Health Plan Data Strategy IT Subcommittee

Project Decisions and PAC Recommendations

Description
Item

HP327

Project Details

(Project Overview Scope of IMS Work Solution Approach)

MLO 2014 Releases

Program Overview:

Sponsors:

This request is for this existing MSP OCI file to be executed against Foundation System M-Set (test environment) in order to conduct regression testing for the
Medicare Business Engine (MBE) California (CA) Pharmacy downstream testing.

Daniel McDermott

HPDW PM / Contact:

IMS Work Scope:

Execute the existing MSP OCI job against FS M-Set for MBE CA Pharmacy regresssion testing

Prasanth Jadaprolu
IT PM / Contact:
NA
Regions:
Other - See Comments
ETL Technology:
Informatica
Data Source:
External Source - See
Comments
Data Target:
CDW
Data Delivery Method:
Save to Database

Solution Approach:
Execution of the existing MSP OCI job against FS M-Set
Save the resulting extract to the predetermined mainframe location

Plan Data Strategy IT Subcommittee

Decisions and PAC Recommendations
2014
HPDW Cost

Funding Source

Hours
156

Comments
$$

14,352

Requested Go-Live Date:

9/2/13
Regulatory:

Regions: California,
Hawaii, MAS, Ohio
Sources:
TPA Dell Diamond
(NCAL, SCAL, HI, MAS)
TPA Meritain (OH)

Recd Disposition

Program Name

Description

AB356

AB356 is a CA mandated law, effective 1/1/10, requiring HMOs and insurance companies to prohibit insurance rate determination based
on gender.

Acumen

Acumen, LLC has been contracted by Medicare to assess and quantify benefit mismatches at the contract level and use these data to
monitor
with
CMS Best
Available
(BAE)
policylow-income subsidy (LIS) status at a particular point in time. As a
In certaincompliance
cases, CMS
systems
do not
reflect aEvidence
beneficiary's
correct
result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. This policy requires
sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's
information is not accurate.

BAE (Best Available

Evidence)

Catamaran

Sponsors
Kurt Merrick

Teresa Ennis

NA

Catamaran, (formerly called HealthTrans) is a pharmacy claim adjudicator for Medicare prescription products
that receives Medicare member eligibility data from the Membership Data Warehouse (MDW) Foundation
System (FS) staging environment, which contains all the required data. Adjudicated claim data from
Catamaran is used to meet the Medicare Part D Plan requirement to provide a monthly Explanation of Benefits
(EOB) notice to each enrollee who uses his/her plan to obtain prescription drugs.
Sheila Rankin

CCES
The California Claims and Encounter Strategy will implement a claims platform to replace four legacy claims systems. It will will enable
market competitive claims performance and product administration capabilities, including eligibility and benefit functions.

CDHC

Michael D Stevenson

The CDHC program seeks to increase consumer knowledge and engagement in health and health care choices through increased
consumer financial engagement and replaces Bank of America as KP's vendor for HRA and HSA accounts. The scope of this project
includes enhancing the capabilities from the basic eligibility exchange with the vendor to include, among others, associated claims and a
Single Sign On through to the vendor's site for the member to use to view claims history.
Brief desc related to adding regions to CDW:
Consumer Directed Health Care (CDHC) utilizes claims extracts to assist eligible members in the management of health care spending
accounts, e.g., Health Reimbursement Account (HRA), Health Spending Account (HSA) and Flex Spending Account (FSA), based on the
amount spent on medical care
Charles R Larsen

CDW

The Claims Data Warehouse (CDW) program provides a central, consistent industry standard view of finalized claims data at an atomic
level for all regions to perform reporting, analytical and operational functions.

EOB

Part D plans are required to provide a monthly Explanation of Benefits (EOB) notice to each enrollee that uses his/her plan to obtain
prescription drugs. The notice is to be sent at the beginning of the month following the month in which prescription drugs are obtained.
The EOB notice may also include information about any formulary changes.
The Evidence of Coverage (EOC) document provides eligibility details to employer groups and members regarding their health plan
coverage.

