Potential for increased provider satisfaction
•
4. BlueCard For Public Exchange Products
Overview The Affordable Care Act (ACA) continues to impact the Blue System on a local and national level. On October 1, 2013, open enrollment began for the new health insurance Exchange marketplaces. Currently, 33 of the 37 primary licensees are offering products on their state or federally facilitated Exchange.
Throughout 2013, the Association worked closely with Plans to complete the implementation of BlueCard for Exchanges. BlueCard for Exchanges refers to the National Programs business policy and system modifications developed to enable Plans to offer competitive products and comply with new federal and state requirements under the ACA. These requirements ensure that small groups meeting the National Account criteria and individuals with purchased coverage on public exchanges can have access to national coverage, similar to the way that national coverage is provided with the BlueCard PPO Program.
Plans that offer public Exchange products in 2015 but did not previously offer products will need to implement operational changes for BlueCard for Exchanges. Currently, participating Plans that add or remove public Exchange products in 2015 must also complete certain implementation steps. The BlueCard for Public Exchange Products Implementation Guide assists Plans in understanding key steps for delivery of products purchased on the public Exchange through National Programs.
Since the implementation of BlueCard for Public Exchange Products, Plans have identified additional Exchange-related impacts to inter-Plan operations. As new Health Care Reform regulations and guidance are released, additional enhancements to National Programs systems will be implemented to support the handling of any unique requirement for Exchange business. Throughout the remainder of 2014, BCBSA will continue to work with Plans to provide updated information about the availability of Exchange qualified PPO/EPO networks for travelers and small group members receiving care out of area. On an as needed basis, BCBSA will continue to work closely with Plans to identify additional changes needed to National Programs policies or systems to allow Plans to meet more detailed Exchange requirements.
Key Info Stage of Development:• Implementation
Key Milestones and Dates:• Determine networks to be made available
in BlueCard PPO Basic for 2015 Plan year and publish list: Q3 2014
• Update National Programs policies to support Exchange network criteria: Q4 2014
• Enhance National Doctor and Hospital Finder to support Exchange requirements: Q3 2014
• Participate in Exchange open enrollment: 11/15/14
• Appx. Size of Plan Work Effort:• Large
•
Platform(s):• ITS• BlueSquared• BlueExchange• Policies• Other: Blue Access Call
Center• Other: IPDS• Other: Mobile app• Other: National Doctor and
Hospital Finder
Audience(s):• Accounts/employer groups• Members/consumers• Providers• Consultants/brokers
• Workgroup(s) Supporting This Effort:• National Programs Operational Workgroup• National Programs Products and Services Workgroup• Plan Legal Department Cooperative
More Info Contact:Karin Keane [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/landingpagele vel3/703150?docId=24895
Business DriversHealth Care Reform has impacted Plans with requirements related to covered services, members and new administrative processes and standards. Plans are in the process of adapting to the new Exchange markets. Individual and employer group mandates and changes to the Medicare Program will also continue to impact Plans. As a result, National Programs will need to continue to support
• Lower medical and administrative costs• More flexible operating models
• Expected shifts of members from the employer group market to individual and government business
•
5. Office of Personnel Management (OPM) Multi-State Plan Program
Overview The 2010 Affordable Care Act (ACA) contains a multi-state option that requires the OPM to enter into contracts with at least two health insurance issuers to offer insurance on Exchanges. These issuers may include a group of health plans affiliated by common ownership and control or by the common use of a nationally licensed service mark. In addition, at least one of these issuers must be a not-for- profit entity (which would include the Blue System). Each contract entered into must be for a uniform term of one year, renewable annually.
Participants in the Multi-State Plan Program (MSPP) will phase in state Multi-State Plan (MSP) offerings over a four-year period, ultimately including every state and Washington, D.C., in the program. In the first year (2014), MSPs must be offered in at least 60 percent (31) of these areas. In the second year, MSPs must be offered in at least 70 percent (36) of these areas. In the third year, MSPs must be offered in at least 85 percent (43) of these areas. Finally, in the fourth and all subsequent years, MSPs must be offered in all states and Washington, D.C.
On June 20, 2013, the Board unanimously approved Blue participation, which included approval of the 2014 contract terms and the Plan Participation Agreement (PPA). Consequently, in the third quarter of 2013, Plans participating in year one completed the OPM MSPP application process and executed PPAs, which reflect Plans’ obligations under the OPM MSPP contract. In 2014, 15 licensees covering 31 states (counting Washington, D.C., as a state) are participating in the MSPP.
In preparation for the 2015 contract year, it is necessary to implement licensees in an additional five states to ensure that, in the event of successful 2015 contract negotiations and contract execution, a sufficient number of Plans participating in year two are prepared for open enrollment beginning on November 15, 2014. Many implementation steps for new 2015 MSPP Plans are the same as or similar to the steps for the BlueCard for Public Exchange Products initiative. Up-to-date information on the Multi-State Plan Program is found on the OPM Multi-State Plan Program page on BlueWeb.
Key Info Stage of Development:• In development
Key Milestones and Dates:• Complete the 2015 application: Q3 2014• Complete 2015 contract negotiations:
Q3 2014• Participate in 2015 open enrollment:
11/15/2014• New and current Plans implement the
MSPP based on 2015 contract requirements: Q4 2014
• Make coverage effective for 2015 MSP enrollees: 1/01/15
• Appx. Size of Plan Work Effort:• Large
•
Platform(s):• ITS• BlueSquared• BlueExchange• Other: Blue Access Call
Center• Other: Mobile app• Other: National Doctor and
Hospital Finder• Other: Print-on-demand
Audience(s):• Accounts/employer groups• Members/consumers• Providers• Consultants/brokers
• Workgroup(s) Supporting This Effort:• OPM Multi-State Plan Option Workgroup
More Info Contact:Karin Keane [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=555 7510
Business DriversHealth Care Reform has impacted Plans with requirements related to covered services, members and new administrative processes and standards. The introduction of Exchanges has resulted in new markets to which Plans will have to adapt. Individual and employer group mandates and changes to the Medicare Program will also impact Plans. As a result, National Programs will need to support
• Lower medical and administrative costs• More flexible operating models
• Expected shifts of members from the employer group market to individual and government business
In the new marketplace and with the ACA OPM MSPP participation option, the Blues considered the value of participating, the risks of participating and the risks of not participating in the program.
The value of participating in an MSPP includes the opportunity for the Blues to protect and grow our relationship with OPM and other federal agencies while shaping the rules for the MSPP. Participation in the program has also given the Blues a guaranteed position for Blue products on the state-run and federally facilitated exchanges.
Blue OPM MSP participation risks include the possibility that OPM will set future rules that may disrupt Blue local markets. Plans may also incur additional administrative expenses if there are any special requirements, and an increase in Plan capacity to support another work stream may be needed. MSPs could possibly attract adverse risks that may not be compensated by risk mitigation initiatives or could attract business away from other Blue Plan Exchange products.
Should the Blues elect not to continue participation in the OPM MSPP, the Blues stand the risk of losing influence in government programs and facing overall weakening of the Blues’ influence on
reform implementation. Competitors that decide to participate may have the ability to shape the MSPP to guarantee their success and further their agendas with OPM. Lastly, OPM could more assertively distance itself from the Blues, and competitors could have their products guaranteed on every fallback and state-run Exchange and, therefore, succeed at reducing Blue market share.
To minimize the risks of participating in the program, the Blues will need to renegotiate a contract with OPM so that the rules for the program support continued participation and do not negatively impact other Blue business. The terms of participation will include minimizing any unique requirements to ensure that MSPs are subject to the same rules, processes and technology that will be required for other local Public Exchange business.
6. Transfer Program
Overview Originally launched in 1951, participation in the Transfer Program became a condition of Blue Plan licensure in 1996 to satisfy the HIPAA requirement of allowing group members to “convert” to individual coverage. The goals of the transfer program as modified over the years have been to
• Identify out-of-area direct pay members so that they may be served by the local Blue Plan
• Coordinate Blue “transfers” to meet the continuous coverage requirements of HIPAA
• Require local Plans to issue conversion coverage in the event that a “transferring” member does not meet local Plan underwriting requirements
Currently, the Transfer Program requires Plans to audit quarterly for potential out-of- area members and "transfer" them to the appropriate Plans to enroll in a medically underwritten product without a break in coverage.
With the enactment of the Affordable Care Act (ACA), medical underwriting is no longer allowed, and members are free to choose products among competing Qualified Health Plans, which eliminates the need for conversion coverage. In addition, persons moving out-of-state receive an exception to the ACA annual open requirement, so consumers can move freely throughout the year and gain enrollment through a “special enrollment period,” without regard to health status.
As a result, participation in the Transfer Program as a condition of Plan licensure is no longer relevant, and the BCBSA Board of Directors approved sunsetting the Transfer Program.
While the Transfer Program in its current form is no longer relevant in the post- reform market, the Inter-Plan Programs Committee (IPPC) recognized that member retention for Blue members moving between Blue Plans is critical and has asked staff to explore a range of options, including
• Leveraging existing Blue Assets (e.g., AskBlue, CallBLUE, StayBlue, bcbs.com) to create consistent support for members moving out-of-area— essentially using marketing vehicles to start member retention upon enrollment
• Enacting potential “auto-enrollment” for Blue members moving to a new service area—for which the IPPC will take into account regulatory requirements, operational considerations and legal considerations, such as HIPAA requirements
Post-enrollment membership and clinical information is exchanged among Plans for care management program enrollment and risk adjustment accuracy purposes.
Key Info Stage of Development:• Design
Key Milestones and Dates:• Submit policy changes to the IPPC
Implementation Sub-Committee for approval: Q3 2014
Appx. Size of Plan Work Effort:• Minimal
• Submit request to the Brand Enhancement and Protection Committee to remove the Transfer Program Language from the License Agreement: Q3 2014
• Create a work plan based on Board recommendations to facilitate member retention and Plans’ information needs: Q3 2014
• Submit changes to the Licensee Agreement to the Board for approval: Q4 2014
• Present IPPC with recommendations for retaining Blue members: Q4 2014
• Platform(s):• Policies
Audience(s):• Plan staff associated with member
retention• Association Staff
• Workgroup(s) Supporting This Effort:• National Programs Products & Services Workgroup
More Info Contact:Amy RogalaBusiness Design Manager [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=301 5928
Business DriversWith the enactment of the Affordable Care Act (ACA), medical underwriting is no longer allowed, and members are free to choose products without regard to health status, which eliminates the need for conversion coverage. In addition, persons moving out-of-state receive an ACA exception, so consumers can move freely throughout the year and gain enrollment through a “special enrollment period,” again without regard to health status. As a result, participation in the Transfer Program as a condition of Plan licensure is no longer relevant.
Henceforth, Blue member retention, support of member enrollment and information sharing in the new retail market will be the focus for the evolving Transfer Program. Plans will leverage existing Blue Assets (e.g., AskBlue, CallBlue, StayBlue) to support members moving out-of-area or those who lose their coverage during the year (e.g., through layoffs)—essentially using marketing channels to support retention efforts.
ServiceService excellence is the foundation for all future national initiatives. Service initiatives focus on the development and enhancement of our delivery platform to provide market-based, timely and efficient business service to members, accounts and providers. To maintain and enhance the Blues’ competitive position, service must be measured in an integrated, comprehensive and flexible manner.
In today’s Health Care Reform (HCR) environment, the Blue Plans have an opportunity to position themselves as strong business partners for our providers, members and accounts and to differentiate themselves through superior service, seamless Blue customer experience and responsiveness to market dynamics.
This section provides details about the Service initiatives:
1. Inter-Plan Data Solutions (IPDS) Business Intelligence Development
2. Provider Data Improvement
3. Policy Review
For a visual summary of Service initiative key milestones, please see the Initiative Timelines in the Timeline Section of the Roadmap.
1. Inter-Plan Data Solutions (IPDS) Business Intelligence Development
Overview IPDS assists Plans with enhanced root cause analytics and performance management tools to improve service to providers and improve transparency for National Programs delivery.
Developing business intelligence decision support and reporting will enable the measurement of Plan performance in an integrated, comprehensive and flexible manner.
IPDS reporting provides Plans with the following report capabilities:• Claim processing End-to-End (E2E) cycle time, including associated
adjustments and gap time• Transactional index measures• Conversational real-time/member liability estimate (RT/MLE) processing
against the service-level agreement (SLA)
IPDS is the source for the inter-Plan end-to-end claims experience measures and the Performance Scorecard.
IPDS receives and loads the IPDS/Inter-Plan Operational Reporting (IPOR) Common Extract files daily.
