The U.S. healthcare industry is regulated under mandates established by the U.S. Department of Health & Human Services (HSS) and Office of Civil Rights (OCR) resulting principally from the Health Insurance Portability and Accountability Act (HIPAA) and administrative simplification provisions of the Affordable Care Act (ACA) and other regulating entities and mandates.
To demonstrate our continued commitment to assure that applicable Change Healthcare products and services meet industry and regulatory requirements and expectations, we maintain the following industry recognized and trusted accreditations and certifications:
CAQH certifies and awards CORE Certification Seals to entities that create, transmit or use the administrative transactions addressed by applicable Operating Rules. CORE Certification means an entity has demonstrated that its IT system or product is operating in conformance with a specific phase(s) of the Operating Rules.
Change Healthcare is CAQH CORE certified for the federally mandated operating rules supporting the Eligibility & Benefits, Claim Status, and Payment & Remittance transactions demonstrating that our associated IT systems and products are operating in conformance with effective standards and operating rules.
Additional information regarding the Operating Rules for HIPAA transactions can be found on the Change Healthcare HIPAASimplified.com website.
Change Healthcare is EHNAC HNAP-EHN and ePAP-EHN accredited.
The Electronic Healthcare Network Accreditation Commission (EHNAC) is a federally recognized standards development organization and tax-exempt, 501(c)(6) non-profit accrediting body designed to improve transactional quality, operational efficiency, and data security in healthcare.
EHNAC indicates the following compliance benefits associated with accreditation:
Reduce risk to PHI and operations through the demonstration of a risk management program with effective controls that appropriately minimize threats.
Prepare organizations for third party audits including 21st Century Cures Act; HIPAA/HITECH compliance audits that are now being conducted for the Office of Civil Rights (OCR); trading partner audits; and state compliance (EHNAC accreditation is required for processing healthcare transactions in the states of Maryland and New Jersey).
Enhance trust for customers, trading partners, and other stakeholders.
EHNAC’s Healthcare Network Accreditation Program (HNAP) Electronic Health Network (EHN) assessment and review covers five main categories of criteria:
Privacy and confidentiality criteria include policies for securing PHI, system access controls, role-based user authentication and other related measures.
Technical performance criteria include transaction monitoring and processing capacity, response timeliness and accuracy, system availability, use of industry standard data formats and other infrastructure practices.
Business practices criteria include policies, procedures, and contract standards to assure truth in advertising, ongoing customer satisfaction measurement, customer service and training, and other related measures.
Physical, human, and administrative resources criteria include the organizational ability to sustain levels of service, maintain escalation procedures, and invest in professional development and other capabilities.
Security criteria include facility access, disaster recovery, business continuity, organizational safeguards, audit trails and other practices.
EHNAC requires that organizations complete the program every two years to maintain accreditation which includes a detailed criteria-based assessment and EHNAC audit and site reviews. Change Healthcare has maintained our EHNAC Electronic Health Network accreditation since 2001.
Change Healthcare has earned HITRUST CSF® Certification status for the solutions listed below and is continually working to achieve HITRUST Certified status for additional solutions in our portfolio. These systems represent a wide variety of the technology solutions offered by Change Healthcare. It is our intention to show that our information security controls are established, reviewed, and communicated centrally and implemented across all business units and technology platforms.
Why is HITRUST Certification Important?
HITRUST has developed the HITRUST CSF, a certifiable framework that provides organizations with the needed structure, detail and clarity relating to information protection.
With input from leading organizations within the industry, HITRUST identified a subset of the HITRUST CSF control requirements that an organization must meet to be HITRUST CSF Certified.
HITRUST CSF Certified status demonstrates that the solutions listed below have met key regulations and industry-defined requirements and are appropriately managing risk.
Change Healthcare Solutions that have achieved HITRUST CSF Certification include:
Change Healthcare Solution Name
AccuPost accelerates the revenue cycle by automatically posting payments to client's HIS/PMS for virtually any payer that provides electronic payment files. AccuPost’s interactive posting technology can also post the following: Contractual Adjustment Computations, Rejection Notes, Primary and Secondary Bill Dates, Medicare and Commercial Claim Status Notes and more.
Charge Capture Advisor
Charge Capture Advisor uses artificial intelligence to optimize revenue opportunities by predicting missing charges and enabling staff to act prior to claim submission. The solution augments existing manual charge capture processes by presenting recommendations for missing service charges alongside coding and claim workflows.
Core Processing System for New Print Platform. CHPS is Change Healthcare Printing System.
Claims & Denial Advisor
Provider solutions from Change Healthcare bring actionable data, analytics and insights across the healthcare ecosystem. And it’s all powered by our Intelligent Healthcare Network™, the single largest financial and administrative healthcare network in the United States.
Claims Automation converts all types of paper claims or claim images to 837 transactions that are then processed as EDI transactions through the clearinghouse. The solution can provide full or partial mailroom services, allowing payers to outsource full or partial mailroom operations, including scanning, imaging and data capture to help streamline processes.