EOC
Harrington Health

Harrington Health provides benefit administration and claim processing with integrated care management, pharmacy and business
process outsourcing services to self-funded commercial and government employers as well as providing administration of fully-insured
plans.

Barry Lue

Sheila Rankin
?

Health Care
Exchanges

Health Care Reform

3Rs
(Reinsurance,
Risk Adjustment,
Risk Corridor)

HealthTrans
HealthWorks

The Affordable Care Act will, beginning in 2014, eliminate health status underwriting through its guaranteed issue and modified
Arthur Southam
community rating requirements and pre-existing condition ban. It will also offer premium tax credits to lower- and middle-income
Americans and create health insurance exchanges. These steps will radically change the nongroup (individual) and small group health
insurance markets in the United States. In KP,the Federal Health Care Exchanges program will entail working with state exchanges to
manage those new members who qualify for the government subsidies for affordable healthcare. Within the KP Program, the Health Care
Exchanges project will focus on support and implementation within Membership Administration.

The Affordable Care Act will, beginning in 2014, eliminate health status underwriting through its guaranteed issue and modified
Arthur Southam
community rating requirements and pre-existing condition ban. It will also offer premium tax credits to lower- and middle-income
Americans and create health insurance exchanges. These steps will radically change the nongroup (individual) and small group health
insurance markets in the United States. The temporary reinsurance and risk corridor programs are designed to ease this transition
between 2014 and 2016; all insurers that seek to participate fully in the Commercial Market must also participate in these risk mitigation
programs by January, 2014.
The Reinsurance program will do this by collecting assessments from insured and self-insured group health plans and paying out funds to
individual plans that cover high-risk individuals.
The Risk Adjustment program will, on a permanent basis, move funds from issuers in the nongroup and small group market (other than
grandfathered plans) with lower-than-average-risk populations to those with higher-risk populations; this will discourage risk selection and
compensate insurers that cover sicker enrollees.
The Risk Corridor program will collect funds from issuers of qualified health plans (primarily but not exclusively plans in the exchanges)
that have lower-than-expected claims costs and pay out those funds to issuers of qualified health plans with higher-than-expected costs.
It will thus stabilize the experience of these plans over the first three years when insurers will have a difficult time predicting exactly how to
set their premiums.

The
Healthworks
program helps
employees
who follow
healthyHealthTrans
behaviors, enabling
cost eligibility
containment
for
HealthTrans
is a pharmacy
claimemployers
adjudicatorreward
for Medicare
prescription
products.
receivesbetter
Medicare
information
for
companies
and
their
employees,
who
are
KP
members.
Currently,
Healthworks
program
reporting
is
accomplished
either
through
members from existing Membership Data Warehouse Staging Foundation System (MDW-FS) extracts.
manually generated reports or reports created by ETL processes developed using AbInitio. The desired future state is to be able to report
directly from the various files the program generates and receives. This entails populating the database tables in the Healthworks Data
Mart with program related data and deploying a reporting tool to utilize the data.
Shajmil Smith
Nancy Botiller

ICD-10

The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (known as "ICD-10") is a medical
classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external
causes of injury or diseases, as maintained by the World Health Organization (WHO).

IRAD

The Inter Regional Analytics Data Mart (IRAD) system supports the Customer Analytics Reporting (CAR) group within the Health Plan
Strategic Market Planning Organization. IRAD provides data that CAR can integrate and interpret into meaningful information for our
Kaiser
Permanente
ClaimsConnect
is an enterprise-wide
platform,replaces
legacy claims systems and brings
large employer
groups
to provide insights
into the burden claims
of Chronic
Disease withinend-of-cycle
their population.
contemporary technology to our claims and encounter processing contributing to the competitiveness of Kaiser Permanente in the
respective regional markets.

KPCC

Dave Schweppe
Marlene Deutchman

KPIF

LA Care

LIS

MBE

MDW

Medicare Part D and

Part C

MLO
MSP

OPPR

WPP

Xcelys

KPIC

Kaiser Permanente Individual and Family (KPIF) manages individual and family memberships, versus group and small group membership
types.