Short-Term Goals (2014 and 2015)• Continue to provide Plans and National Programs with reporting and
decision support• Continue to educate and support Plans and National Programs staff on the
use of IPDS, responding to Plan requests for ad hoc reporting, use of the IPDS application and training
• Migrate the IPDS application to a new technology platform that will improve report performance and provide for future analytical capabilities
• Transition Performance Tracking System (PTS) reports to IPDS in support of the PTS Sunset initiative
• Validate the transitioned PTS reports during a dual reporting period• Update IPDS reporting to support the new adjustment modernization
process• Improve IPDS report filter capabilities• Improve the IPDS Completed Claims Report Series to better align reported
data with IPDS user needs• Improve IPDS support and maintenance activities
Long-Term Goals (2016 and beyond)• Provide Plans with operational improvements to enhance analytical
processes• Migrate the Licensee Desk Level Audit (LDLA) extract process to IPDS
Ongoing• Create industry-leading standards using data available to support National
Programs initiatives (e.g., provider satisfaction, medical advice, claim modernization)
Key Info Stage of Development:• In development
Key Milestones and Dates:• Continue collecting Plan claims data:
Ongoing• Complete the migration to a new
technology-based platform: Q3 2014• Implement data integration and reporting
enhancements:o 14.5 Implementation: 10/19/14 o 15.0 Implementation: 4/19/15 o 15.5 Implementation: 10/11/15 o 16.0 Implementation: 4/17/16 o 16.5 Implementation: 10/16/16 o 17.0 Implementation: 4/23/17 o 17.5 Implementation: 10/15/17
• Schedule additional IPDS application implementations (IPDS application releases that are off cycle from the National Programs release cycle will not impact Plans): As necessary
• Complete PTS Sunset: 2015
• Appx. Size of Plan Work Effort:• Small to medium**Depends on release/implementation
Platform(s):• ITS• BlueSquared
Audience(s):• Accounts/employer groups• Consultants/brokers• Providers• Consumers/members
• Workgroup(s) Supporting This Effort:• National Programs Business Applications Workgroup• National Programs Operations Workgroup
More Info Contact:Caryn JoynerDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/programs/blue card/business-applications/-/asset_publisher/i9oo7cE5SIc4/content/inter- plan-data-solutions
Business DriversThe primary objective of business intelligence development is to support the corporate-wide informatics strategy by providing the Association and Plans with decision support that enables them to effectively compete in the National Account marketplace. Specifically, this initiative provides value by supporting
• Provider and member satisfaction enhancements• Plan performance and operating efficiencies• Transparency between Blue Plans and business partners• Claim modernization and product development initiatives• Creation of industry-leading standards• Business-case development for Governance action items• National Programs initiatives that require inter-Plan claim data
In addition, IPDS supports the National Programs Performance Reporting Strategy. This strategy is a
multi-year, multi-phased approach designed to improve Plan performance reporting from both an operational and an analytical perspective. In support of this strategy, IPDS will provide solutions to
• Address Plan concerns raised through various workgroups and forums• Sunset PTS by 2015• Reduce the number of performance extract processes that Plans are required to support
•
2. Provider Data Improvement
Overview The goal of this initiative is to improve the completeness and accuracy of provider data to support provider cost and quality analytics, consumer transparency initiatives, product development and evaluation, and regulatory requirements.
Background
The Provider Data Repository (PDR) was initially developed to support the creation of provider directories for National Account business. As the healthcare industry has evolved, expanded uses for provider data have been identified in product development and analytics, and in support of consumer engagement initiatives. As a result, over time, the provider data that the Association collects have expanded to include more comprehensive information, including cost and quality data.
Business Need
PDR provider data are being used more often to support tools that enable consumers to make informed decisions about their healthcare, products that improve healthcare access and outcomes, and analytics that help develop and evaluate new programs. From a program perspective as well as a legal and brand protection perspective, it is critical that the data are complete and accurate. This initiative includes actions that BCBSA and Plans will take to ensure the integrity of provider data.
In addition, the ability to accurately match claims data to providers is fundamental to supporting the analytic capabilities required for success in the emerging healthcare environment and to meeting regulatory requirements. Accurate provider-to-claims data matching is also foundational to supporting Blue Distinction Centers for Specialty Care, Blue Distinction Total Care, BlueDistinction Evolution, National Consumer Cost Transparency, ValueQuest, and Patient Review of Physicians and Risk Adjustment. However, due to inconsistencies in how providers are identified in PDR and on claims, efficiently and accurately matching providers with claims data is challenging. The lack of a common identifier requires complex mapping strategies to link claims to providers. These mapping strategies are inefficient and error-prone, often leading to mismatched or unmatched data.
Business Objectives
Provider Data Quality Improvement Strategy
BCBSA will develop a provider data quality improvement strategy in 2014, incorporating input gathered from Plans via structured innovation techniques. The strategy will contain actionable steps for improving the completeness and accuracy of BCBSA’s provider data. A key objective of the strategy is that Plan investment in implementing the action steps must be low. Target completion for the strategy is the third quarter of 2014.
Provider Number Alignment
To enable accurate provider-to-claims data matching, on February 19, 2014, the Inter-Plan Programs Committee (IPPC) Implementation Sub-Committee approved a change to IP/MA 6.01, Claims-Related Requirements, which requires Plans to use the same provider number on claims, or Submission Formats (SF), and on provider data submissions, or Provider Data Formats (PDF). This requirement is effective with National Programs
Release 15.5. The cost to implement the requirement will vary based on the complexity of a Plan’s systems and the number of system platforms impacted. Any costs incurred by Plans to support this requirement are one-time, not ongoing, costs. Plans that already align the provider number on the SF and PDF will not have any work effort. Aligning the provider ID used on claims with those submitted on the PDF will improve the accuracy and integrity of the provider data used to support the development, management and evaluation of Blue Distinction programs, new care delivery models and consumer transparency tools.
National Provider Identifier (NPI) Validation
The NPI is a key data element used to match provider data from third-party sources with provider data in PDR. Therefore, it’s essential that Plans’ PDFs contain the NPI. Plans are required to populate the NPI on PDFs in accordance with IP 6.12/MA6.11, National Provider Identifier. This policy requirement will be enforced with an Inter-Plan Teleprocessing Services (ITS) PDF software edit in National Programs Release 15.5.
Provider Data Repository Enhancements
BCBSA will enhance the capabilities of PDR to improve the quality and value of data to downstream applications and to safeguard the integrity of the provider data. This work will occur during 2014 and will not require Plan action. These enhancements include
• Improving the usability of Plan-facing reports, including improving provider data load results and provider network composition
• Improving the PDR feature for Plans to load and approve Physician Quality Measures (PQM) data and related disclaimers
• Capturing and disseminating National Committee for Quality Assurance (NCQA) Patient Centered Specialty Practice Recognitions, Hospital Value- Based Purchasing Measures and physician photos (pilot program)
• Strengthening the business rules for matching third-party provider data with PDR provider records and improving the usability of the PDR feature for resolving match issues
• Improving the usability and accountability of the PDR feature for requesting provider data extracts
•
Key Info Stage of Development:• Preliminary/research• In development
Key Milestones and Dates:Changes with Plan Impact• Provider Data Quality Improvement
Strategy: Q3 2014• National Programs Release 15.5
implementation: 10/11/15• Implement policy requirements:
10/11/15PDR improvements (no Plan impact)• Design, develop, test and deploy solution:
2014
• Appx. Size of Plan Work Effort:• Medium to large
• • Platform(s):• ITS• PDR
Audience(s):• Plans• Providers• Accounts/employer groups• Consultants/brokers• Consumers/members
• Workgroup(s) Supporting This Effort:• National Programs Business Applications Workgroup• National Programs Operations Workgroup
More Info Contact:Ann BehlingDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=359 6008
Business DriversAccurate provider data are foundational to supporting consumer transparency initiatives, performing provider cost and quality analytics, and ensuring support for regulatory requirements. Improving the quality of data will enable Plans to use the provider data asset to its fullest potential.
3. Policy Review
Overview In March 2013, the Board of Directors committed to reviewing the Inter-Plan Policies to ensure relevance and necessity, given the new and emerging market environment. As part of the review, all Inter-Plan Programs policies, provisions and processing standards were evaluated to ensure that they enable Plan success in local marketplaces, protect Plans’ exclusive service areas, promote sales in the highly competitive National Account market, protect the Brands and align with established criteria. In August 2013, the Inter-Plan Programs Committee (IPPC) identified criteria and guiding principles to assist in the review of the policies, provisions and processing standards.
During the Governance cycle during the first quarter of 2014, the IPPC endorsed and the Board approved the initial recommendations presented as part of the overall Inter-Plan Programs (IPP) policy evaluation. All relevant modifications have also been incorporated into the Inter-Plan Medicare Advantage (MA) Program policies, provisions and processing standards since the IPP policies are leveraged as the foundation for the MA Program.
The IPP/MA policies and processing standards were categorized as follows:
• Category 1—Delete: Remove the 15 policies that have content that is informational only (no Plan requirements specified) or that duplicates requirements already specified in other policies.
• Category 2—Keep: Retain 99 policies; however, implement technical modifications to streamline existing language/requirements, relocate relevant information for proper placement, delete irrelevant outdated information and correct policy references due to reorganization.
• Category 3—New: Add 13 policies, created from existing processing standards, because the content provides Plan requirements but does not meet the established criteria of a processing standard.
• Category 4—Processing Standards: Delete all 44 processing standards and shift relevant requirements/information to the applicable policies or reference materials.
• Category 5—Proposed Revisions (Operational Efficiencies): Modify four of five policies initially identified for further consideration to provide additional flexibility in administering inter-Plan requirements.
Proposed recommendations, as well as all
Key Info Stage of Development:• In development
Key Milestones and Dates:• Submit recommendations
to IPPC Implementation S u b c o m m i t t e e f o r approval: Q3 2014
• Appx. Size of Plan Work Effort:• Small to medium
• • Platform(s):• Not applicable
Audience(s):• Plans
• Workgroup(s) Supporting This Effort:• National Programs Operations Workgroup
More Info Contact: BlueWeb Page:Janice Griffin http://bluewebportal.bcbs.com/
article?id=376Managing Director, Program [email protected]
Mary Kay CarollaManager, Policy and Compliance312-297-6260MaryKay.Carolla@bcbsa
Business DriversThe existing IPP policies and processing standards were established in 1994 and provide Plans with the business, operational and technical requirements necessary to support Inter-Plan Programs. These policies were developed to promote consistent administration of the operational requirements and processes among all Plans. The corresponding MA Program policies and processing standards were established in 2005. The proposed modifications will ensure that duplicative and/or out-of-date information is removed and provide Plans with a consolidated and more streamlined set of policy requirements.
RegulatoryIn addition to meeting requirements related to the market and Health Care Reform (HCR), Plans and the Association must take steps to comply with upcoming regulatory requirements, including the implementation of the International Classification of Diseases, Tenth Revision (ICD-10). These requirements are designed to improve administrative transactions, the effectiveness of communication between payers and providers, and the ability to classify diseases and care delivery for analytical purposes.
This section provides details about the Regulatory initiatives:
1. ICD-10
2. Administrative Simplification
For a visual summary of Regulatory initiative key milestones, please see the Initiative Timelines in the Timeline Section of the Roadmap.
1. ICD-10
Overview In the United States, a clinical modification of the International Classification of Diseases, Tenth Revision (ICD-10-CM) will be utilized for the classification of clinical morbidity. ICD-10-CM for diagnosis coding and the ICD-10 Procedure Coding System (ICD-10-PCS) for institutional inpatient procedure coding were adopted for use as of October 1, 2014, in the final rule posted in the Federal Register and dated September 5, 2012. Subsequently, the date was delayed by Bill HR4302, signed into law on April 2, 2014, which states, “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD-10 code sets as the standard for codes sets under section 1173 (c) of the Social Security Act (42 U.S.C. 1320d-2 (c)) and section 162.1002 of title 45, Code of Federal Regulations.” The new compliance is pending announcement by CMS.
ICD-10 represents a major revision to ICD-9-CM diagnosis and procedure coding. Changes will include the use of alphanumeric codes, restructured categories, a revised coding scheme and significantly expanded detail of procedure and diagnosis codes. ICD-10 has approximately 800 more code categories than ICD-9.
Although ICD-10 codes cannot be used in production before October 1, 2015, changes to Inter-Plan Teleprocessing Services (ITS) formats to accommodate ICD- 10 were completed with the implementation of ITS 12.0 (on October 14, 2012) to allow adequate Plan testing. In this release, ITS was enhanced to allow reporting of both ICD-9 and ICD-10 in separate fields, starting on the compliance date. The use of separate fields for each ICD code version supports claims that are incurred prior to October 1, 2015, but filed after that date as well as dual-code reporting when a Par/Host Plan converts an ICD-10 code received from a provider to ICD-9 for pricing. No custom changes will be required for BlueExchange® to accommodate ICD-10.
