Facets and Health Insurance Lines of Business

Now-a-days health care market is very challenging. Health care payer organizations need such a tool that supports multiple lines of business and complex products offerings. TriZetto’s Facets system is a great answer for all the challenges that the complex health care market pose. The Facets system contains broad functionality to serve a wide range of lines of business from commercial to government programs to specialty.

The Facets system provides a comprehensive solution that supports the administration of each of insurance company's  business line on one integrated platform. Lines of business that can be serviced through Facets are:

Commercial Business Lines	Govt. Programs	Special Business lines
Large Group	Medicare Advantage	Behavioral Health
Small Group	Medicaid	Dental
Family/Individual	Medicare Part D	Disability
Consumer-Directed	Medicare Supplemental	Vision

Group: In Facets, members/subscriber belongs to a group. A Group is a logical collection of subscribers/members who are treated as a single unit.

Consumer-Directed Health Plan: Consumer-Directed Health Plan (CDHP) means offering a high-deductible health plan paired with a spending account for out-of-pocket costs such as a Health Savings Account (HSA) or Integrated Health Reimbursement Arrangement (HRA). What all CDHPs have in common is a personal healthcare account used to pay for medical expenses.

Medicare:

A federal health insurance program for people 65 and older and certain younger people with disabilities. It also covers people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Original Medicare:

Original Medicare is a fee-for-service health plan that has two parts: Part A (Hospital Insurance) and Part B (Medical Insurance).

Medicare Advantage

Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare to provide policy holders with all their Part A and Part B benefits. It is known as Medicare Part C.  Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. Most Medicare services are covered through the plan that aren’t paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.

Medicare Part D

A program that helps pay for prescription drugs for people with Medicare who join a plan that includes Medicare prescription drug coverage.

Medicare Supplemental:

Medicare Supplemental  Insurance policy known as Medigap is a policy that is sold by private companies. It can help pay some of the health care costs that Original Medicare doesn't cover like copay, coinsurance, and deductibles.

Medicaid:

Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, like nursing home care and personal care services. Each state has different rules about eligibility and applying for Medicaid.

Behavioral Health Services:

Behavioral Health Services are needed when depression, changes in eating and sleeping habits, sudden poor performance in work, avoiding tendency, anxiety, suicidal tendency, feelings of worthlessness or guilt, hopelessness, lack of motivation and enthusiasm ,etc. are visible in a person's life.

CT Colonograpy/Virtual Colonoscopy & Cologuard in Grandfathered Health Plans

The Affordable Care Act is the demarcation line between Grandfathered health plans and Non-grandfathered health plans. A Grandfathered health plan is a  group health plan that was created—or an individual health insurance policy that was purchased—on or before March 23, 2010. March 23, 2010 is the effective date of the Affordable Care Act.

Grandfathered plans are exempted from many changes required under the Affordable Care Act. For example, preventive care/wellness benefit is not free in grandfathered plans. There is no limit on out-of-pocket maximums in grandfathered plan. On the other hand, preventive care is free in non-grandfathered plans. There are limitations on out-of-pocket maximums in non-grandfathered plan.

CT Colonograpy & Cologuard screenings are not mandatory in Grandfathered Health Plans. But if a health plan under grandfathered plan covers colorectal cancer screenings as a wellness benefit, this benefit will include coverage for CT Colonograpy and Cologuard. In that case, scenarios will be as follows:

Typical Scenario for CT Colonograpy or Virtual Colonoscopy:

Benefit Limit: Once in every 5 years

Place of Treatment: As defined by the health insurance companies

Age Limit: 50-75 years or 76-85(network providers)

Claim will apply contract benefits. In case of members aged 76-85, prior authorization is required. Claims for members aged less than 50 or greater than 85 will be denied.

CPT4 and Diagnosis codes: Specific CPT4 and Diagnosis codes will have to be used. Otherwise, claim will be denied.

Providers: Specific provider types as defined by the health insurance companies will have to be used.

In case of out-of-network providers, claim will apply out-of-network contract benefits.

Typical Scenario for Cologuard:

Benefit Limit: Once in every 3 years

Place of Treatment: As defined by the health insurance companies

Age Limit: 50-75 years or 76-85(network providers)

Claim will apply contract benefits. In case of members aged 76-85, prior authorization is required. Claims for members aged less than 50 or greater than 85 will be denied.

CPT4 and Diagnosis codes: Specific CPT4 and Diagnosis codes will have to be used. Otherwise, claim will be denied.

Providers: Specific provider types as defined by the health insurance companies will have to be used.

In case of out-of-network providers, claim will apply out-of-network contract benefits.

Age: 50-75 years or 76-85(network providers)

Claim will apply contract benefits. In case of members aged 76-85, prior authorization is required. Claims for members aged less than 50 or greater than 85 will be denied.

CPT4 and Diagnosis codes: Specific CPT4 and Diagnosis codes will have to be used. Otherwise, claim will be denied.

Providers: Specific provider types as defined by the health insurance companies will be have to used.

In case of out-of-network providers, claim will apply out-of-network contract benefits. 