L.A. Care Health Plan,the nations largest public health plan, serves more than 1 million Los Angeles County residents through 5 free /
low-cost health insurance programs. KP will be participating in a Duals Demo Program, contracting with L.A. Care as the service provider
for Dual Eligibles, beneficiaries who qualify for both Medicare and Medicaid benefits in Los Angeles County.
Sheila Rankin
The Medicare Modernization Act of 2003 added a prescription drug benefit (Medicare Part D) to Medicare in January 2006. The law also
provides financial assistance with
the cost of Medicare Part D prescription drugs, plan premiums, deductibles and copayments for Medicare beneficiaries with low incomes
The
Business
is a comprehensive,
who Medicare
meet certain
incomeEngine
and asset
qualifications. third-party system that handles Medicare Administrative functions for enrollment,
NA
disenrollment, reconciliation, reporting and accounting. By integrating with the KP membership, financial reporting and member
correspondence systems, this single source will enable complete, accurate reporting on Medicare revenue, fast and consistent reaction to
Centers for Medicare and Medicaid Services (CMS) changes, and the ability to pursue other strategic projects.
Kelley Keele
Provides a single trusted source (current and historical) of membership data (Membership Profile, Member/Person Demographics,
Customer Group/SubGroup, Medicare, Medicaid, Contract, Coverage, Premium, Dues, and Payment) across all regions that supports all
membership reporting and analytical functions requiring this information; as well as supporting operational functions such as Medicare
Administration (e.g., Medicare Letters); and enabling Audit & Compliance Reporting functions both to our Customers & Regulatory
agencies.
Matt Barrett
Medicare Part D is a federal program which subsidizes the costs of prescription drugs for Medicare beneficiaries in the United States.
Medicare Part C is a Medicare Advantage plan that includes Medicare Part A (hospital coverage), Medicare Part B (medical coverage)
and Medicare Part D (prescription coverage).

NA

The
Medicare
LettersPayer
Optimization
(MLO)
projectdesigned
aims to standardize
Medicare
Membership
letter
generation
across
regions,
reduce by
Medicare
Secondary
(MSP) is
a program
to protect Medicare
Trust
Funds from
paying
for services
and
items covered
costs
of
new
or
modified
letter
deployment,
and
provide
KP
Customer
Service
and
California
Service
Center
(CSC)
the
ability
to
a members primary insurance coverage. To realize these benefits to the Medicare Trust Funds, providers, physicians, and otherview
document
images
online.
Anthony Putman
suppliers must
have
access to accurate, up-to-date information about all health insurance or coverage that Medicare beneficiaries may
have (Other Coverage Insurance (OCI)). Medicare regulations require that all entities that bill Medicare for services or items rendered to
Medicare beneficiaries must determine whether Medicare is the primary payer for those services or items.
Sheila Rankin
The Out Patient Pharmacy Replacement (OPPR) seeks to integrate three different "legacy" pharmacy systems into a new sustainable,
common pharmacy system, which will utilize new technology infrastructure. The system will provide functionality to enable monitoring,
reporting and auditing capabilities to comply with state, Federal, SOX, HIPAA, Medicare Part D, and KPIT regulatory / compliance
requirements, as well as increase efficiency in managing future regulatory requirements.

Steven Choy

The KP Internet Group (eBusiness) built and supports KP.org and the Web Presence Platform (WPP), which provide online health
support to members, providers and customers. The WPP initiative is developing tools, applications, brand security and reusable
components to migrate the extracted data from the less stable KP.org to the WPP.

Asim Qadir

The Xcelys Claims Program is implementing a new claims platform across the Kaiser Permanente regions. The platform includes DELLs
Xcelys application for their claims processing system. The implementation will replace end-of-cycle legacy claims systems and bring
contemporary technology to our claims and encounter processing contributing to the competitiveness of Kaiser Permanente in the
respective regional markets. (Replaced by KPCC)
NA
Kaiser Permanente Insurance Company (KPIC) is a subsidiary of Kaiser Foundation Health Plan (KFHP), Inc.