All Plans have been invited to participate in the ICD-10 Transition Workgroup (TW). This workgroup provides advice and recommendations for facilitating the transition to ICD-10 codes at Plans and for implementing ICD-10 codes for local business and in National Programs transactions. The TW consists of the ICD-10 Plan and NASCO Project Leaders for the ICD-10 implementation.
Key Info Stage of Development:• Finalized
Key Milestones and Dates:• Conduct Plan surveys to
determine ICD- 10 readiness: Quarterly thru 2015
• Use ICD-10 for claims incurred on or after 10/01/15: 10/01/15
• Require use of ICD-10: 10/01/15
• Appx. Size of Plan Work Effort:GOVERNMENT MANDATE• Extra large
•
Platform(s):• ITS• BlueSquared
Audience(s):• Providers• Plans• Other: Vendors
• Workgroup(s) Supporting This Effort:• ICD-10 Transition Workgroup
More Info Contact:Joan Robinson Project Manager [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=302 6475
Business DriversThe transition to ICD-10 is a government mandate that is expected to capture more precise healthcare information and to bring the United States in step with coding systems worldwide. The value of the transition will be far-reaching and will result in
• Greater coding accuracy and specificity• Higher-quality information for measuring healthcare service quality, safety and efficiency• Improved efficiencies and lower costs• Reduced number of coding errors• Greater achievement of the benefits of an electronic health record• Improved ability to track and respond to international public health threats• Space to accommodate future expansion• Improved ability to detect fraud
•
2. Administrative Simplification
Overview The Affordable Care Act (ACA), and specifically the new administrative simplification provisions, requires the Association and all Blue Plans to look for ways to remain engaged in the new era of healthcare. The goals laid out under administrative simplification “to reduce the clerical burden on patients, healthcare providers and health plans” will result in changes in the upcoming months and years. While the provisions apply to mainly the administrative and financial standards mandated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the ACA administrative simplification also includes adding new standards over time.
The ACA laid out a series of provisions and, in some instances, corresponding dates for the adoption of new standards and operating rules, for review and amendment of standards and operating rules, and for compliance certification by health plans. The Secretary of the Department of Health and Human Services (HHS) will adopt these provisions through the regulatory process, oftentimes utilizing an interim final rule approach in lieu of a proposed rule and then final rule approach.
Provisions Currently in Effect and Compliance Date
• Operating rules for eligibility and claim status: January 1, 2013
• Electronic funds transfer (EFT) standard: January 1, 2014
• Operating rules for electronic remittance advice (ERA) and EFT: January 1, 2014
Provisions with Regulations Issued and Compliance Dates
• Unique health plan identifier (HPID)o Health Plans to obtain HPIDs:
November 5, 2014**Small health plans have until November 5, 2015
o Required use in standard transactions: November 7, 2016
Provisions with No Regulations Issued and Statutory Date
• New standardso Claims attachments standard: January
1, 2016• Operating rules
o Operating rules for claims, enrollment, premium payment and referral/pre-authorizations: January 1, 2016
o Claims attachments: January 1, 2016• Compliance certification by health plans
o Standards and operating rules for
Key Info Stage of Development:• Dependent upon
provision, based on availability of regulation
Key Milestones and Dates:Health Plan Identifier• Identify National Programs
impacts:Q3-Q4 2014
• Identify solutions to address National Programs impacts: Q3-Q4 2014
Other Provisions• Identify impacts and
solutions:Dependent on release of regulations
Appx. Size of Plan Work Effort:GOVERNMENT MANDATE• Dependent upon provision
• • Platform(s):• ITS• BlueSquared• BlueExchange• Plan software• Other: BCBSA
Audience(s):• Providers• Plans• Other: Vendors
• Workgroup(s) Supporting This Effort:• Regulatory and Standards Information
Sharing Forum• Other Plan workgroups as needed, based on
the specific provision
More Info Contact:Gail Kocher [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=376 2888
Business DriversAdministrative simplification provisions are a government mandate and are designed to further improve the effectiveness and efficiency of the healthcare system. The use of standard transactions and code sets will enhance and further simplify the administration of healthcare and enable the efficient electronic transmission of certain health information. These additional provisions are designed to improve the utility of the existing HIPAA transactions and reduce administrative burden and costs.
National Programs Technology
Technology: Platform Release PlanningTo ensure that Blue Plans continue supporting National Account business processes as efficiently as possible, this section presents anticipated release dates for future updates and enhancements to technology platforms. This section also provides details about technology platforms and upcoming implementations.
1. Inter-Plan Teleprocessing Services (ITS)2. BlueSquared® (Blue2)
3. Inter-Plan Data Solutions (IPDS) Extract
4. BlueExchange® (BX)
5. Licensee Desk Level Audit (LDLA)6. BlueGuest®
7. National Consumer Cost Transparency (NCCT) Technical Infrastructure
8. Inter-Plan Operational Reporting (IPOR)
9. Inter-Plan Data Exchange (IPDEX)
10. Datanet Lite (DNL)
11. Value-Based Programs Care Delivery Platform
More detailed information on each of these releases can be found in Appendix 1: Technology Implementation Plan.
For a visual summary of Technology Platform key milestones, please see the Technology Platform Timelines in the Timeline Section of the Roadmap.
1. Inter-Plan Teleprocessing Services (ITS)
Overview ITS includes common language, data formats, software and procedures that allow Plans to access, send, receive and control claims information. These commonalities enable System-wide processing and reimbursement of BlueCard claims.
Business functions to be supported in upcoming releases include the following.
Short-Term Goals (2014)• Value-Based Programs enhancements• Sunset of functionality migrated to
BlueSquared• Submission Format (SF) Message Codes
to support Bariatric Blue Distinction Center (BDC) designations
• Provider Data Format (PDF) validation edits
• Operational improvements to enhance ITS transactions
Long-Term Goals (2015 and beyond)• Health Plan Identifier (HPID) and
administrative simplification• Value-Based Programs enhancements• Purge improvements• Migration of Capitation Bulk Settlement
Format (CBF) online• Revamp of Plan Profile
We are focusing future enhancements on supporting high-priority market requirements, Health Care Reform and operational efficiencies.
Key Info Stage of Development:• In development to
finalized*
*Depends on release/implementation
Key Milestones and Dates:• 14.5 Implementation:
10/19/14• 15.0 Release: 11/06/14• 15.0 Implementation:
4/19/15• 15.5 Release: 5/14/15• 15.5 Implementation:
10/11/15• 16.0 Release: 11/12/15• 16.0 Implementation:
4/17/16• 16.5 Release: 5/12/16• 16.5 Implementation:
10/16/16• 17.0 Release: 11/10/16• 17.0 Implementation:
4/23/17• 17.5 Release: 5/11/17• 17.5 Implementation:
10/15/17
• Appx. Size of Plan Work Effort:• Large to extra large**Depends on release/implementation
Platform(s):• ITS• BlueSquared• PDR• LDLA• Plan Software• Other: IPDS• Other: IPOR
Audience(s):• Plans
More Info Contact:Patty SimpsonDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=296 6589
Business DriversITS will continue to be modernized to leverage contemporary technology and the significant investment in existing software tools. This modernization will be done through renovation of reusable components in a service-oriented portfolio. Modernization and renovation of ITS will be driven by business need and will be integrated into a more unified portfolio of products operating on Java 2 Platform, Enterprise Edition (J2EE) and mainframe platforms to enable improved interoperability among Plans. The improved interoperability will be realized through capabilities such as real-time messaging, Web user interfaces, integrated exceptions management and enhanced information storage and access.
Many aspects of ITS will be modernized through support for real-time claims adjudication (RTCA) and member liability estimation (MLE), and eventually all of the online components will move to BlueSquared. However, the current ITS batch processes and Network Data Mover (NDM) transmission for claims-related transactions—Submission Format (SF), Disposition Format (DF) and Reconciliation Format (RF)—are expected to continue over the long term.
2. BlueSquared® (Blue2)
Overview Blue2 is the Association’s remotely deployed application suite that facilitates National Programs business processes in real-time by providing common Plan services and National Programs messaging services.
The National Programs business processes currently supported by Blue2 include the abilities to
• Send and respond to medical record and pre-existing information requests
• Send and respond to general inquiries, misrouted claims, provider quality issues and case-specific rate negotiation requests
• Send informational messages, miscellaneous attachments, Coordination of Benefits (COB) questionnaires and Global Fee messages
• Send and respond to claim appeal requests and send claim appeal status messages and claim appeal misroute messages
• Send and respond to National Programs escalation messages
• Create, update and send Submission Formats (SFs) via real-time transport using the Claims Administration function
• Create and send Health Insurance Portability and Accountability Act (HIPAA) claim status inquiries for National Programs claims (Inter-Plan Teleprocessing Services (ITS) and non-ITS)
• Perform searches through Standard Claims Collection Facility (SCCF) history and claim listings using various criteria
• View Blue2 messages and ITS formats on other Plans’ databases
• View SF and Disposition Format (DF) details though the Blue2 user interface
• Create, update and send DFs via real-time transport using the Claims Administration function, incorporating functionality previously supported via the ITS Online Entry and Correction (OEC) and Home Plan Aid (HPA) tools
Business functions to be supported in upcoming releases include
• Adjustment Messages (Release 14.5)• Selective Purge and Recovery
functionality (Release 15.0)• Capitation Bulk Settlement Format (CBF)
Modernization (Release 15.0)• Plan Profile Modernization (Release 16.0)
Key Info Stage of Development:• In development to finalize**Depends on release/implementation
Key Milestones and Dates:• 14.5 Implementation:
10/19/14• 15.0 Release: 11/06/14• 15.0 Implementation:
4/19/15
Appx. Size of Plan Work Effort:• Medium to extra large**Depends on release/implementation
• 15.5 Release: 5/14/15• 15.5 Implementation:
10/11/15• 16.0 Release: 11/12/15• 16.0 Implementation:
4/17/16• 16.5 Release: 5/12/16• 16.5 Implementation:
10/16/16• 17.0 Release: 11/10/16• 17.0 Implementation:
4/23/17• 17.5 Release: 5/11/17• 17.5 Implementation:
10/15/17
• Platform(s):• BlueSquared
Audience(s):• Plans
More Info Contact:Patty SimpsonDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=324 3753
Business DriversThe business objectives for Blue2 are to improve provider satisfaction, facilitate operational excellence and increase speed to market for business solutions.
The near-term vision for Blue2 is to
• Promote administrative efficiency through web-based service capabilities, flexible on- demand access to data and real-time exchanges of messages and other claims-related transactions
• Enrich member and provider satisfaction by improving efficiencies in handling exception situations and enhancing operational capabilities
The long-term vision for Blue2 is to
• Be a single entry point for all current and future National Programs business and data functions
•
3. Inter-Plan Data Solutions (IPDS) Extract
Overview The primary objective of the IPDS extract is to provide the Association with analytical, reporting and decision support data for improving provider satisfaction and Plan performance.
The extract collects claim and line-level data from Plans. Data are extracted from the Plans’ Formats database(s) and transmitted to the Association daily. Plans are required to submit extracts for all Inter-Plan Teleprocessing Services (ITS) and BlueSquared (Blue2) transactions.
As of Release 14.0 (implementation on April 13, 2014), the IPDS extract process was enhanced to incorporate the Inter-Plan Operational Reporting (IPOR) Blue2 message extract process. This process is now referred to as the IPDS/IPOR Common Extract process. This process captures the data elements needed for both the IPDS Application and the IPOR Data Mart.
Short-Term Goals (2014 and 2015)
The IPDS/IPOR Common Extract will be updated to support a number of initiatives:
• Capture additional claims-related data to support payment innovations and adjustment modernization initiatives
• Capture additional claims-related data to support the National Programs initiatives
Long-Term Goals (2016 and beyond)
The data to be collected will be driven by the new initiatives undertaken by the Association and the Plans to compete in the National Account marketplace. These new initiatives may
• Improve provider and member satisfaction• Support the business case for
Governance action items• Enhance Plan performance and operating
efficiencies• Support claim modernization and product
development initiatives
For more information, also see the IPDS Business Intelligence Developmentinitiative.
