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Administrative Simplification

MAHP and its Member Health Plans are committed to Administrative Simplification and have been collaborating with Blue Cross and Blue Shield of Massachusetts (BCBSMA), the Massachusetts Hospital Association (MHA), the Massachusetts Medical Society (MMS), and various provider groups in order to streamline health plan administrative processes.

 

To date, these collaborative efforts have resulted in the following achievements:

 

Credentialing

  • The establishment of a standardized process for physician credentialing by Massachusetts health plans and hospitals.
  • The development of a uniform credentialing application used by physicians, MA health plans and MA hospitals.
  • Commitment by MA health plans to process 95% of complete initial applications within 30 days and communicate regularly with physicians on their application status.
  • In January 2005, Massachusetts health plans founded Health Care Administrative Solutions (HCAS) in order to collaborate on administrative simplification initiatives.
  • HCAS currently serves as the single point-of-entry for providers to submit credentialing information used by HCAS and participating health plans to verify a provider’s qualifications.  Please visit the HCAS website for more information.

 

Coding

A statewide advisory committee has been formed, comprised of various state agencies, legislators from the House and Senate, MAHP, MMS, MHA, BCBSMA, the Massachusetts Health Information Management Association (MaHIMA), the Massachusetts Health Data Consortium (MHDC), America's Health Insurance Plans (AHIP), and a MassHealth contracted managed care organization.

 

This advisory committee has worked on the adoption, implementation and compliance with the Health Insurance Portability and Accountability Act (HIPAA) compliant code sets; the International Classification of Diseases (ICD); the American Medical Association's Current Procedural Terminology codes, reporting guidelines and conventions; and the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System.

 

Massachusetts Health Care Administrative Simplification Collaborative

  • In 2009, MAHP and its Member Health Plans, BCBSMA, MHA, and MMS joined the Employers Action Coalition on Health Care’s Administrative Simplification Collaborative.

 

2009 – 2010 Initiatives

  • The collaborative identified eligibility verification, duplicate claims denials, provider claims appeals, and payer medical policies as high priority items for 2009 and 2010.
  • On March 15, 2010, HCAS, on behalf of the collaborative, launched an eligibility verification training website for providers.  The eligibility provider tools may be viewed using the following link:  Eligibility Tools & Resources.
  • The majority of MA based health plans and MassHealth have agreed to implement the Council for Affordable Quality Healthcare’s (CAQH) Committee on Operating Rules for Information Exchange (CORE) Name Normalization Rule for eligibility verification transactions by January 1, 2012 to coincide with the HIPAA 5010 implementation.

 

2011 Initiatives

  • Priorities for 2011 include the implementation of a universal provider claims appeals form, credentialing, prior authorizations and referrals, and HIPAA 5010 implementation coordination with payers and providers.
  • More information on the universal provider claims appeals form will be provided as it becomes available.