Daniel McDermott

Acronym

Definition

Acronym

Definition

Acronym

AB356

California Assembly Bill 356

FSDW

Foundation Systems Data Warehouse

NMC/SMIL

AOMS

Authorized Outside Medical Services

FSMD

Dunning Extract for the CM Regions

NMF-LIS

BAE

Best Available Evidence

GA

Georgia

NPS

BCP

Business Continuity Plan

GAE

Group Auto Enrollment

NVS

BENX

Benefit Extract

HASP

HIPAA Application Security Program

NW

BI

Business Intelligence

HD

Incident Originating from HelpDesk/Application Abend

OCPS

BICN

Medicare New Enrollments and terminations

HDHP

High Deductible Health Plan

ODS

BSC

Broker Sales Compensation

HEDIS

The Healthcare Effectiveness Data and Information Set

OH

CA OCI

California Other Coverage Insurance

HERA

Small Groups Business Sales

OLAP

CAMD

Dunning Extract for California

HESTIA

Personal Advantage and Enrollment System

OOA

CAMDM

CA Membership Data Mart

HHS

Department of Health and Human Services

OPPR

CARES

Community Assistance Review Enrollment System

HI

Hawaii

PAC

CARS

Common Archive Retrieval System

HMI

Department of Health Management and Informatics

PBM

CAS

Customer Account Services

HP CHATS

Health Plan Customer Handling and Tracking System

PHI

CATS

Claims Adjudication and Tracking System

HPUB

Publications Distribution System

PIMS

CCES

California Claims and Encounter Strategy

HRA

Health Reuimbursement Account

PMO

CDHC

Consumer Directed Health Care

HT

HealthTrans

POC

CDW

Claims Data Warehouse

HTRN-HDHP

Healthtrans Eligibility Extract for Part D and HDHP

PSC

CIWRS

Complaint Integrated Workflow & Reporting System

ICD-10

International Statistical Classification of Diseases

PSDD

CM

Common Membership

IMP

Implementation

PSP

CMS

Centers for Medicare and Medicaid

IMS

Information Management Systems

QA

CO

Colorado

IRAD

Inter Regional Analytical Data Mart

QSG

CR

Change Request

ITC

Information Technology Compliance

RAC

DDI

Data De-Identification

KP Edits

KP EDI System

RFC

DEF

Definition

KPCC

KP Claims Connect

ROC

DEV

Development

KPEG

KP EDI Gateway

SAS

DIT

Development Integration Testing

KPHC

KP Health Connect

SBAR

DPPS

Diamond Platform Production Support

KPIC BENX

KP Insurance Company Benefit Extract

SBB

DW

Data Warehouse

KPIF

KP Indivdual and Family

SBE

ECPS

Electronic Commerce Payment System

KPIT

KP Information Technology

SCAL

EDGE

Effective Data Gathering Expertise

LIS

Low Income Subsidy

SFTP

EDI

Electronic Data Interchange

LOB

Line of Business

SHPS

EES

Enterprise Environment Services

LOE

Level Of Effort

SIT

EOB

Explanation of Benefits

LSDD

Logical Solution Design Document

SNP

EOC

Evidence of Coverage

MAP

Marketing Analytics Platform

SPPS

ERISA

Employee Retirement Income Security Act

MAS

Mid-Atlantic States

SUNGARD

ERRP

Early Retiree Reinsurance Program

MBE

Medicare Business Engine

ESRD

End Stage Renal Desease

MCMR

Connextions Membership Extract

ETL

Extract Transform & Load

MDOL

Medicare Online Documentation

ETS

Enterprise Testing Services

MDW

Membership Data Warehouse

FAME

Focus, Audit, and Marketing Extracts

MDW2

Membership Data Warehouse 2

FS

Foundation Systems

MITS

Member Integrated Tracking System

FS EM FE

Foundation Systems Electronic Media Front End

MLO

Medicare Letter Optimization

FS ODS