Key Info Stage of Development:• In development to
finalized
Key Milestones and Dates:• Perform daily extracts:
Monday to Friday (ongoing)
• 14.5 Implementation: 10/19/14
• 15.0 Release: 11/06/14• 15.0 Implementation:
4/19/15
Appx. Size of Plan Work Effort:• Small to medium**Depends on release/implementation
• 15.5 Release: 5/14/15• 15.5 Implementation:
10/11/15• 16.0 Release: 11/12/15• 16.0 Implementation:
4/17/16• 16.5 Release: 5/12/16• 16.5 Implementation:
10/16/16• 17.0 Release: 11/10/16• 17.0 Implementation:
4/23/17• 17.5 Release: 5/11/17• 17.5 Implementation:
10/15/17
• Platform(s):• ITS• BlueSquared
Audience(s):• Plans
More Info Contact: BlueWeb Page:Caryn Joyner http://bluewebportal.bcbs.com/
programs/blueDirector, Business Applications card/business-applications/-312-297-5673 /asset_publisher/
i9oo7cE5SIc4/content/[email protected] plan-data-solutions
Lee LangkampManager, Informatics/[email protected]
Business DriversIntegration of existing data sources (End-to-End) in the IPDS Data Warehouse is key to supporting the decision-making process. IPDS Business Intelligence Development will provide Plans and the Association with an interactive solution to analytical reporting, data modeling and decision support for improving provider satisfaction and Plan operational performance.
4. BlueExchange® (BX)
Overview BX is the Association’s National Programs system for select Health Insurance Portability and Accountability Act (HIPAA) transaction processing. To accomplish this task, BX supports both batch and real-time transactions. BX provides standard formats, secure and reliable Plan-to-Plan communications, common validation processes and performance measurements to ensure timely processing of select HIPAA transactions.
Transactions processed by BX include• 270/271–Health Care Eligibility Benefit
Inquiry and Response• 276/277–Health Care Claim Status
Request and Response• 278-13/278-11–Health Care Services
Request for Review and Response• 835–Health Care Claim Payment/Advice
for Medicare Crossover• 999–Implementation Acknowledgement• TA1–Interchange Acknowledgement
Plans are integrating BX into Member Out-of-Pocket (MOP) solutions. The MOP solution is transparent to BX. BX accepts 270–Health Care Eligibility Benefit Inquiries and responds with member benefit information via the 271–Health Care Eligibility Benefit Response.
BX has two types of milestones: technology platform releases and Plan requirements.
BX Technology Platform Releases
These releases help improve the transaction processes by supporting enhanced performance measurements, transaction edits and reporting tools. BX releases occur bi-annually (as needed) and are numbered (e.g., 14.0, 14.5). At this time, only maintenance releases are planned.
Since July 1, 2011 (Release 9.0), BX and Plans have supported the HIPAA 005010/005010A1 (5010) version of transactions.
BX Plan Requirements
These requirements focus on the standardization of the format and content of the responses returned to providers who submit inquiries. The most recent initiative was the “Next Iteration” of BX, which Plans implemented on or before January 1, 2013. This iteration of requirements focused on primarily
• Improving BX 271–Health Care Eligibility Benefit Responses to increase provider satisfaction
• Plan requirements resulting from the adoption of operating rules under the Affordable Care Act (ACA) administrative
A new BX 271–Health Care Eligibility Benefit Response requirement was approved during the second-quarter 2014 IPCC Governance cycle. The policy will be effective on January 1, 2015. The policy will require Control/Home Licensees to notify providers about eligibility requests received within months two and three of the Exchange individual grace period. The responsibility of this requirement will fall to the Plans. No BX changes are required to support this new policy.
Key Info Stage of Development:• Maintenance only
Key Milestones and Dates:Technology Platform• 14.5 Implementation*:
11/16/14• 15.0 Implementation*:
5/17/15• 15.5 Implementation*:
11/08/15• 16.0 Implementation*:
5/15/16• 16.5 Implementation*:
11/13/16• 17.0 Implementation*:
5/21/17• 17.5 Implementation*:
11/12/17*Maintenance updates and production defect fixes release scheduled only if needed
Plan Requirements• Make the grace period
policy effective:1/01/2015
Appx. Size of Plan Work Effort:• Small to medium**Depends on scope of release
Platform(s):• BlueExchange
Audience(s):• Plans
More Info Contact:Caryn JoynerDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/programs/blue card/business-applications/-/asset_publisher/i9oo7cE5SIc4/content/bluee xchange
Business DriversThe business objective of BX is to improve provider satisfaction through the timely and consistent processing of standard HIPAA transactions from providers.
BX continues to process more than 99 percent of real-time transactions in less than 5 seconds and experiences volumes in excess of 2 million transactions per day.
5. Licensee Desk Level Audit (LDLA)
Overview The LDLA program is an audit of the Inter-Plan Teleprocessing Services (ITS) Submission Format (SF), ITS Disposition Format (DF) and the NASCO Processing System (NPS) records for National Programs claims. Each year, at a minimum, the LDLA application must be modified to incorporate the latest changes to the ITS and NASCO software. In addition, other modifications are made to incorporate enhancements to the audit application.
Key Info Stage of Development:• In development to
finalized**Depends on release/implementation
Key Milestones and Dates:• 14.5 Implementation:
10/19/14• 15.0 Implementation:
4/19/15• 15.5 Implementation:
10/11/15• 16.0 Implementation:
4/17/16• 16.5 Implementation:
10/16/16• 17.0 Implementation:
4/23/17• 17.5 Implementation:
10/15/17
• Appx. Size of Plan Work Effort:• Small
• • Platform(s):• LDLA
Audience(s):• Plans
More Info Contact:LDLA Helpdesk [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=325 1017
Business DriversTo ensure the integrity of the audit program, the LDLA web-based application and the LDLA Extraction program will be modified in accordance with ITS and NASCO release schedules, at a minimum. Because the Association maintains these programs, little or no effort is required by Plans to incorporate the modifications.
6. BlueGuest®
Overview BlueGuest is the system that Health Maintenance Organizations (HMOs) use to administer guest membership for the Away From Home Care®
(AFHC) program. BlueGuest consists of a web-based user interface with a centralized database that houses the guest membership applications and inter-HMO billing forms.
Key Info Stage of Development:• Not applicable
Key Milestones and Dates:• No releases planned for
2014• Appx. Size of Plan Work Effort:• Not applicable
• • Platform(s):• BlueGuest
Audience(s):• Plans
More Info Contact:Kelli Clymer Senior Consultant [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=295 4787
Business DriversBlueGuest provides value to Plans through a web-based application that enables Plans to quickly create, store and send data. The Association handles all development, testing and release implementation, which limits the need for utilizing Plan resources.
7. National Consumer Cost Transparency (NCCT) Technical Infrastructure1.
Appx. Size of Plan Work Effort:• Large
• 14.5 Release target: 10/13/14
• 15.0 Release target: 4/30/15
• 15.5 Release target: 10/31/15
• 16.0 Release target: 4/29/16
• 16.5 Release target: 10/31/16
• Platform(s):• Other: Database• Other: Web service
Audience(s):• Plans
More Info Contact:Mike DowdBusiness Design Manager [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=300 9376
Business DriversA Web service layer and centralized database have been built by BCBSA. The Web service approach to functional development gives Blue Plans the flexibility to customize the display for various customer segments and to integrate the cost functionality into their online customer service suite.
8. Inter-Plan Operational Reporting (IPOR)
Overview IPOR Data Mart is an optional solution that enables Plans to extract and load operational data to a local data mart. The IPOR Data Mart enables the generation of daily reports for managing day-to-day National Programs business. Currently, Plans have two options to obtain reports:
• Develop and generate reports from their IPOR Data Mart using a local reporting application
• Utilize Datanet Lite report capabilities
IPOR also provides a mechanism to remove data from the IPOR Data Mart when it is no longer needed for open inventory management.
IPOR utilizes the Inter-Plan Data Solutions (IPDS)/IPOR Common Extract process to capture claim data.
Short-Term Goals (2014 and 2015)• Include additional ITS and BlueSquared
(Blue2) data elements in the IPOR Data Mart to support local Plan operational reporting needs
• Incorporate data elements required to support open inventory management associated with National Programs initiatives
• Perform defect resolution to ensure the accuracy of data loaded into the IPOR Data Mart
• Improve IPOR Data Mart operational procedures
Long-Term Goals (2016 and beyond)• Future enhancements will focus on
supporting the open inventory management needs associated with high-priority market requirements, Health Care Reform and operational efficiencies.
Key Info Stage of Development:• In development to
finalized*
*Depends on release/implementation
Key Milestones and Dates:• 14.5 Implementation:
10/19/14• 15.0 Release: 11/06/14• 15.0 Implementation:
4/19/15• 15.5 Release: 5/14/15• 15.5 Implementation:
10/11/15• 16.0 Release: 11/12/15• 16.0 Implementation:
4/17/16• 16.5 Release: 5/12/16• 16.5 Implementation:
10/16/16• 17.0 Release: 11/10/16
Appx. Size of Plan Work Effort:• Medium
• 17.0 Implementation: 4/23/17
• 17.5 Release: 5/11/17• 17.5 Implementation:
10/15/17
• Platform(s):• ITS• BlueSquared
Audience(s):• Plans
More Info Contact:Caryn JoynerDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=550 1951
Business DriversThe Association is in the midst of executing the National Programs Performance Reporting Strategy. This strategy is a multi-year, multi-phased approach designed to improve Plan performance reporting from both an operational and an analytical perspective. The strategy will
• Address Plan concerns raised through various workgroups and forums
• Provide basic daily operational performance monitoring tools for Plans to use on a voluntary basis• Reduce the number of performance extract processes that Plans are required to support• Sunset the PTS by 2015
IPOR supports this strategy by meeting Plans’ operational and performance reporting needs. As the short-term goals listed above are achieved, the number of extract processes will be reduced and PTS Sunset activities will be supported.
9. Inter-Plan Data Exchange (IPDEX)
Overview With IPDEX, Plans have the ability to access information and attachments from their partner Plans that support financial settlements and episode-based payment reimbursement methodologies. The information is transferred between Plans through this software, with the appropriate security parameters.
The software resides at BCBSA, and Plans do not require a local technical implementation. Plans access this application through an Internet portal.
Business functions currently supported include• Proactive notification of Episode Based
Payment (EBP) arrangements.Notification of EBP will be required for all Par/Host Plans that provide BlueCard access to these types of payment arrangements.
• Gain sharing/incentive payment data for retroactive settlement in conjunction with the Capitation Bulk Settlement Format (CBF) in Inter-Plan Teleprocessing Services (ITS)
• Licensee administration
Long-Term Goals (2015 and beyond)• Automation of the CBF Bulk Settlement
process will be implemented in ITS. Once functionality is available in ITS, IPDEX will be sunset and no longer supported.
Key Info Stage of Development:• In development to
finalized*
*Depends on release/implementation
Key Milestones and Dates:• Sunset*: 2015*No new functionality is planned for IPDEX
Appx. Size of Plan Work Effort:• Small**Training of appropriate staff and integration into business processes
Platform(s):• ITS
Audience(s):• Plans
More Info Contact:Caryn JoynerDirector, Business Design [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=326 7845
Business DriversInnovative provider payment and network models are essential to supporting more coordinated, efficient and quality-driven healthcare. This development is driven by primarily market demand for products/networks that slow the rate of growth in healthcare costs. In addition, Health Care Reform is expected to
lead the changes in commercial business.
Plans are exploring and developing new approaches that change the strategy used for determining providers’ total financial compensation to focus on outcomes and quality. These approaches must be made available for national delivery to support National Accounts and individual travelers. Arrangements may be specific to individual providers or provider organizations. Multiple arrangements may exist in a Plan’s market.
As Plans implement new payment and network models locally, necessary enhancements are being made to National Programs software to accommodate the national delivery of these new models. In the short term, IPDEX meets the business objective to assist with the exchange of supporting detail data for financial settlements and episode-based payment reimbursement methodologies. The long- term approach will rely on the automation of the CBF Bulk Settlement process.
10. Datanet Lite (DNL)
Overview The Association has partnered with Proteligence, Inc., a respected organization that has worked with many Plan customers, to make a “lite” version of the Datanet tool currently available to Plans.
Datanet Lite is an application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
Datanet Lite connects directly to the Inter-Plan Operational Reporting (IPOR) tables using queries and calculations provided by the Association. This process ensures that the data are up to date and accurate. Because of the direct connection to IPOR, scores can be generated as frequently as needed, including daily, monthly and quarterly.
The use of Datanet Lite is optional. Plans may elect to use it for daily operational scorecard and inventory management.
Short Term (2014 and 2015)• Transition operational reporting from the
Performance Tracking System (PTS) to Datanet Lite
• Update operational and scorecard reports to support the adjustment modernization effort
• Support reporting requirements resulting from National Programs initiatives
Long Term (2016 and Beyond)
Datanet Lite will be updated as appropriate to support new initiatives undertaken by the Association and the Plans to compete in the National Account marketplace.
