Best Practice Recommendations Overview
Washington State Law (SB 5346) And Federal Law (HIPAA) call for a variety of "solutions" (guidelines, standards, processes, etc.) to simplify health care
administration. As the entity responsible for promoting voluntary adoption, OneHealthPort will apply the
Best Practice Recommendation (BPR) model to deliver these solutions. A BPR is a better way to get
things done that's pragmatic and works for everyone. It is not about just simplifying or standardizing current work
flow or technology practices, the whole emphasis is moving the industry to best workflow and technology practices.
A BPR:
- Can describe policy, procedures, workflow practices and information exchange standards
- Is biased toward electronic solutions as opposed to paper-based and manually intensive processes
- Will leverage national standards where possible
BPRs are developed in a work group process. Key steps in this process include:
- The Washington Healthcare Forum Board sets strategic focus. For those areas covered under SB 5346, the Forum works collaboratively with the Office of the Insurance Commissioner.
- OneHealthPort staff scopes larger issues with community input and validates the scope with the OneHealthPort Board of Directors
- A call for participation goes out to interested representatives from payers and providers for:
- A Work Group - subject matter experts who meet in person at least monthly to develop specific BPRs, membership
limited to 20-25 (includes OIC). Some work groups are currently full.
- A Stakeholder Group - subject matter experts, virtual discussion, comments on draft BPRs. If you are
interested in participating in a Stakeholder Group and you'd like to hear more, please click here.
- The Work Group finalizes the BPR based on Stakeholder feedback. The adopted BPR is posted on the OneHealthPort web site and publicized.
- As the BPR is implemented and adopted, it goes through a continuous quality improvement process of measurement, assessment, refinement and ongoing adoption.
The BPR model also recognizes that while a collaborative community process develops the solution, implementation occurs at
the individual enterprise level.
The chart below indicates the BPRs that have been developed. If SB5346 applies to the BPR, the appropriate section is indicated.
BPR
|
Summary Explanation
|
SB 5346 Section
|
BPR Links
|
| Eligibility & Benefits |
| Requesting and Receiving Coverage Information for Eligibility and Benefits (HIPAA 270-271)
| Defines the set of eligibility and benefits information to be made available on health plan web sites and within the HIPAA 270-271 transaction set.
| Section 8 (1)
|
BPR
|
| Prospective Review |
| Browser Capabilities for Pre-Authorization & Admission Notification
| Defines pre-authorization and admission notification information and related capabilities to be made available on health plan web sites.
| Section 10 (1) (c)
|
BPR
|
| Extenuating Circumstances around Pre-Authorization & Admission Notification
| Identifies situations where obtaining a pre-authorization is extremely difficult if not impossible. Outlines practices to be followed by provider organizations and health plans when these situations arise so that claims will not be denied for lack of pre-authorization.
| Section 10 (1) (a) (i)
|
BPR |
| Standard Notification Timeframes for Pre-Authorization Requests
| Defines standard timelines for health plan processing of pre-authorization requests from providers and for providers to submit requested documentation to health plans.
| Section 10 (1) (a) (ii)
| BPR
|
| Claims Processing |
| Claim Coding Policy and Edits: Standardization & Transparency
| Calls for adoption of national correct coding initiative (NCCI) edit policies and Medicare Physician Fee Schedule Database (MPFSDB) indicators by health plans and provider organizations.
| Section 9 (1) (a, b)
|
BPR
|
| Creating and Receiving the Health Care Claim Acknowledgement (HIPAA 277CA)
| Outlines best practices to be followed by payers when confirming receipt of a batch of 837 claims. This notification is prior to claim adjudication so that it will not contain any processing information.
|
|
BPR
|
| Reconsideration of a Health Plan's Policy Regarding Code Edits
| Outlines practices to be followed:
- by provider organizations when requesting a health plan to reconsider their policy about a specific code edit and
- by health plans when processing and responding to those requests.
(Note: This BPR is related to policy changes and not specific claims)
| section 9 (1)(e)
| - BPR
|
|
| Submitting & Processing Claims(HIPAA 837)
| Outlines best practices to be followed by providers when submitting claim.
|
| BPR
|
| Electronic Processing of Corrections to Institutional Claims(HIPAA 837I)
| Outlines practices for submitting corrected claims (using the HIPAA 837 transaction) that will reduce the number of situations when corrected Institutional claims are denied as duplicates.
| Section 9 (1) (d)
|
BPR
|
| Electronic Processing of Corrections to Professional Claims(HIPAA 837P)
| Outlines practices for submitting corrected claims (using the HIPAA 837 transaction) that will reduce the number of situations when corrected Professional claims are denied as duplicates.
| Section 9 (1) (d)
|
BPR
|
| Exchanging Explanation of Payment Information between Providers and Health Plans(HIPAA 837 & 835)
| Outlines practices to be followed by health plans and providers when creating and processing claims for patients that have more than one source of health care coverage. It also defines how the 837 Claims transaction and the 835 Payment/Advice transaction should be used to exchange Coordination of Benefits information between provider organizations and health plans.
|
|
BPR
| Requesting and Receiving Claims Status Information(HIPAA 276-277)
| Defines the set of claims status information to be made available on health plan web sites and within the HIPAA 276-277 transaction set.
|
| BPR
|
| Processing & Reporting Remittance Information(HIPAA 835)
| Outlines best practices to be followed by payers when creating an electronic Remittance Advice.
|
| BPR
|
| Standard Coding of Denials and Adjustments in the HIPAA 835 Remittance Advice Transaction(HIPAA 835)
| Identifies common business reasons for adjusting/denying a claim and recommends the specific HIPAA codes to be reported by health plans on the 835 Remittance Advice transaction when adjusting/denying a claim for those business reasons.
| Section 9 (1) (c)
| BPR
|
|