Features of EDI 837P- Part IV

HL Segment:

HL stands for  Hierarchical Level. The HL segment is used to identify levels of detail information using a hierarchical structure, such as relating line-item data to shipment data, and packaging data to line-item data. HL Segment  indicates Hierarchical Level of Provider, Subscriber or Patient.  This is why this segment is followed by PRV segment or SBR segment or PAT segment.

Hierarchical ID is a unique number assigned by the sender to identify a particular data segment in a hierarchical structure. The first HL01 within each ST-SE envelope must begin with "1", and be incremented by one each time an HL is used in the transaction. Only numeric values are allowed in HL01.

First HL segment code example:

HL*1**20*1~ (BILLING PROVIDER)

1 = HL sequence number

**(blank)= there is no parent HL (characteristic of the billing provider HL)

20 = information source

1 = there is at least one child HL to this HL

First HL segment is followed by PRV segment. Sample PRV segment-

PRV*BI*PXC*207ND0900X~

PRV01=BI refers to  Billing

PRV02=PXC refers to Health Care Provider Taxonomy code identifier.

PRV03=207ND0900X refers to Provider's Taxonomy code

Note: Taxonomy code refers to the provider type and area of specialization for health care providers. Each taxonomy code is a unique ten character alphanumeric code that enables providers to identify their specialty at the claim level. The taxonomy code 207ND0900X means Dermatology

Second HL segment code example:

HL*2*1*22*1~(SUBSCRIBER)

2 = HL sequence number

1 = parent HL

22 = subscriber

1 = there is at least one child HL to this HL.

Second HL segment is followed by SBR segment. Sample SBR segment-

SBR✽P✽18✽GRP01020102✽✽✽✽✽✽BL~

SBR01=Payer Responsibility Sequence Number Code, P=Primary. S=Secondary, T= Tertiary, A=Payer Responsibility Four

SBR02=Individual Relationship Code, 18=self

SBR03= policy or group number

SBR09=Code identifying type of claim, BL = Blue Cross/Blue Shield

Some other examples:

AM= Automobile Medical, BL=Blue Cross/Blue Shield, CH=Champus, CI=Commercial Insurance Co., DS=Disability, FI=Federal Employees Program, HM=Health Maintenance Organization, LM =Liability Medical, MA=Medicare Part A, MB= Medicare Part B, MC= Medicaid, OF=Other Federal Program, it is usually used for Medicare Part D claims, TV= Title V, VA=Veterans Affairs Plan, WC=Workers’ Compensation Health Claim, ZZ= Mutually Defined, Use Code ZZ when Type of Insurance is not known.

Third HL segment code example:

HL*3*2*23*0~(PATIENT)

3 = HL sequence number

2 = parent HL

23 = dependent

0 = no subordinate HLs in this HL (there is no child HL to this HL - claim level data follows)

Third HL segment is followed by PAT segment. Sample PAT segment-

PAT*19~

PAT01= Specifies the patient’s relationship to the person insured.

Some Relationship code examples-

01=Spouse, 19=Child, 20=Employee, 21=Unknown, 3= Organ Donor, 53=Life Partner, G8=Other Relationship

Cost Sharing in Health Insurance & Facets-Part II

Principal Stake holders of Cost Sharing:
1. Plan Sponsor
2. Plan holder or Policy Holder.
3. Business Team
4. Technical Team
5. Testing Team
6. Providers.

Typical Simple Scenario 1:

Individual Health Plan(Network Providers)

Plan Year:1-1-2016 to 12-1-2016

Plan Year Deductible: $1000

Coinsurance:50%-50%

Copay for Specialist visit: $100

Out-Of-Pocket Maximum:$2000

Special Note: Deductible, coinsurance, copay will be counted towards out-of-pocket amount.

1-1-2016: The plan-holder(patient) goes to  a specialist doctor. The doctor's allowable charge is $500 including copay. In this case, deductible amount will be $400. No coinsurance will be applied here. Out-of-pocket amount will be $500.

2-1-2016: The plan-holder(patient) goes to  another specialist doctor. The doctor's allowable charge is $400 including copay. In this case, deductible amount will be $300. No coinsurance will be applied here. Out-of-pocket amount will be $400.

3-1-2016: The plan-holder(patient) goes to another specialist doctor. The doctor's allowable charge is $400 including copayment. In this case, deductible amount will be $300. No coinsurance will be applied here. Out-of-pocket amount will be $400.

During these three visits total deductible amount will be $400 +$300+$300=$1000. So plan's deductible limit $1000 is met here. So from the 4th visit no deductible will be applied. Now plan will start paying as per contract. Total out-of-pocket for these three visits will be $500+ $400+$400=$1300

4-1-2016: The plan-holder(patient) goes to another specialist doctor. The doctor's allowable charge is $700 including copay. In this case, there will be no deductible. As coinsurance rate is 50%-50%, the insurance company will pay 50% of $600, that is, $300. This is known as benefit. This benefit will not be counted towards out-of-pocket.

The remaining 50% of $600, that is, $300 will be paid by the policy-holder.  In this visit, copay $100+coinsurance $300 , that is, $400 will be counted towards out-of-pocket amount.