Key Info Stage of Development:• Finalized
Key Milestones and Dates:• 14.5.1 Implementation:
8/28/14• 15.0* Implementation:
Spring 2015• 15.5* Implementation: Fall
2015• 16.0* Implementation:
Spring 2016• 16.5* Implementation: Fall
2016• 17.0* Implementation:
Spring 2017• 17.5* Implementation: Fall
2107*Implementation as needed
Appx. Size of Plan Work Effort:• Small
• • Platform(s):• Other: IPDS/IPOR
Common Extract
Audience(s):• Plans
More Info Contact:Caryn JoynerDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=327 8302
Business DriversThe Association is in the midst of executing the National Programs Performance Reporting Strategy. This strategy is a multi-year, multi-phased approach designed to improve Plan performance reporting from both an operational and an analytical perspective. The strategy will
• Address Plan concerns raised through various workgroups and forums
• Provide basic daily operational performance monitoring tools for Plans to use on a voluntary basis• Reduce the number of performance extract processes that Plans are required to support• Sunset PTS by 2015
In support of this strategy, Datanet Lite provides daily open inventory reports and transactional scores to effectively manage daily operations. It is also expected that a small number of PTS reports will transition to the Datanet Lite report series as part of the PTS Sunset activities.
11. Value-Based Programs Care Delivery Platform
Overview New BlueCard enhancements accommodate Plans’ Value-Based Programs (formerly Payment Innovations). As part of the evolution of BlueCard, the delivery platform facilitates the exchange of information to allow National Account members access to local value-based programs, including Patient-Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). Critical components that support this process include
• Provider Information: Identification of providers participating in the PCMH and ACO programs
• Attribution: Assignment of National Account members to local value-based programs
• Care Coordination: Facilitation of data exchange between Plans for pre- service, admissions and discharge notifications
• Financial Settlement: Settlement of non-claim expenses between Plans
New operating models have been developed, and policies have been approved by the Board of Directors to support a consistent national delivery program for effective dates January 1, 2015, and beyond.
Staff members have worked with Plans to develop the standards and policies to support the national delivery platform. Ongoing work continues, with Plan-specific implementation project plans and Plan visits to consider business and technical requirements.
Key Info Stage of Development:• In development
Key Milestones and Dates:• 2014 Release 2
Implementation*:8/15/14
• 2014 Release 3 Implementation*:10/17/14
• 2014 Release 4 Implementation*:11/28/14
• 15.0 Implementation: 4/08/15
• 15.5 Implementation: 10/08/15
• 16.0 Implementation: 4/08/16
• 16.5 Implementation: 10/08/16
• 17.0 Implementation: 04/08/17
• 17.5 Implementation: 10/08/17
*Data software is available in Plan Validation Environment (PVE) for testing
Appx. Size of Plan Work Effort:• Large
• • Platform(s):• ITS• BlueSquared• Other: Value-Based
Programs Care Delivery Platform
Audience(s):• Plans
More Info Contact:Samuel BullockDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=548 6415
Business DriversAs Plans develop and implement alternative payment models and network arrangements, it is critical to
• Understand Plan approaches and strategies• Define national requirements for payment innovation and Blue Distinction Total Care
• Enhance System-wide capabilities to support National Programs delivery for BlueCard and National Accounts
New payment and network models are essential to support more coordinated, efficient and quality- driven healthcare. High-performing delivery systems can be supported by payment models that reward physicians for ensuring a high value of delivered care, improving quality, encouraging coordination and optimizing services to control cost. Coordination among providers can be supported by aligning provider incentives and by bundling payment for clinically related services. The optimal payment model and pathway to implementation will vary across the delivery system due to differing market characteristics. Network management strategies can be used with new payment approaches to further align provider
incentives.
Stakeholders include consultants, brokers, accounts and providers who have indicated interest in these new models. Based on results from a 2012 survey, Plans will continue to expand these solutions in their markets over the next several years. Plans are actively developing care delivery strategies to improve quality and control costs. Plans are also implementing new programs, and some pilot programs have shown positive impacts on cost and quality. To support the delivery of the local Plan programs to National Accounts, a new data exchange solution is in development. It provides the supporting operational platform for the Blue Distinction Total Care initiative and value- based programs.
Technology: Ongoing MaintenanceThis section presents information on ongoing initiatives that play a critical role in the reporting, auditing and collection of key Plan data.
1. Provider Data Format (PDF)
2. Licensee Desk Level Audit (LDLA) Extracts
3. Performance Tracking System (PTS) Extracts
4. National Consumer Cost Transparency (NCCT) Data Submission to BCBSA
5. Physician and Hospital Quality Measurement
6. Blue Physician Recognition (BPR) Program
7. Patient Experience1.
1. Provider Data Format (PDF)
Overview The PDF is a standard data layout and format that Plans use to report hospital, physician and other provider data to the Association.
PDF transmits Plan provider network information, including provider-specific information on physicians, hospitals and other network providers, on a weekly basis. Plan PDF information is loaded to the Provider Data Repository and is used for providing specific services to Plans (e.g., geographic and disruption analyses) and for analytics and reporting purposes.
Plans submit provider data to the Association according to their established weekly submission schedule (ranging from Monday through Saturday) via the PDF standard format.
Data submitted includes, but is not limited to,• Provider name, street address, city, state
and phone number for physicians and hospitals
• Provider types (e.g., medical doctor)• Provider specialties (e.g., cardiovascular
disease)
For more information on future data, please see the Consumer Transparency: National Consumer Cost Transparency initiative in this Roadmap.
Key Info Key Milestones and Dates:• Plans submit provider data to the
Association: Weekly
More Info Contact:Lee Langkamp Enterprise Information [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=300 1491
2. Licensee Desk Level Audit (LDLA) Extracts
Overview In support of the LDLA Program, monthly extract files for National Programs claims (BlueCard, Inter-Plan Teleprocessing Services (ITS) Custom and NASCO) are created by Plans and NASCO and transmitted to the Association. These monthly extract files are then transferred and loaded into a central database for use in the LDLA web-based application for auditing.
The output files are due to the Association by the 10th of every month. Par/Host Plans have a total of 10 calendar days from the first of every month to execute the extract program and transmit the output files to the Association.
Key Info Key Milestones and Dates:• Par/Host Plans execute extract program and
transmit output files to Association: No later than the 10th of each month
More Info Contact:LDLA Helpdesk [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=325 1017
3. Performance Tracking System (PTS) Extracts
Overview The PTS is a reporting system that uses several measurement criteria to provide information related to Inter-Plan Teleprocessing Services (ITS) production volumes and processing performance. The Association and Plan management use this information to identify and resolve problems and, therefore, improve ITS/BlueCard performance.
ITS staff at each Plan and vendors must transmit the PTS data file to the Association no later than the end of the ninth calendar day of each month. The PTS files will contain the Plan’s performance and transaction volume data to month end. The approved Plan-specific data files are transmitted via BluesNet to the Association and then copied to data sets for processing.
Note: PTS reporting sunsets in Release 15.5.
Key Info Key Milestones and Dates:• Plans and vendors transmit PTS data file to
Association: No later than 9th of each month
More Info Contact:Brenda Muehlbauer Manager, National Programs [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=3314728
4. National Consumer Cost Transparency (NCCT) Data Submission to BCBSA
1.5. Physician and Hospital Quality Measurement
Overview Publicly reporting information on the quality of physicians and hospitals allows members to better identify and select high-quality providers. Support for members making healthcare decisions based on cost and quality is a market and Health Care Reform imperative. Currently, hospital quality and some physician measurement results are displayed on the National Doctor and Hospital Finder. To meet National Account requirements, the Blues have committed to developing and implementing physician quality measurement programs, including consistent national display of quality measures, across all Plans. The Inter-Plan Programs Committee (IPPC) will continue to review standards for publicly reporting physician and hospital clinical quality information to members and for aligning reporting with government regulations.
Physician Quality Measurement (PQM)
This program displays physician performance measures to assist members in selecting a provider. The program is based on select Healthcare Effectiveness Data and Information Set (HEDIS®) physician performance measures. The PQM program displays physician performance measurements, supporting data, local comparison scores from Plans and consumer educational information on the National Doctor and Hospital Finder.
Hospital Quality Measurement (HQM)
HQM refers to the display of widely accepted and publicly available hospital quality results on the Blue National Doctor and Hospital Finder, including process and outcomes measure results from the Centers for Medicare and Medicaid Services (CMS). HQM also includes results for vendor-developed metrics for risk-adjusted complications for medical, surgical and obstetric care and all-cause inpatient mortality. The HQM results displayed on the Finder represent the Blue standard for hospital quality transparency.
Quality Reporting Program Enhancements and Data Sharing
The display of physician and hospital quality information will be enhanced through 2014 based on in-depth consumer insight research, member usability testing and feedback. HQM measurement data will be expanded to include CMS Hospital Value-Based Program (HVBP) data as released during 2014 and 2015.
At Plans’ request, provider quality results are made available from a central repository to support the display of quality information to members.
Key Info Key Milestones and Dates:PQM• Plans submit PQM data files for annual
refresh: Date is dependent on last file submission*
• Provide PQM data extract to Plans: Currently available upon request
*Plans may voluntarily submit PQM data more frequently.
HQM• Provide HQM data to Plans: Currently
available upon request
More Info Contact: BlueWeb Page:Mary Conlisk http://bluewebportal.bcbs.com/
article?id=336PQM Business Design Manager
5200
Madelon RaszHQM Business Design [email protected]
6. Blue Physician Recognition (BPR) Program
Overview The BPR Program is designed to reinforce Blue Plans’ commitment to quality by providing more meaningful and consistent information on physician quality improvement and recognition on the National Doctor and Hospital Finder site. The Program eligibility criteria developed by a Blue Plan Task Force are used by Plans to identify any primary care or specialist physician (or group/practice) who demonstrates commitment to delivering quality and patient-centered care. Participation in a local, regional or national Quality Improvement (QI) or Recognition Program that meets the BPR Quality and Recognition Program Standards qualifies a physician (or group/practice) for an overall BPR indicator on the National Doctor and Hospital Finder site.
The BPR Program aims to leverage and advance local Plan experiences in implementing successful approaches to driving improvement at the point of care.
Key Info Key Milestones and Dates:• Populate Provider Data File BPR indicator:
Weekly• Verify recognitions: Annually
More Info Contact:Mary ConliskBPR Business Design Manager [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=336 3077
7. Patient Experience
Overview Engaging and empowering consumers to make more knowledgeable healthcare decisions is a fundamental priority and a market requirement. In the rapidly changing healthcare environment, consumers need information that can help them take an active role in managing care for themselves and their families. There are two Patient Experience initiatives, one for individual providers and one for hospitals.
Patient Review of Physicians and Professional Providers (PRP)
The Blue National Patient Review Database has been enhanced to offer additional capabilities to Plans, including options to add provider types, Spanish language reviews, provider response and email notification. The Consumer Transparency Portal functions were expanded to include PRP Moderation and Reporting services. Leveraging the enhanced Blue PRP capabilities to maximize Plan adoption and increase Blue review data volume is a key strategic objective for 2014 and 2015.
Hospital Patient Experience
The current standard for hospital patient experience is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience survey results, which are publicly available from the Centers for Medicare and Medicaid Services (CMS). The Association currently incorporates HCAHPS results into the hospital profile pages on the National Doctor and Hospital Finder for member ease of use. Plans interested in displaying HCAHPS results to local and/or National Account members may request the data from the Association.
Key Info Key Milestones and Dates:Patient Review of Physicians
• Plans must use PRP version 3.0: Q4 2014 Hospital Patient Experience• Plans request HCAHPS data from BCBSA
for Plan use, including localbusiness, on a voluntary basis: Quarterly, as
available from CMS
More Info Contact:Marisa LewisDirector, Consumer Tools [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=336 5211
Technology: Software Standards
Overview The Association has published a document detailing system software standards. This document identifies the Association standards for required system software packages used to support application software hosted by National Programs and National Programs application software deployed at Plans, such as Inter-Plan Teleprocessing Services (ITS), BlueSquared, and various extracts, including Inter- Plan Data Solutions (IPDS)/End-to-End (E2E), Provider Data Format (PDF) and Membership Exchange Format (MEF). The Association software standards do not apply to Plan system software used only in support of local Plan business.
Identifying these standards provides the Association and Plans many benefits:
• Allows the Association and Plans to take advantage of technology advancements
• Allows Plans to anticipate software acquisitions and deployments
• Removes the risks of using unsupported software
• Reduces unnecessary variability while helping to improve National Programs application software quality
The Association will publish these software standards yearly to coincide with Plan budgetary cycles. This timing will allow for appropriate advance planning and provide Plans the information needed to ensure that required resources are included in the next year’s budgets.
The 2014 version of the System Software Standards was published on February 27, 2014.
