Title
a. Approve and authorize execution by the Director of Health of Electronic Data Interchange ("EDI") Provider Trading Partner Agreement, authorizing Gateway EDI to receive County of Monterey d/b/a/ Monterey County Health Department Laboratory ("County Laboratory") claim files of TRICARE beneficiaries for submission to PBGA, L.L.C.; and
b. Approve and authorize execution by the Director of Health of Addendum to ERA Enrollment Form for Billing Services and Clearinghouses between County of Monterey d/b/a Monterey County Health Department Laboratory and PGBA, LLC, authorizing Gateway EDI to receive Electronic Remittance Advices ("ERAs") in connection with County Laboratory claim files of TRICARE beneficiaries for submission to PBGA, L.L.C; and
c. Approve and authorize execution by the Director of Health of Medi-Cal Telecommunications Provider and Biller Application/Agreement, authorizing Gateway EDI to receive County Laboratory claim files of Medi-Cal beneficiaries for submission to the California Department of Health Care Services; and
d. Approve and authorize execution by the Director of Health of Medi-Cal Telecommunications Provider and Biller Application/Agreement, authorizing Gateway EDI to receive 835-Transaction Data in connection with County Laboratory claim files of Medi-Cal beneficiaries submitted to the California Department of Health Care Services; and
e. Approve and authorize execution by the Director of Health ERA Enrollment Form, authorizing Gateway EDI to receive ERAs in connection with County Laboratory claim files of Anthem Blue Cross beneficiaries; and
f. Approve and authorize execution by the Director of Health of Provider Authorization Form Electronic Payment Information, authorizing Gateway EDI to receive ERAs in connection with County Laboratory claim files of Blue Shield of California beneficiaries; and
g. Approve and authorize execution by the Director of Health, subject to County Counsel approval, of additional written authorization forms, authorizing Gateway EDI to receive County Laboratory claim files of beneficiaries of other health plans and payers. This delegation expires June 30, 2019.
Report
RECOMMENDATION:
It is recommended that the Board of Supervisors:
a. Approve and authorize execution by the Director of Health of Electronic Data Interchange ("EDI") Provider Trading Partner Agreement, authorizing Gateway EDI to receive County of Monterey d/b/a/ Monterey County Health Department Laboratory ("County Laboratory") claim files of TRICARE beneficiaries for submission to PBGA, L.L.C.; and
b. Approve and authorize execution by the Director of Health of Addendum to ERA Enrollment Form for Billing Services and Clearinghouses between County of Monterey d/b/a Monterey County Health Department Laboratory and PGBA, LLC, authorizing Gateway EDI to receive Electronic Remittance Advices ("ERAs") in connection with County Laboratory claim files of TRICARE beneficiaries for submission to PBGA, L.L.C; and
c. Approve and authorize execution by the Director of Health of Medi-Cal Telecommunications Provider and Biller Application/Agreement, authorizing Gateway EDI to receive County Laboratory claim files of Medi-Cal beneficiaries for submission to the California Department of Health Care Services; and
d. Approve and authorize execution by the Director of Health of Medi-Cal Telecommunications Provider and Biller Application/Agreement, authorizing Gateway EDI to receive 835-Transaction Data in connection with County Laboratory claim files of Medi-Cal beneficiaries submitted to the California Department of Health Care Services; and
e. Approve and authorize execution by the Director of Health ERA Enrollment Form, authorizing Gateway EDI to receive ERAs in connection with County Laboratory claim files of Anthem Blue Cross beneficiaries; and
f. Approve and authorize execution by the Director of Health of Provider Authorization Form Electronic Payment Information, authorizing Gateway EDI to receive ERAs in connection with County Laboratory claim files of Blue Shield of California beneficiaries; and
g. Approve and authorize execution by the Director of Health, subject to County Counsel approval, of additional written authorization forms, authorizing Gateway EDI to receive County Laboratory claim files of beneficiaries of other health plans and payers. This delegation expires June 30, 2019.
