OneHealthPort

Best Practice Recommendations Overview

SB 5346 calls for a variety of "solutions" (guidelines, standards, processes, etc.) to simplify health care administration. As the entity responsible for promoting voluntary adoption, the WorkSMART Institute 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. While most BPRs are being designed for SB 5346, some BPRs will address simplification opportunities not covered under SB 5346.

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.

WorkSMART 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). 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 WorkSMART 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 WorkSMART 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. The Chart notes whether the BPR has been "Finalized" and is the latest published version or is "Collecting Stakeholder Feedback" on a near final draft form. If the BPR applies to SB 5346 the sections of the bill the BPRs are related to are also noted:

BPRs related to Sb 5346

Status	Best Practice Recommendation	Summary Explanation	SB 5346 Section
Finalized	BPR - Reconsideration of a Health Plan's Policy Regarding Code Edits Process14	Outlines practices to be followed: a) by provider organizations when requesting a health plan to reconsider their policy about a specific code edit and b) by health plans when processing and responding to those requests."	section 9 (1)(e)
Finalized	COB - Exchanging Explanation of Payment Information between Providers and Health Plans	This document provides recommendations for how health plans and providers should process claims in situations where a patient has more than one source of health care coverage. It defines how the 837 Claims transactions and the 835 Payment/Advice transaction should be used to exchange Coordination of Benefits information between provider organizations and health plan.	n/a
Finalized	Requesting and Receiving Coverage Information for Eligibility and Benefits	Guides electronic exchange of eligibility and benefits information between providers and payers - Batch and web formats	Section 8 (1)
Finalized	Extenuating Circumstances Around Pre-Authorization & Admission Notification	Guides payers and providers in responding to extenuating circumstances that may complicate requests for pre-authorization and admission notifications	Section 10 (1) (a) (i)
Finalized	Electronic Processing of Corrections to Professional Claims	Implementation of this recommendation should reduce the number of situations when corrected Professional claims are denied as duplicates.	Section 9 (1) (d)
Finalized	Electronic Processing of Corrections to Institutional Claims	Implementation of this recommendation should reduce the number of situations when corrected Institutional claims are denied as duplicates.	Section 9 (1) (d))
Pending WAC Changes	Standard Notification Timeframes for Pre-Authorization Requests	Defines standard timelines for payer processing of pre-authorization requests from providers and for document submission to health plans by providers	Section 10 (1) (a) (ii)
Finalized	Browser Capabilities for Pre-Authorization & Admission Notification	Guides implementation and adoption of browser based tools by WorkSMART Institute, payers and providers to simplify processing of pre-authorization and admission notifications	Section 10 (1) (c)
Finalized	Claim Coding Policy and Edits: Standardization and Transparency	Guides implementation and adoption of national correct coding initiative (NCCI) edit policies and Medicare Physician Fee Schedule Database (MPFSDB) indicatprs policies by payers and providers.	Section 9 (1) (a, b)
Finalized	BPR - Standard Coding of Denials and Adjustments in the 835RA	Identifies common business reasons for adjusting/denying a claim and recommends the specific HIPAA codes to be reported on the 835 Remittance Advice by health plans when adjusting/denying a claim for those business reasons.	Section 9 (1) (c)