Key Info Key Milestones and Dates:• Publish System Software Standards: Yearly
More Info Contact:IPPT Help Desk [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=331 9014
National Programs Timelines
Initiative and Technology TimelinesThe following pages contain timelines for each of the National Programs initiatives. Each timeline contains Association-related, quarterly milestones (as of June 30, 2014) that are detailed over the next 3 years. Cross-divisional Association initiatives are not included.
Although these timelines and milestones are current as of June 30, 2014, work on these initiatives will evolve and change, which Plans should consider for budgeting and resource purposes.
For more details on these key milestones, please see each specific initiative or technology platform. The
timelines show the key milestones by quarter.
National Programs Initiatives: Association Key Milestones Timelines
NETWORKS2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
1. Blue Distinction® Specialty Care Program
2. Blue Distinction® Total Care
3. National Programs Care Management
Q1 Q2 Q3 Q4
COST2014 2015 2016 2017
1. PlanConnexion® Collaborative Services (VOLUNTARY)Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2. Risk Adjustment
Q1 Q2 Q3 Q4
PRODUCTS2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
1. Consumer Transparency: National Consumer Cost Transparency
2. Reference-Based Benefits
3. Health Information Technology (HIT) Strategy (VOLUNTARY)
4. BlueCard for Public Exchange Products
5.
Office of Personnel Management (OPM) Multi-State Plan Program
6. Transfer Program
Q1 Q2 Q3 Q4
SERVICE2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
1. Inter-Plan Data Solutions (IPDS) Business Intelligence Development
2. Provider Data Improvement
3. Policy Review
Q1 Q2 Q3 Q4
REGULATORY2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
1. ICD-10
2. Administrative Simplification
Q1 Q2 Q3 Q4
National Programs Technology Platform Releases: Association Key Milestones Timelines
Inter-Plan Teleprocessing
2014 2015 2016 2017Services (ITS)Q3 Q4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
ITS 14.5
ITS 15.0
ITS 15.5
ITS 16.0
ITS 16.5
ITS 17.0
ITS 17.5
Q1 Q2 Q3 Q4
BlueSquared (Blue2)2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Blue2 14.5
Blue2 15.0
Blue2 15.5
Blue2 16.0
Blue2 16.5
Blue2 17.0
Blue2 17.5
Q1 Q2 Q3 Q4
Inter-Plan Data Solutions
2014 2015 2016 2017(IPDS) ExtractQ3 Q4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
IPDS 14.5
IPDS 15.0
IPDS 15.5
IPDS 16.0
IPDS 16.5
IPDS 17.0
IPDS 17.5
Q1 Q2 Q3 Q4
BlueExchange (BX)2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
BX 14.5
BX 15.0
BX 15.5
BX 16.0
BX 16.5
BX 17.0
BX 17.5
Q1 Q2 Q3 Q4
Licensee Desk Level Audit
2014 2015 2016 2017(LDLA)Q3 Q4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
LDLA 14.5
LDLA 15.0
LDLA 15.5
LDLA 16.0
LDLA 16.5
LDLA 17.0
LDLA 17.5
Q1 Q2 Q3 Q4
BlueGuest2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
No planned releases for 2014
National Consumer Cost Transparency (NCCT) Technical
2014 2015 2016 2017InfrastructureQ3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
NCCT 14.5
NCCT 15.0
NCCT 15.5
NCCT 16.0
NCCT 16.5
Q1 Q2 Q3 Q4
Inter-Plan Operating Reporting
2014 2015 2016 2017(IPOR)Q3 Q4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
IPOR 14.5
IPOR 15.0
IPOR 15.5
IPOR 16.0
IPOR 16.5
IPOR 17.0
IPOR 17.5
Q1 Q2 Q3 Q4
Inter-Plan Data Exchange
2014 2015 2016 2017(IPDEX)No enhancements or initiatives are currently defined. This application will sunset in 2015.Q3 Q4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Q1 Q2 Q3 Q4
Datanet Lite (DNL)2014 2015 2016 2017
Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
DNL 14.5
DNL 15.0*
DNL 15.5*
DNL 16.0*
DNL 16.5*
DNL 17.0*
DNL 17.5*
*Implementation as needed
Q1 Q2 Q3 Q4
Value-Based Pro grams Care
2014 2015 2016 2017Delivery PlatformQ3 Q4
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Value-Based Programs Care Delivery Platform 2
014 Release 2
Value-Based Programs Care Delivery Platform 2014 Release 3
Val
ue-Based Programs Care Delivery Platform 2014 Release 4
Value-Based Program
s Care Delivery Platform 15.0*
Value-Based Programs Care Delivery Platform 1
5.5*
Value-Based Programs Care Delivery Platform 16.0*
Value-Based Progra
ms Care Delivery Platform 16.5*
Value-Based Programs Care Delivery Platform
17.0*
Value-Based Programs Care Delivery Platform 17.5*
*Implementation as needed
Q1 Q2 Q3 Q4
Appendix 1: Technology Implementation Plan
Appendix 1: Technology Implementation Plan
Overview The multi-year Business and Technology Implementation Plan was designed to document National Programs development initiatives on an ongoing basis. The Implementation Plan will assist Plans in assessing the financial and resource impacts of potential initiatives, allowing better preparation for implementations and driving system improvements to market faster and more efficiently.
For more detailed information, refer to the Online Multi-Year Business and Technical Roadmap located on the National Programs Release Central BlueWeb page: http://bluewebportal.bcbs.com/article?id=5501951.
Key Info This Appendix includes information on the following releases:
• Inter-Plan Teleprocessing System (ITS) 14.5, 15.0, 15.5, 16.0, 16.5, 17.0 and17.5
• BlueSquared (Blue2) 14.5, 15.0, 15.5, 16.0, 16.5, 17.0 and 17.5• Inter-Plan Data Solutions (IPDS) 14.5, 15.0, 15.5, 16.0, 16.5, 17.0 and 17.5• Inter-Plan Operational Reporting (IPOR)
14.5, 15.0, 15.5, 16.0, 16.5, 17.0 and17.5
• BlueExchange (BX) 14.5, 15.0, 15.5, 16.0, 16.5, 17.0 and 17.5• Licensee Desk Level Audit (LDLA) 14.5, 15.0, 15.5, 16.0, 16.5, 17.0 and 17.5• BlueGuest (no planned releases)• National Consumer Cost Transparency
(NCCT) Technical Infrastructure 14.5, 15.0, 15.5, 16.0 and 16.5
• Inter-Plan Data Exchange (IPEDX) (currently no planned releases)
• Value-Based Programs Care Delivery Platform* 2014 Release 2, 2014 Release 3, 2014 Release 4, 15.0, 15.5, 16.0, 16.5, 17.0 and 17.5
*Formerly Payment Innovations Delivery Platform (PIDP)
More Info Contact:Samuel BullockDirector, Business Applications [email protected]
BlueWeb Page:http://bluewebportal.bcbs.com/article?id=681 3168
2014 National Programs Multi-Year Strategic Roadmap proprietary and confidential Page - 101
Technology Implementation Plan
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 14.5
5/15/14 Release Scope 1/23/14
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
Enhancements♣
International payment direction
♣ RF transmission edit
♣Suppression of all non- exception displays during RT processing
♣ Close-out DF message code changes
♣ Excess day modification for LOS
♣ SF message codes for BDC Bariatric Designation
♣ Sunset HPA Workstation and OEC DF
♣ Common extract changes for Value- Based Programs (formerly Payment Innovations)
♣ New report for cumulative ITS invalid records
Areas to Consider♣
Underwriting/Actuarial
♣ Provider Reimbursement
♣ Network Development
♣ Claims Coding/Adjudication
♣ Care/Disease Management
♣Analytics/Informatics/ Data Warehouse
♣ z/OS version 1.13
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/30/14
Conversion Specifications
2/06/14
Implementation Milestones Global Certification Scenarios
2/27/14
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
4/03/14
LRM4/17/14
Configuration Guide DDLsDraft Deployment Notes
5/01/14
Scheduled Addendum1
8/28/14
Scheduled Addendum2
9/18/14
Implementation
10/19/14
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 15.0 11/06/14 Release Scope
7/17/14
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
Enhancements♣ Sunset
SIRF, adjustment to NFs and ITFI
♣ IPP claim search table report enhancement
♣ DF close-out message code edits
♣ Purge Recovery User Interface
♣ ITS Report File enhancements
♣ Provider Type Specialty Code enhancements
♣ PDF enhancements
♣ V a l u e -B a s e d P r o g r a m r e l a t e d enhancements (CBF)
♣ Individual grace period
♣ Individual and SHOP Only Networks
♣ Various edit enhancements
Areas to Consider♣
Underwriting/Actuarial
♣ Provider Reimbursement
♣ Network Development
♣ Claims Coding/Adjudication
♣ Care/Disease Management
♣ Analytics/Informatics/ Data Warehouse
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/24/14
Conversion Specifications
7/31/14
Implementation Milestones Global Certification Scenarios
8/21/14
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/25/14
LRM10/02/14
Configuration Guide DDLsDraft Deployment Notes
10/23/14
Scheduled Addendum1
2/26/15
Scheduled Addendum2
3/19/15
Implementation
4/19/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 15.5 5/14/15 Release Scope
1/22/15
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
Planned Enhancements♣ HPID/
Administrative Simplification
♣ Veteran Affairs payment direction
♣ New BlueCard for Exchanges requirements
♣ Blue Distinction arrays enhancements
♣ ITS Edit to require NPI on PDF
♣ Medicaid requirements
♣ New OPM Multi-State Requirements
♣ Medicare Advantage DF Balancing enhancement
Areas to Consider♣
Underwriting/Actuarial
♣ Provider Reimbursement
♣ Network Development
♣ Claims Coding/Adjudication
♣ Care/Disease Management
♣ Analytics/Informatics/ Data Warehouse
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/29/15
Conversion Specifications
2/05/15
Implementation Milestones Global Certification Scenarios
2/26/15
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
4/02/15
LRM4/09/15
Configuration Guide DDLsDraft Deployment Notes
4/30/15
Scheduled Addendum1
8/20/15
Scheduled Addendum2
9/10/15
Implementation
10/11/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 16.0 11/12/15 Release Scope
7/15/15
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/22/15
Conversion Specifications
7/29/15
Implementation Milestones Global Certification Scenarios
8/19/15
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/23/15
LRM9/30/15
Configuration Guide DDLsDraft Deployment Notes
10/21/15
Scheduled Addendum1
2/25/16
Scheduled Addendum2
3/17/16
Implementation
4/17/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 16.5 5/12/16 Release Scope
1/21/16
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/28/16
Conversion Specifications
2/04/16
Implementation Milestones Global Certification Scenarios
2/25/16
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
3/31/16
LRM4/07/16
Configuration Guide DDLsDraft Deployment Notes
4/28/16
Scheduled Addendum1
8/25/16
Scheduled Addendum2
9/15/16
Implementation
10/16/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 17.0 11/10/16 Release Scope
7/15/16
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/22/16
Conversion Specifications
7/29/16
Implementation Milestones Global Certification Scenarios
8/19/16
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/23/16
LRM9/30/16
Configuration Guide DDLsDraft Deployment Notes
10/21/16
Scheduled Addendum1
2/16/17
Scheduled Addendum2
3/16/17
Implementation
4/23/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
ITS 17.5 5/11/17 Release Scope
1/19/17
♣ ITS is a set of common language data formats, software and procedures that allows Plans to access, send and receive data and is the electronic tool set Plans use to process National Programs claims.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/26/17
Conversion Specifications
2/02/17
Implementation Milestones Global Certification Scenarios
2/23/17
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
3/30/17
LRM4/06/17
Configuration Guide DDLsDraft Deployment Notes
4/27/17
Scheduled Addendum1
8/24/17
Scheduled Addendum2
9/14/17
Implementation
10/15/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
14.5
5/15/14 Release Scope
1/23/14
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
Enhancements♣ Adjustment
request and response capabilities
♣ Claims administration invalid claims enhancement
♣ Blue2 Node enhancement
♣ Open Message Cancelation enhancement
♣Externalization of Blue2
and claims administration reference data
♣ Care Coordination Phase 2 - PAD
♣ Training/Education
♣ Operations/Claims
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/30/14
Conversion Specifications
2/06/14
Implementation Milestones Global Certification Scenarios
2/27/14
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
4/03/14
LRM4/17/14
Configuration Guide DDLsDraft Deployment Notes
5/01/14
Scheduled Addendum1
8/28/14
Scheduled Addendum2
9/18/14
Implementation
10/19/14
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
15.0
11/06/14 Release Scope
7/17/14
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
Enhancements♣ CBF
Modernization
♣ CBF enhancements in support of Value-Based Programs
♣ CA line of service summary view
♣ UI enhancement for exception handling
♣ Default/auto-population enhancement
♣ BCWW guarantee of payment forms
♣ Training/Education
♣ Operations/Claims
♣WebSphere Application Servicer v8.5
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/24/14
Conversion Specifications
7/31/14
Implementation Milestones Global Certification Scenarios
8/21/14
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/25/14
LRM10/02/14
Configuration Guide DDLsDraft Deployment Notes
10/23/14
Scheduled Addendum1
2/26/15
Scheduled Addendum2
3/19/15
Implementation
4/19/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
15.5
5/14/15 Release Scope
1/22/15
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
Planned Enhancements♣ Error code
narrative display
♣ Message attachment size enhancement
♣ Single sign-on
♣ Plan Code/Station Code Synchronization enhancement
♣ Training/Education
♣ Operations/Claims
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/29/15
Conversion Specifications
2/05/15
Implementation Milestones Global Certification Scenarios
2/26/15
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
4/02/15
LRM4/09/15
Configuration Guide DDLsDraft Deployment Notes
4/30/15
Scheduled Addendum1
8/20/15
Scheduled Addendum2
9/10/15
Implementation
10/11/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
16.0
11/12/15 Release Scope
7/15/15
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
♣ Pending Prioritization
♣ Pending Prioritization
♣ Pending Prioritization
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/22/15
Conversion Specifications
7/29/15
Implementation Milestones Global Certification Scenarios
8/19/15
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/23/15
LRM9/30/15
Configuration Guide DDLsDraft Deployment Notes
10/21/15
Scheduled Addendum1
2/25/16
Scheduled Addendum2
3/17/16
Implementation
4/17/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
16.5
5/12/16 Release Scope
1/21/16
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
♣ Pending Prioritization
♣ Pending Prioritization
♣ Pending Prioritization
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/28/16
Conversion Specifications
2/04/16
Implementation Milestones Global Certification Scenarios
2/25/16
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
3/31/16
LRM4/07/16
Configuration Guide DDLsDraft Deployment Notes
4/28/16
Scheduled Addendum1
8/25/16
Scheduled Addendum2
9/15/16
Implementation
10/16/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
17.0
11/10/16 Release Scope
7/15/16
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
♣ Pending Prioritization
♣ Pending Prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/22/16