Foundation Systems Operational Data Store

MON

Mid-Atlantic States, Ohio, Northwest

TBD

To Be Determined

MSP

Medicare Secondary Payer

TMS

The Membership System

MSP MIR

Medicare Secondary Payor

TST

Testing

MSP OCI

Medicare Secondary Payor Other Coverage Insurance

UAT

User Acceptance Testing

MSSA

Marketing Sales, and Service Administration

WEBAN

Web Analytics

NAOL

National Apply Online

WIP

Work In Progress

NCAL

Northern California

WIT

Workflow Integration Testing

NGT

National Group Termination

WPP

Web Presence Platform

Definition
New Member Contact/Sales & Marketing Info & Labels
National Medicare Finance Low Income Subsidy
National Pricing System
National Validation System
Northwest
Outside Claims Processing System
Operational Data Store
Ohio
On Line Analytical Processing
Out of Area
Out Patient Pharmacy Replacement Pharmacy
Portfolio Approval Council
Pharmacy Benefit Manager
Protected Health Information
Pharmacy Information Management System
Program Management Office
Proof of Concept
Pricing System Cost
Physical Solution Design Document
Print Strategy Pathway
Quality Assurance
Quality Support Group
Regional Approval Council
Request for Change
Regions Outside California
Statistical Analysis System
Situation, Background, Assessment, Recommendation
Small Business Broker
Small Business Employer
Southern California
Secure File Transfer Protocol
HRA Bank of America Extract
System Integration Testing
Special Needs Plan
Strategy Planning and Portfolio Services
Vendor NCAL Membership extract

For Predefined Filters

PAC/Client Funding Type Values

Regulatory Status Values

HPDW PM Values

HP PAC HPDS

Yes

Alex Theodossis

HP PAC Sales and Marketing

No

Connie Farkas

HP PAC KP Claims Connect

TBD

David Perez

HP PAC Medicare

Janet Motoike

HP PAC Products and Benefits

Nancy Lee

HP PAC Membership

Ron Macias

HP PAC Client Funded HPDS National Initiative

Sai Kasibatla

HP PAC ICD-10 Program

Thao Trinh

Client Funded - See Comment

Robert Palle

In Progress

NA

Other - See Comment

TBD
Prasanth Jadaprolu

File Delivery Method

Data Targets

FTP

Mainframe

California Diamond

SFTP

Database Location

Catamaran Claims Extract

Save to Mainframe location

Internal Server

CDW

Save to predefined location

NEDI

Common Membership

Other - Describe in Comments Field

CDW

External Source - See Comments

NA

MDW 2.0

Foundation System

Save to Database

MDW Staging

Data sources

Internal Flat File

IRAD
KPCC

MDW 2.0
MDW Staging
Mid-Atlantic/Ohio/Northwest (MON) Diamond
Other - See Comments
IT PM Values
Sponsors

Barbara Simmons

Anthony Putman

Bob Jackson

Arthur Southam

Dalita Isahakian

Asim Qadir

Denise X Brummond

Barry Lue

Eric Hicks

Bryan Matsuura

Jessica Kenwood

Charles R Larsen

John Kolb

Daniel McDermott

Kay McBreairty

Dave Schweppe

Mari-Jo Suzuki

Kelley Keele

NA

Kurt Merrick

Neil Hanson

Marlene Deutchman

Peter Weiser

Matt Barrett

Raju Dumbre

Michael D Stevenson

Ravi Ramachandran

NA

Rhoda Miller

Nancy Botiller

Robert W Klusman

Shajmil Smith

Susan Cho

Sheila Rankin

Tess Kemie

Steven Choy

Tim Overhuls

TBD

Senthil Arumugham

Teresa Ennis

ETL Tools

Regions

Ab Initio

California

Informatica

All
Colorado
Georgia
Hawaii
Northern California
Northwest
Ohio
Southern California
6 Regions
6 Regions Less MAS
Other - See Comments
Mid-Atlantic States, Ohio, Northwest, Colorado