ClaimsXten™ is a clinical-based payment solution for payers who want to create and deploy flexible, automated rules to help improve patient accuracy, reduce appeals and realize medical and administrative savings. Health plans are increasing looking to leverage analytics to identify and control improper payments. Auto-adjudication of claims according to a payer’s policy and provider contracts reduces overpayment, provides transparency to providers, reduces need for retrospective audits and supports claim processing and payment accuracy.
Our full-service Medical Record Retrieval & Clinical Review solutions provide value for payer plans and risk-bearing medical groups that wants to increase incremental revenue & improve plan RAF, HEDIS & Star scores while pursuing improved quality & compliance goals.
Consumer Payments & Communications
Consumer Payments and Communications empowers your member engagement efforts by facilitating member payments and enabling member communications. Member Correspondence Advocate is an engagement solution for health plans that want to maximize the effectiveness of their member correspondence to increase satisfaction and retention, and reduce costs— including welcome kits, ID cards, EOBs, and other digital and print communications.
A cloud-based, test identification and policy management solution that drives appropriate molecular diagnostics (MDx) coverage and reimbursement, DEX™ Diagnostics Exchange improves molecular diagnostic test management and provides unique test identification with DEX Z-Codes™.
Eligibility & Enrollment
Our market-leading predictive analytics and machine learning capabilities offer a data-driven, patient-centric approach to social program qualification. We help health plans identify, reach, and assist qualified members with enrollment into these programs.
EDGE Complete™ provides Commercial ACA Submissions to CMS EDGE Servers
Enterprise Imaging Network™
Enterprise imaging solutions help hospitals improve clinical, financial and operational outcomes with lower overall costs and increase care team productivity. Our imaging solutions orchestrate imaging workflow and provide analytics to uncover actionable insights from your data in a secure cloud environment.
Intelligent Medical Network
Intelligent Medical Network helps modernize technology to improve performance and stability of transaction processing. The solution enables blockchain, artificial intelligence, machine learning to improve efficiency through self-service and automation capabilities.
An evidence-based clinical decision support solution that enables clinically appropriate medical utilization decisions. InterQual solutions are licensed and used by payers, providers, government entities and consulting groups to promote evidence-based care, improve quality and value and reduce unnecessary costs.
Medical Network Developer Platform
Our development platform application programming interfaces (APIs) allow healthcare companies to access electronic data interface (EDI) transactions and more, through one secure platform in an easy to use, JSON format. No X12 expertise is required. Our Aps allow companies to eliminate the burden of complex implementations, saving time and money, and significantly reducing onboarding time.
MedRx™ Network helps pharmacies in the US process claims that are billed to a patient’s medical benefits, such as vaccines, inhalation drugs and diabetic supplies. Our customer support teams have a deep understanding of Medicare Part B policies and guide our customers on troubleshooting rejected claims.
NextGen Payment Platform
NextGen is a cloud platform of our SmartPay™ solution offering consumer and business payments in shared, common, cloud-hosted environment.
Patient Billing & Statements
Patient Billing & Statements helps hospitals and healthcare systems create personalized statements created with design thinking and consumer research insight to help expediate the patient payment collections and improve patient engagement. Our solution provides accurate and easy-to-understand patient statements and health communications designed to help facilitate quicker patient processing.
Patient Responsibility Estimator
Application Program Interface utilizing REST (Representational State Transfer) Web service architecture framework to estimate the patient cost of a procedure. This application is exposed externally through the Developer API gateway.
Payer Connectivity Services
A payer solution providing a claims administration, routing and first-pass adjudication system for payers who want to consolidate and manage their inbound and outbound transaction steams at a single connection point. The solution provides a portal for visibility into claims trends and outliers, correcting claims and managing workflow.
With a blend of technology and skilled revenue cycle experts, Payment Automation helps health organizations streamline their remittance processing and healthcare payments by integrating key processing functions into a single solution. Payment Automation helps to reduce the high cost of manual remittance processing; coverts paper-based explanation of benefits (EOBs) to post-able 835 files, improves productivity and efficiency, reduces PHI risks, and enhances secondary billing.
Pharmacy Benefits Services and Third-Party Administration
Medicaid Pharmacy Benefits Services (PBS) is one of the most experienced solutions fully dedicated to state plan pharmacy needs, currently serving over 5 million Medicaid lives in 18 states. We offer clinical, financial and data services to help state plans manage their pharmacy costs and support optimal member outcomes.
Analytics solutions to help various provider segments understand their data and improve financial performance. Across our solutions we leverage the data drawn from our Intelligent Healthcare Network, which is unparalleled in its scope across the industry.
Revenue Performance Advisor
End to end revenue cycle management software solution for physician practices, labs, home health, medical billing services and other providers wanting to simplify workflows, reduce denials, optimize revenue and improve patient engagement.
Risk View™ is a risk adjustment program management platform including risk scoring, targeting analytics and return on investment (ROI), business intelligence, risk adjustment operations workflow tools and program management support.
SmartPay™ simplifies each step of the billing and payments process into one place, helping you to collect more patient payments, get paid faster, reduce your collection costs, and lower patient write-offs.