Conversion Specifications
7/29/16
Implementation Milestones Global Certification Scenarios
8/19/16
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/23/16
LRM9/30/16
Configuration Guide DDLsDraft Deployment Notes
10/21/16
Scheduled Addendum1
2/16/17
Scheduled Addendum2
3/16/17
Implementation
4/23/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Squared (Blue2)
17.5
5/11/17 Release Scope
1/19/17
♣ Facilitates National Programs business processes in real- time by providing common Plan services and National Programs messaging services
♣ Pending Prioritization
♣ Pending Prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/26/17
Conversion Specifications
2/02/17
Implementation Milestones Global Certification Scenarios
2/23/17
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
3/30/17
LRM4/06/17
Configuration Guide DDLsDraft Deployment Notes
4/27/17
Scheduled Addendum1
8/24/17
Scheduled Addendum2
9/14/17
Implementation
10/15/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 14.5 5/15/14(Daily
Extract Software)
Release Scope
1/23/14
♣ Provides decision support to enhance member and provider satisfaction
ApplicationEnhancements♣ Migration of
internal BCBSA financial reports
♣ Migration of PTS operational reports to IPDS
♣ Reporting support for National Programs initiatives, including Adjustment Modernization
Daily Extract Enhancements♣ Capture of
additional data elements to support National Programs initiatives
Areas to Consider♣
Operational/Claims
♣Operational/Customer Service
♣ Training/Education
♣ Global Certification
♣ None at this time
♣ ♣
Functional Specification
1/30/14
Implementation Milestones Global Certification Scenarios
2/27/14
Draft Release Notes
4/03/14
Draft Deployment Notes
5/01/14
Scheduled Addendum1
8/28/14
Scheduled Addendum2
9/18/14
Implementation
10/19/14
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 15.0 11/06/14(Daily
Extract Software)
Release Scope
7/17/14
♣ Provides decision support to enhance member and provider satisfaction
ApplicationEnhancements♣ Gap audit
improvements
♣ Reporting support for National Programs initiatives
♣ Data integrity improvements
♣ Alpha Prefix filters for TIM and RT/MLE
Daily Extract Enhancements♣ Capture of
additional data elements to support National Programs initiatives
Areas to Consider♣
Operational/Claims
♣Operational/Customer Service
♣ Training/Education
♣ Global Certification
♣ None at this time
♣ ♣
Functional Specification
7/24/14
Implementation Milestones Global Certification Scenarios
8/21/14
Draft Release Notes
9/25/14
Draft Deployment Notes
10/23/14
Scheduled Addendum1
2/26/15
Scheduled Addendum2
3/19/15
Implementation
4/19/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 15.5 5/14/15(Daily
Extract Software)
Release Scope
1/22/15
♣ Provides decision support to enhance member and provider satisfaction
Planned ApplicationEnhancements♣ Reporting
support for National Programs initiatives
♣ Completion of Claim Report Series redesign
♣ Operational improvements
Planned Daily Extract Enhancements♣ Capture of
additional data elements to support National Programs initiatives
Areas to Consider♣
Operational/Claims
♣Operational/Customer Service
♣ Training/Education
♣ Global Certification
♣ None at this time
♣ ♣
Functional Specification
1/29/15
Implementation Milestones Global Certification Scenarios
2/26/15
Draft Release Notes
4/02/15
Draft Deployment Notes
4/30/15
Scheduled Addendum1
8/20/15
Scheduled Addendum2
9/10/15
Implementation
10/11/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 16.0 11/12/15(Daily
Extract Software)
Release Scope
7/15/15
♣ Provides decision support to enhance member and provider satisfaction
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Functional Specification
7/22/15
Implementation Milestones Global Certification Scenarios
8/19/15
Draft Release Notes
9/23/15
Draft Deployment Notes
10/21/15
Scheduled Addendum1
2/25/16
Scheduled Addendum2
3/17/16
Implementation
4/17/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 16.5 5/12/16(Daily
Extract Software
Release Scope
1/21/16
♣ Provides decision support to enhance member and provider satisfaction
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Functional Specification
1/28/16
Implementation Milestones Global Certification Scenarios
2/25/16
Draft Release Notes
3/31/16
Draft Deployment Notes
4/28/16
Scheduled Addendum1
8/25/16
Scheduled Addendum2
9/15/16
Implementation
10/16/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 17.0 11/10/16(Daily
Extract Software)
Release Scope
7/15/16
♣ Provides decision support to enhance member and provider satisfaction
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Functional Specification
7/22/16
Implementation Milestones Global Certification Scenarios
8/19/16
Draft Release Notes
9/23/16
Draft Deployment Notes
10/21/16
Scheduled Addendum1
2/16/17
Scheduled Addendum2
3/16/17
Implementation
4/23/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDS 17.5 5/11/17(Daily
Extract Software)
Release Scope
1/19/17
♣ Provides decision support to enhance member and provider satisfaction
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Functional Specification
1/26/17
Implementation Milestones Global Certification Scenarios
2/23/17
Draft Release Notes
3/30/17
Draft Deployment Notes
4/27/17
Scheduled Addendum1
8/24/17
Scheduled Addendum2
9/14/17
Implementation
10/15/17
Release
Release Date Mi
lest
ones Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Exchang
e (BX) 14.5
N/A Implementation 11/16/
14
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non-HIPAA transactions between Plans. BlueExchange supports real-timeand batch processing.
♣ Contents limited to production defects (if any)
♣ P l a n s m u s t e n s u r e complianc e o f t h e i r validation software.
♣ BX Message Hub will reject transactions with trailing zeroes on dollar amounts.
♣ None at this time
Blue Exchang
e (BX) 15.0
N/A Implementation 5/17/
15
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non- HIPAA transactionsbetween Plans. BlueExchange supports real-time and batch processing.
♣ Contents limited to production defects (if any) and only scheduled as needed
♣ Plans should review contents to determine impacts.
♣ None at this time
Release
Release Date Mi
lest
ones Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Exchang
e (BX) 15.5
N/A Implementation 11/08/
15
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non-HIPAA transactions between Plans. BlueExchange supports real-timeand batch processing.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Blue Exchang
e (BX) 16.0
N/A Implementation 5/15/
16
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non- HIPAA transactionsbetween Plans. BlueExchange supports real-time and batchprocessing.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release
Release Date Mi
lest
ones Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Exchang
e (BX) 16.5
N/A Implementation 11/13/
16
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non-HIPAA transactions between Plans. BlueExchange supports real-timeand batch processing.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Blue Exchang
e (BX) 17.0
N/A Implementation 5/21/
17
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non- HIPAA transactionsbetween Plans. BlueExchange supports real-time and batchprocessing.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release
Release Date Mi
lest
ones Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Blue Exchang
e (BX) 17.5
N/A Implementation 11/12/
17
♣BlueExchange is an electronic National Programs clearinghouse used for managing the flow ofstandard HIPAA- compliant and non-HIPAA transactions between Plans. BlueExchange supports real-timeand batch processing.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release
Release Date Mi
lest
ones Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
LDLA 14.5
N/A Implementation 10/19/
14
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 14.5
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
LDLA 15.0
N/A Implementation 4/19/
15
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 15.0
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
LDLA 15.5
N/A Implementation 10/11/
15
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 15.5
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
LDLA 16.0
N/A Implementation 4/17/
16
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 16.0
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
LDLA 16.5
N/A Implementation 10/16/
16
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 16.5
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
Release
Release Date Mi
lest
ones Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
LDLA 17.0
N/A Implementation 4/23/
17
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 16.0
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
LDLA 17.5
N/A Implementation 10/15/
17
♣ Financial a n d administra t i v e audits
♣ Plan-requested enhancements
♣Application changes to align with ITS 16.5
Areas to Consider♣
Financial/Accounting
♣Operational
♣ Training/Education
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
BlueGuest N/A No planned releases Note: Releases to correctdefects will be scheduled on anas needed basis
♣ N/A ♣ N/A ♣ N/A ♣ N/A
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
NCCT 14.5
N/A Implement ationFall 2014
♣ Enables members to obtain information on estimated costs for common healthcare services
♣ Pending prioritization
♣Treatment categories to support the fall 2014 cost data refresh
Areas to Consider♣ Provider
♣ Account
♣Operational/Claims
♣Operational/Customer Service
♣ Network/Provider Contract
♣ Training/Education
♣ None at this time
NCCT 15.0
N/A Implement ationSpring 2015
♣ Enables members to obtain information on estimated costs for common healthcare services
♣ Pending prioritization
Areas to Consider♣ Provider
♣ Account
♣Operational/Claims
♣Operational/Customer Service
♣ Network/Provider Contract
♣ Training/Education
♣ None at this time
NCCT 15.5
N/A Implement ationFall 2015
♣ Enables members to obtain information on estimated costs for common healthcare services
♣ Pending prioritization
Areas to Consider♣ Provider
♣ Account
♣Operational/Claims
♣Operational/Customer Service
♣ Network/Provider Contract
♣ Training/Education
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
NCCT 16.0
N/A Implement ationSpring 2016
♣ Enables members to obtain information on estimated costs for common healthcare services
♣ Pending prioritization
Areas to Consider♣ Provider
♣ Account
♣Operational/Claims
♣Operational/Customer Service
♣ Network/Provider Contract
♣ Training/Education
♣ None at this time
NCCT 16.5
N/A Implement ationFall 2016
♣ Enables members to obtain information on estimated costs for common healthcare services
♣ Pending prioritization
Areas to Consider♣ Provider
♣ Account
♣Operational/Claims
♣Operational/Customer Service
♣ Network/Provider Contract
♣ Training/Education
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 14.5 5/15/14 Release Scope
1/23/14
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣ Operational enhancements
♣ National Programs initiative support: PAD, Adjustment Modernization
Areas to Consider♣
Operational/Claims
♣Operational/Customer Service
♣ Training/Education
♣ Global Certification
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/30/14
Conversion Specifications
2/06/14
Implementation Milestones Global Certification Scenarios
2/27/14
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
4/03/14
LRM4/17/14
Configuration Guide DDLsDraft Deployment Notes
5/01/14
Scheduled Addendum1
8/28/14
Scheduled Addendum2
9/18/14
Implementation
10/19/14
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 15.0 11/06/14 Release Scope
7/17/14
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣ Additional data elements for custom reporting
♣ National Programs support
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/24/14
Conversion Specifications
7/31/14
Implementation Milestones Global Certification Scenarios
8/21/14
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/25/14
LRM10/02/14
Configuration Guide DDLsDraft Deployment Notes
10/23/14
Scheduled Addendum1
2/26/15
Scheduled Addendum2
3/19/15
Implementation
4/19/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 15.5 5/14/15 Release Scope
1/22/15
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣Maintenance Release
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/29/15
Conversion Specifications
2/05/15
Implementation Milestones Global Certification Scenarios
2/26/15
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
4/02/15
LRM4/09/15
Configuration Guide DDLsDraft Deployment Notes
4/30/15
Scheduled Addendum1
8/20/15
Scheduled Addendum2
9/10/15
Implementation
10/11/15
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 16.0 11/12/15 Release Scope
7/15/15
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/22/15
Conversion Specifications
7/29/15
Implementation Milestones Global Certification Scenarios
8/19/15
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/23/15
LRM9/30/15
Configuration Guide DDLsDraft Deployment Notes
10/21/15
Scheduled Addendum1
2/25/16
Scheduled Addendum2
3/17/16
Implementation
4/17/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 16.5 5/12/16 Release Scope
1/21/16
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/28/16
Conversion Specifications
2/04/16
Implementation Milestones Global Certification Scenarios
2/25/16
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
3/31/16
LRM4/07/16
Configuration Guide DDLsDraft Deployment Notes
4/28/16
Scheduled Addendum1
8/25/16
Scheduled Addendum2
9/15/16
Implementation
10/16/16
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 17.0 11/10/16 Release Scope
7/15/16
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
7/22/16
Conversion Specifications
7/29/16
Implementation Milestones Global Certification Scenarios
8/19/16
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
9/23/16
LRM9/30/16
Configuration Guide DDLsDraft Deployment Notes
10/21/16
Scheduled Addendum1
2/16/17
Scheduled Addendum2
3/16/17
Implementation
4/23/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPOR 17.5 5/11/17 Release Scope
1/19/17
♣ An optional solution that enables Plans to extract and load operational data to a local IPOR data mart and that supports the generation of daily reports for managing day-to- day National Programs business
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
♣ ♣
Business Requirements System Use Cases Functional Specification Supplemental SpecificationsRequirements Traceability Matrix
1/26/17
Conversion Specifications
2/02/17
Implementation Milestones Global Certification Scenarios
2/23/17
Draft Release Notes Draft Schemas Draft WSDLsDraft Software Log
3/30/17
LRM4/06/17
Configuration Guide DDLsDraft Deployment Notes
4/27/17
Scheduled Addendum1
8/24/17
Scheduled Addendum2
9/14/17
Implementation
10/15/17
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
IPDEX N/A Implementation N/A
♣ Centrally hosted software application that supports the secure transfer between Plans of data that are not related to individual claims payment
♣ IPDEX will be retired with the implementation of the CBF Modernization initiative in Release 15.0.