SUMMARY/DISCUSSION:
The Monterey County Health Department (MCHD) seeks to enter into an agreement to allow Gateway EDI to act as the medical clearinghouse of County Laboratory claims for submission to payers. A written authorization to act as the clearinghouse of claims submitted to payers, such as Medi-Cal, PBGA, L.L.C., Blue Cross, and Blue Shield must be signed. In some cases, a written authorization is required to permit the clearinghouse to receive Electronic Remittance Advices, or ERAs, electronic version of payment explanations detailing a providers' claims payment or, if the claims are denied, explanations of the denials.
The Board of Supervisors (BOS) approved in November 2007, Agreement #A-11307 between MCHD and Oregon Community Health Information Network (OCHIN) for the operation of an Electronic Medical Record (EMR) system for its Clinic Services Division. Since that time MCHD has gone back before the BOS for approval of additional amendments that increased funding and broadened services. MCHD's Regional Teams and TB Unit, as well as its County Laboratory now utilize OCHIN's services.
OCHIN, a collaboration of community and public health clinics in Washington, Oregon, and California joined together to participate in the operation of an Epic Practice Management (PM) and EMR system, which includes billing capabilities and electronic remittance for claims for payment to payors, such as those listed in the "Subject" of this report. OCHIN entered into an agreement with Epic Systems Corporation by which OCHIN has obtained certain rights to practice management and EMR software. MCHD has access to these services through membership (contracting) with OCHIN. Membership in OCHIN provides access to an industry leading electronic medical record system, EPIC, that the County could neither acquire nor operate separately. OCHIN contracts directly with Gateway EDI who acts as the clearinghouse for medical claims.
Gateway EDI, a wholly owned subsidiary of TriZetto Corporation, is a medical claims clearinghouse that accepts claims from providers and then submits those claims to payers electronically. Gateway EDI also checks claims for errors before sending them to payers. This gives providers a chance to correct mistakes early in the process.
The claims process follows these steps:
•Providers send their claim files to Gateway EDI
•Claims are checked for missing or incorrect information using Gateway EDI's proprietary editing process
•Claims that pass the Gateway EDI editing process are translated into a HIPAA-compliant ANSI format and then sent to payors
•Claims that do not pass the editing process are returned to the provider, with a list of needed corrections; providers can then correct and resubmit these claims
Gateway's Electronic Remittance Advice allows for remits to be received by the County Laboratory directly (through EPIC system), eliminating the need for data entry or filing. Advantages are: 1) Instant data in standard formats. Live data in ANSI 835 or National Standard Format (NSF), reducing paperwork; 2) Reports are tailored to fit the County Laboratory needs; 3) The system automatically creates secondary claims and links them, so the County Laboratory will always have the latest updates for posting payments. The entire process provides instant access to properly organized and formatted electronic remittance, providing fewer errors and better efficiency.
OTHER AGENCY INVOLVEMENT:
County Counsel reviewed the agreements and authorizations and recommended seeking Board of Supervisors approval due to non-standard language. County Risk Manager has reviewed but not approved the agreements and authorizations, which lack the County's standard insurance and indemnification requirements. County Auditor-Controller has reviewed the agreements and authorizations and understands that County contracts with OCHIN and payment for these services will be through OCHIN directly to Gateway EDI. PBGA, L.L.C. on file with the Clerk of the Board; Addendum PBGA, L.L.C (for ERAs) on file with the Clerk of the Board; California Department of Health Care Services on file with the Clerk of the Board; California Department of Health Care Services - 835-Transaction Data on file with the Clerk of the Board ; Anthem Blue Cross on file with the Clerk of the Board; Blue Shield of California on file with the Clerk of the Board
FINANCING:
MCHD contracts with OCHIN. OCHIN in turn will pay for these Agreements. MCHD anticipates paying OCHIN approximately $4,500.00 per year for these services. There are sufficient appropriations included in the Health Department's (HEA003-8124) Adopted Budget for Fiscal Year 2013-14 for this Agreement.
Prepared by: Kathy Robinson, Management Analyst II, 1286
Approved by: Ray Bullick, Director of Health, 4526
Attachments:
PBGA, L.L.C. on file with the Clerk of the Board
Addendum PBGA, L.L.C (for ERAs) on file with the Clerk of the Board
California Department of Health Care Services on file with the Clerk of the Board
California Department of Health Care Services - 835-Transaction Data on file with the Clerk of the Board
Anthem Blue Cross on file with the Clerk of the Board
Blue Shield of California on file with the Clerk of the Board