Transparency & Provider Search
Empowers people to choose the right care with simple provider, cost and quality search and integrated member engagement. Powered by the industry’s richest data set, most accurate cost estimates, and AI powered predictive engagement, True View proactively engages members to be involved in their health and choices for care by promoting savings, better outcomes, and supporting value-based care initiatives.
HHS Administrative Simplification Optimization Program
As a trusted industry leader and in support of our commitment to compliance, Change Healthcare volunteered and was selected to participate in the U.S. Department of Health & Human Services (HHS) Administrative Simplification Optimization Program pilot. The program comprises a formal assessment by the National Standards Group (NSG) within the Centers for Medicare & Medicaid Services (CMS), to review compliance with federally mandated transaction standards, code sets, unique identifiers, and operating rules.
Change Healthcare is one of the first organizations certified by the NSG demonstrating that our Medical, Hospital, and Dental Exchange batch and real-time services and solutions have been reviewed for compliance with the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification regulations and Affordable Care Act (ACA) Operating Rule provisions.
The Maryland Health Care Commission is an independent regulatory agency whose mission is to plan for health system needs, promote informed decision-making, increase accountability, and improve access in a rapidly changing health care environment by providing timely and accurate information on availability, cost, and quality of services to policy makers, purchasers, providers and the public.
The Maryland Health Care Commission certifies Electronic Healthcare Networks that meet national standards for security, business processes, technical performance, privacy and confidentiality when transmitting patient health information. As part of the evaluation process, MHCC reviews an EHN’s national accreditation site audit and recommends areas where enhancements would help reduce risks of exposure to data breaches.
Maryland Regulation 10.25.07, Certification of Electronic Health Networks and Medical Care Electronic Claims Clearinghouses, requires third party payers that accept electronic health care transactions originating in Maryland to accept electronic health care transactions only from MHCC certified EHNs. MHCC-EHN certification demonstrates that Change Healthcare meets a number of national and local standards intended to ensure high quality business operations and the existence of sound privacy and security policies. MHCC certification represents to other networks, payers, and providers that Change Healthcare meets a reasonable level of quality and technical performance.
MHCC requires that EHN’s complete the evaluation process every two years to maintain certification.
The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality by assessing and reporting on the quality of health-related programs. NCQA certification is a reliable indicator that an organization is well-managed and demonstrates the organization's commitment to meeting and maintaining industry developed quality standards.
NCQA's Healthcare Effectiveness Data and Information Set (HEDIS) Measure Certification is precise, automated testing that verifies compliance with HEDIS Specifications and satisfies the source code review portion of the HEDIS Compliance Audit™. Since its introduction in 1993, HEDIS has evolved to become the gold standard in managed care performance measurement. Change Healthcare has been providing certified HEDIS reporting solutions since 1997.
For each consecutive year since 2005, Change Healthcare's Quality Performance Advisor™ solution has been NCQA HEDIS Measures Certified in all measures. Quality Performance Advisor™ also received NCQA certification for the California Value Based Pay for Performance (VBPP) program. This statewide initiative is one of the largest alternative payment models in the United States.
Change Healthcare’s Compliance Reporter™ solution has been NCQA HEDIS Measures Certified every year since 2012. Compliance Reporter™ also supports Quality Assurance Reporting Requirements (QARR) measures as required in the state of New York.
Change Healthcare's Quality Performance Advisor™ and Compliance Reporter™ solutions power a suite of web-based HEDIS offerings, including certified rate reporting and analytics, hybrid medical record reviews, and customizable reporting across measures, enabling health plans to effectively manage and optimize HEDIS processes, reporting, submission, and results.
NCQA's Physician and Hospital Directories certification validates quality measures for online solutions which help eligible individuals choose physicians and hospitals. Change Healthcare's Provider Directory solution has been NCQA Health Information Product Physician and Hospital Directories (HIP4) Certified in all measures. Change Healthcare's Provider Directory solution helps members easily search and compare doctors, specialists, hospitals, imaging centers and more in a user-friendly interface. Combined with our cost transparency solution, Provider Directory empowers members to take a more active role in their health, guiding them to make smarter decisions for healthier outcomes.
The following Change Healthcare solutions are Payment Card Industry Data Security Standard (PCI DSS) certified:
This annual certification verifies that these Change Healthcare solutions have passed the rigorous standards promulgated by the PCI DSS.
The PCI DSS is a set of security requirements created by an association of credit card brands, including VISA, MasterCard and American Express intended to protect cardholder data (credit card data). The steady increase in electronic payment options available makes it extremely important to protect customers’ personal information. You can learn more about the PCI DSS and the standards it requires at www.pcisecuritystandards.org/security_standards.
Change Healthcare abides by all applicable PCI DSS requirements under which we secure any and all cardholder data that we store, process or transmit for our customers. This notification is part of the certification process.
Keeping our customers’ information secure is a top priority for Change Healthcare. We dedicate extensive resources to make sure personal medical and financial information is secure and we strive to build a company culture that reinforces trust at every opportunity.
We appreciate your continued partnership. If you have any questions about the Change Healthcare PCI Compliance efforts or the measures we’re taking to keep your data safe, please contact your account representative or the Security Compliance Team.
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