♣ None ♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Datanet Lite
(DNL) 14.5.1
8/28/14 Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ National Programs initiative support: PAD, Adjustment Modernization, PTS Sunset
♣Operational/Claims
♣Operational/Customer Service
♣ Training/Education
♣ None at this time
Datanet Lite
(DNL) 15.0
TBD Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Datanet Lite
(DNL) 15.5
TBD Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Datanet Lite
(DNL) 16.0
TBD Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Datanet Lite
(DNL) 16.5
TBD Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Datanet Lite
(DNL) 17.0
TBD Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Datanet Lite
(DNL) 17.5
TBD Implementation N/A
♣ Datanet Lite is an optional application that provides Plans with open inventory management reports and a National Programs Transactional Index Measurement Scorecard.
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Value- Based
Programs Care
Delivery Platform
2014Release
2
8/15/14
Note: This is the date that the software will be available to Plans in the Plan Validation Environment.
Implement ationVaries by Plan
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣Enhancements in support of Competitive Service Area restrictions
Areas to Consider♣ Provider
Reporting
♣ Claims Coding/Adjudication
♣ Care/Disease Management
♣Analytics/Informatics/ Data Warehouse
♣ None at this time
Value- Based
Programs Care
Delivery Platform
2014Release
3
10/17/14
Note: This is the date the software will be available to Plans in the Plan Validation Environment.
Implement ationVaries by Plan
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣Enhancements in support of state privacy regulations
♣ Phase one of the Master Member Index enhancement
Areas to Consider♣ Provider
Reporting
♣ Claims Coding/Adjudication
♣ Care/Disease Management
♣Analytics/Informatics/ Data Warehouse
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Value- Based
Programs Care
Delivery Platform
2014Release 4
11/28/14
Note: This is the date the software will be available to Plans in the Plan Validation Environment.
Implementation
Varies by Plan
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Internal BCBSA reports to track activity/volumes on the data exchange platform
♣ Purge process for data exchange platform
♣ Report portal for non- BHI Plans
Areas to Consider♣ Provider
Reporting
♣ Claims Coding/Adjudication
♣ Care/Disease Management
♣ Analytics/Informatics/ Data Warehouse
♣ None at this time
Value- Based
Programs Care
Delivery Platform
15.0
N/A Implementation
4/08/15
Note: The implementation date will align with the National Data Warehouse (NDW) release schedule.
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Value- Based
Programs Care
Delivery Platform
15.5
N/A Implementation
10/08/15
N o t e : T h e implementation d a t e w i l l align with the NDW release schedule.
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Value- Based
Programs Care
Delivery Platform
16.0
N/A Implementation
4/08/16
N o t e : T h e implementation d a t e w i l l align with the NDW release schedule.
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Value- Based
Programs Care
Delivery Platform
16.5
N/A Implementation
10/08/16
N o t e : T h e implementation d a t e w i l l align with the NDW release schedule.
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Value- Based
Programs Care
Delivery Platform
17.0
N/A Implementation
4/08/17*N o t e : T h e implementation d a t e w i l l align with the NDW release schedule.
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Release Release Date Mile
stones
Business Function
Contents Include
Plan Impact Areas
Hard/Software Mandates
Value- Based
Programs Care
Delivery Platform
17.5
N/A Implementation
10/08/17
N o t e : T h e implementation d a t e w i l l align with the NDW release schedule.
♣ Inter-Plan data transfer pipeline for sharing membership, claims and attribution results to enable Par/Host Plans to manage their local Value- Based Programs and Control/Home Plans to manage their national account member participation, account communication and billing
♣ Pending prioritization
♣ Pending prioritization
♣ None at this time
Appendix 2: Technology Platform Matrix
The National Programs Technology Platform Matrix provides a “one-stop” resource for cross-referencing the Technology Platforms for each National Programs initiative. For example, the matrix shows all initiatives that impact the BlueExchange® platform.
Initiative Name
Platform MatrixITS Blue
Squared
BlueExchange
PDR LDLA
BlueGuest
Plan Software
PoliciesNASCOBlueServNot Applicable
Other
Networks1. Blue Distinction®
Specialty Care Program
X X X
2. Blue Distinction®
Total Care
X X X X X
3. National Programs Care Management
X X
Cost1. PlanConnexion®
Collaborative Services (Voluntary)
X X X
2. Risk Adjustment
X X X
Products1. Consumer Transparency: National Consumer Cost Transparency
X
2. Reference-Based Benefits
X
3. Health Information Technology (HIT) Strategy (Voluntary)
X X
4. BlueCard for Public Exchange Products
X X X X X
Initiative Name
Platform MatrixITS Blue
Squared
BlueExchange
PDR LDLA
BlueGuest
Plan Software
PoliciesNASCOBlueServNot Applicable
Other
5. Office of Personnel Management (OPM) Multi-State Plan Program
X X X X
6. Transfer Program
X
Service
1. Inter-Plan Data Solutions (IPDS) Business Intelligence Development
X X
2. Provider Data Improvement
X X
3. Policy Review
X
Regulatory1. ICD-10
X X
2. Administrative Simplification
X X X X X
Index
AAdministrative Simplification ......... 2, 5, 49, 52, 104, 147Affordable Care Act (ACA). 5, 24, 33, 35, 36, 38, 39, 52,
61
BBlue Distinction 9Blue Distinction® Specialty Care Program . 2, 5, 8, 9, 10,
11, 12, 13, 19, 44, 55, 74, 104, 146Blue Distinction® Total Care ....................... 5, 12, 44, 74Blue Health Intelligence (BHI)......................... 9, 23, 142
Blue Physician Recognition (BPR) Program..... 3, 75, 82
BlueCard for Public Exchange Products.... 5, 25, 33, 35,104, 146
BlueExchange (BX) 3, 14, 19, 34, 36, 50, 53, 54, 61, 62,101, 123, 124, 125, 126, 146
BlueGuest ................................. 3, 54, 64, 101, 128, 146BlueSquared (Blue2) .... 3, 13, 19, 21, 34, 36, 42, 51, 53,
54, 55, 56, 57, 58, 59, 60, 65, 67, 68, 73, 84, 101,109, 110, 111, 112, 113, 114, 115, 146
Business Intelligence Development ......................59, 60
DDatanet Lite (DNL)........ 3, 54, 67, 71, 72, 138, 139, 140
EElectronic Provider Access ............................. 14, 16, 17 Enhanced National Programs Performance Scorecard................................................. 41, 71, 138, 139, 140
HHealth Care Reform4, 5, 6, 8, 13, 14, 18, 30, 33, 34, 36,
40, 49, 55, 57, 67, 70, 80Health Information Technology (HIT) Strategy ..2, 5, 25,
30, 31, 146Health Information Technology Strategy (HIT) .....30, 31 Healthcare Reform 80
IICD-10 ............................................ 2, 5, 49, 50, 51, 147
Integrated Health Management (IHM) 17Business Intelligence Development ....... 2, 40, 41, 147
Extract ............................................................ 3, 54, 59Inter-Plan Operational Reporting (IPOR)... 3, 41, 54, 56,
59, 67, 68, 71, 101, 131, 132, 133, 134, 135, 136,137
Inter-Plan Teleprocessing Services (ITS) .... 3, 9, 10, 13,16, 19, 21, 24, 34, 36, 42, 44, 46, 50, 51, 53, 54, 55,56, 57, 59, 60, 63, 65, 67, 68, 69, 73, 77, 78, 84,101, 102, 103, 104, 105, 106, 107, 108, 127, 128,
146
LLicensee Desk Level Audit (LDLA) 3, 41, 54, 56, 63, 75,
77, 101, 127, 128, 146Extracts .......................................................... 3, 75, 77
NNational Consumer Cost Tool (NCCT) 65
Technical Infrastructure 65National Consumer Cost Transparency (NCCT)2, 3, 10,
19, 25, 26, 27, 28, 29, 44, 54, 65, 75, 76, 79, 101,129, 130, 146
Data Submission to BCBSA ............................... 75, 79Technical Infrastructure.......................... 3, 54, 65, 101
National Programs Care Management ....... 2, 8, 14, 146 National Programs Strategic RoadmapBlue System Strategic Priorities ............................. 2, 4 BlueWeb ................................................................ 2, 6
Document Updates ................................................ 2, 6Executive Summary ............................................... 2, 4Overview ................................................................ 2, 4
OOffice of Personnel Management (OPM) Multi-State Plan Program............... 2, 5, 25, 35, 36, 37, 104, 147
PPatient Experience ........................................... 3, 75, 83
Payment Innovations .................................. 73, 101, 102Performance Tracking System (PTS) .. 3, 41, 42, 43, 68,
71, 72, 75, 78, 116, 138Extracts .......................................................... 3, 75, 78
Physician and Hospital Quality Measurement .. 3, 75, 80PlanConnexion ..................................................... 19, 22®
Inter-Plan Data Exchange (IPDEX).... 3, 54, 69, 70, 101,PlanConnexion
Collaborative Services 2, 5, 18, 19, 21,138
Inter-Plan Data Solutions (IPDS)2, 3, 13, 34, 40, 41, 42,43, 54, 56, 59, 60, 67, 71, 84, 101, 116, 117, 118,119, 120, 121, 122, 14722, 23, 24, 146
Policy Review ........................................... 2, 40, 47, 147Provider Data Format (PDF).. 3, 44, 55, 75, 76, 84, 103,
104Provider Data Improvement...................... 2, 40, 44, 147Provider Financial Responsibility.................... 14, 16, 17
RReference-Based Benefits.................. 2, 25, 28, 29, 146Risk Adjustment........................ 2, 5, 18, 23, 24, 44, 146
SSoftware Standards ................................................3, 84
TTechnology Implementation Plan............ 3, 54, 101, 102Technology Platform Matrix ..................................3, 146
TimelinesNational Programs Initiatives ............................... 3, 86
Technology Platform Releases 91Transfer Program ........................... 2, 5, 25, 38, 39, 147
VValue-Based Programs Care Delivery Platform .... 3, 13, 19, 44, 54, 55, 73, 80, 101, 102, 103, 110, 141, 142,
143, 144, 145