Total out-of-pocket for these four visits will be $500+ $400+$400+$400=$1700.00

5-1-2016: The plan-holder(patient) goes to another specialist doctor. The doctor's allowable charge is $400 excluding copay. As coinsurance rate is 50%-50%, the insurance company will pay 50% of $400, that is, $200. This is known as benefit. This benefit will not be counted towards out-of-pocket. The remaining 50% of $400, that is, $200 will be paid by the policy-holder.  In this visit, copay $100+coinsurance $200, that is, $300 will be counted towards out-of-pocket amount.

Total out-of-pocket for these five visits will be $500+ $400+$400+$400+$300= $2000.00. As total out-of-pocket maximum limit of the health plan is $2000.00, so there will be no coinsurance for the next visits. The policy holder or patients will not spend any money from his pocket during this plan year.

6-1-2016: The plan-holder(patient) goes to another specialist doctor. The doctor's allowable charge is $400. As total out-of-pocket maximum limit $2000.00 is met in 5th visit, so the insurance company will pay 100% of the total cost, that is, $400.

Facets can make cost sharing calculations very accurately. You can check it manually. Enter claim data in facets and process the claim, facets will show you copay, deductible, coinsurance  and out-of-pocket as per the policy holder's health plan's covered benefits.

Cost Sharing in Health Insurance & Facets-Part I

Cost sharing in a health insurance plan means the share of costs the policy-holder pays out of his own pocket for covered benefits in a policy period. This generally includes deductible, coinsurance, copay, out-of-pocket maximum. Typically cost sharing does not apply to Premiums, uncovered costs, or balance billing.

When a policy holder enrolls himself in a health insurance plan, the concerned health insurance company sends the policy holder Benefit Summary of the health plan. From this Benefit Summary, the policy holder knows what are covered and non-covered. It will also say what are deductible, coinsurance, copayment and out-of-pocket.

Copay generally means the policy holder's cost for a doctor or a hospital visit. Deductible means the policy holder's cost before the health plan starts to pay. Coinsurance means policy holder's cost sharing after the deductible is met. Out-of-pocket maximum means the maximum amount the policy holder has to pay for covered services in a plan year. After he spends this amount on deductibles, copay, and coinsurance, his health plan pays 100% of the costs of covered benefits.

Premium means the amount the policy holder pays for his health insurance every month. Balance Billing means a bill that the provider  bills for the difference between the provider’s charge and the allowed amount. For example, if the provider’s charge is $200 and the allowed amount is $150, the provider may bill the policy holder for the remaining $50. This $50  bill is the example of balance billing.  

I will give  one very simple example of cost sharing in Part II . Complex examples will be given in some separate postings.

Facets Commission Application Group

The insurance business is unthinkable without commissions. Every insurance company has agents and brokers who sell its products to a health plan’s policyholders. In return, they are given commissions. Facets Commission application group allows Health care provider organizations to define and maintain detailed commission information for these agents and brokers. They can identify individual and group entities and record common information such as licensing, professional history and carrier affiliations, as well as detailed indicative and demographic information. They can also establish commission arrangements, which define the methods, assignments, schedules and agreements used to calculate and pay commission entities. Some of the applications of the Commission application group are as follows:

1. Affiliated Carrier

2. Commission Adjustments

3.  Commission Arrangement

4.  Commission Entity Inquiry

5. Commission Inquiry

6. Commission Schedule

7. Commission Summary

8. Common Commission Entity

Features of EDI 837P- Part III

BHT Segment:

BHT*0019*00*565743*20110523*154959*CH~

This segment conveys the electronic transmission status of the 837 batch contained in this ST-SE envelope(BHT02). Here 00 for original and 18 for reissue. This segment also contains Reference identification for tracking purpose(BHT03), Current Date(BHT04), Current Time(BHT05) and Transaction type(BHT06)- CH for service claims and RP for reporting encounters.

NM1 Segment:

NM1*41*2*SAMPLE INC*****46*496103~

NM1 refers to an organization, a physical location, property or an individual. So to determine whether NM1 Segment is the submitter Segment(41) or the receiver Segment(40) or the billing provider Segment(85) or the referring provider Segment(DN) or the rendering provider Segment(82)  or some other Segment, we have to check the value of NM101.

Most of the time NM1 Segment is the beginning of a loop. So it may be followed by other segments like PER Segment (EDI Contact Name), N3 Segment (Street address), N4 Segment (City, State and zip code), etc.

Segment		NM101 Meaning		Name of the Loop
NM1*41*2	Submitter Identifier Code		1000A loop
NM1*40*1	Receiver Identifier Code		1000B loop
NM1*85*2	Billing Provider  Identifier Code		2010AA loop
NM1*87*1	Pay To_Provider Identifier Code		2010AB loop
NM1*IL*2	Insured or Subscriber's Identifier Code		2010BA loop
NM1*PR*1	Payer Identifier Code		2010BB loop
NM1*DN*2	Referring Provider Identifier Code		2310A loop
NM1*82*2	Rendering Provider  Identifier Code		2310B loop
NM1*77*2	77- Service Location  Identifier Code		2310C loop

If NM101=1, it indicates Person and if NM101=2, it indicates Non-Person Entity.