machine readable and consumer support tools

HTTPS://WWW.REGTAP.INFO

April 13, 2018

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The information provided in this presentation is not intended to take the place of the statutes, regulations, and formal poli cy guidance that it is based upon. This presentation summarizes current policy and operations as of the date it was shared. Links to certain source documents may have been provid ed for your reference. We encourage persons attending the presentation to refer to the applicable statutes, regulations, and other guidance for complete and current information.

Machine Readable and Consumer Support Tools


• Basic Process – quick overview

• Troubleshooting: Process – review of common issues encountered and how to resolve them

• Troubleshooting: Coverage – review of self - service troubleshooting tools to be used for

troubleshooting display of covered items

Machine Readable Data Overview

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File creation (ongoing cycle): • Issuers create and update files on a continuous basis, with updates

made to each provider/facility/drug item at least every 30 days • Any files included in the index file will be reviewed during the daily crawl

Index File Submission: • One - time submission through https://marketplace.cms.gov/submission

and resubmission of the URL itself, technical contact, or covered HIOS IDs change

Daily Crawl: • Submitted index file URLs are crawled, files are downloaded and

validated • Providers/facility/drug items that pass validation are included in that

day’s database and used to display coverage on HealthCare.gov

Machine Readable Data Process

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https://marketplace.cms.gov/submission


Common Errors EncounteredFile creation (ongoing cycle): • Items left out of files – search within file to ensure the relevant item is

properly noted, and has the correct plan ID(s) and year(s) • Files left out of index file – check to ensure that all links are correct and

included within the index file

Index File Submission: • Typos or incorrect technical contact: resubmit if necessary

Daily Crawl: • Submitted index file URLs are crawled, files are downloaded and

validated • Providers/facility/drug items that pass validation are included in that

day’s database and used to display coverage on HealthCare.gov

Machine Readable Data Process:

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• Valid files from the daily crawl will make up the coverage database and are used to display coverage on HealthCare.gov.

• Providers, facilities, and drugs are shown as follows: – Covered / In Network:

• Any NPI or RxCUI listed with a Plan ID (and valid year) will be shown as “Covered” or “In Network”

– Not Covered / Out of Network: • Any NPI or RxCUI not included will be shown as “Not Covered” or

“Out of Network”

Machine Readable Data: Coverage

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• Tools and tips we’ll cover for each stage of creating, validating, and reviewing your data: – Before import and validation: Schema

Validation Tool – After import and validation: Coverage

Validation Tool – On - Website data checking: Tips for using

Chrome ‘Inspect’

Coverage Troubleshooting Tools

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• Schema validator still available at http://coverage-

–- beta.herokuapp.com/

Upload entire files to check against schema OR

– Copy - paste portions of files to check against schema • Note:

– After clicking ‘validate’, review may take a few minutes to display results, particularly at high traffic times

–

validator

When encountering warnings and errors, a “show more” option is available to display beyond the first few errors. • Warnings and errors being emailed daily have a limited text

output per file validated, but more can be displayed here for self-service review without having to wait to clear earlier errors.

• *Syntax errors cause validation to stop, and will not display any subsequent errors downstream in the file.

Schema Validator

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http://coverage-validator-beta.herokuapp.com/

HTTPS://WWW.REGTAP.INFO8

HTTPS://WWW.REGTAP.INFO9


• Coverage validator at https://cmsgov.github.io/coverage-inspector/index.htmlallows self - service review of the following items: – Plan IDs per HIOS ID – NPI lookup tool querying NPPES – RxCUI lookup tool querying NIH/ RxNav – Drug name (string) to show RxCUI and NIH’s display

Name – Provider name (string) with ZIP search to show NPI, and

NPPES name, specialty, taxonomy – Drug coverage – Provider coverage

Coverage Validator Tool Functions

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https://cmsgov.github.io/coverage-inspector/index.html


Coverage Validator: Plan IDs per HIOS ID

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Coverage Validator: NPI lookup

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Coverage Validator: RxCUI lookup

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Coverage Validator: Drug Name lookup

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Coverage Validator: Provider Name lookup

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Coverage Validator: Drug coverage lookup

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Coverage Validator: Provider coverage lookup

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Validation on HealthCare.gov: Using Chrome’s ‘Inspect’ Tool

• Within Window Shopping, when testing provider and drug coverage against your submitted JSON files, it is important to check what RxCUI or NPI is displayed.

• The browser Chrome includes a free ‘Inspect’ tool that is useful to determine

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• Start at https://www.healthcare.gov/see-plans/ and enter information for your test scenario up to the Provider / Drug search page shown below

Window Shopping with “Inspect”

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https://www.healthcare.gov/see-plans/


• Right - click or secondary click to display the pop - up menu; select “Inspect”


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• First: within the “Inspect” pane, click “Network” • Next: Enter your search string (provider or drug) and click Search


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• First: on the process Name panel, find the search process and click it • Next: Expand the providers results next to it to see the NPI for each

displayed search result


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• Tips for using the Inspect results: – Numbering starts at 0, not 1, so when troubleshooting you must match each

result to the NPI record that falls with it in order (see arrows showing providers matched to their NPI)

– Taking a screenshot here to show NPI or RxCUI is helpful when comparing plan results’ coverage of providers and drugs

– Prior to submitting a help ticket, Issuers can utilize this method to ensure that the NPI or RxCUI that they are reporting issues with is truly the one they are seeing as “Covered” or “Not Covered”, “In Network” or “Out of Network”


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• If you’re still experiencing a coverage mismatch or have additional questions, our team responds to UserVoice tickets that are submitted through https://cms-provider-directory.uservoice.com/

• “Why isn’t this covered/in network?” should include: – ZIP Code to reproduce search, Plan ID, NPI/ RxCUI of item that should

be covered, and notation of which of the JSON files within your index file is the one that contains that item, screenshot from HealthCare.gov (optional), Issuer ID/Name

• “Why is this covered/in network?” should include: – ZIP Code to reproduce search, Plan ID, name of item that is showing

the coverage, screenshot from HealthCare.gov showing the coverage, Issuer ID/Name

• Other questions about searches and item display should always include the steps to reproduce your search, screenshots if relevant, and basic information identifying for which Issuer you are reporting the issue and where/when the issue occurred.

Submitting Help Desk Tickets

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https://cms-provider-directory.uservoice.com/


Network Breadth Pilot

April 2018

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The information provided in this presentation is not intended to take the place of the statutes, regulations, and formal poli cy guidance that it is based upon. This presentation summarizes current policy and operations as of the date it was shared. Links to certain source documents may have been provid ed for your reference. We encourage persons attending the presentation to refer to the applicable statutes, regulations, and other guidance for complete and current information.



* PY18 Summary

* PY19 Updates


PY2018 Summary • Ratings computed at the county level • Data integrity check process implemented

to validate National Provider Identifiers (NPIs) and hospitals

• Time and distance measurements same as PY18 – modified Medicare Advantage (MA) measurements

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PY2019 Updates • Ratings computed at the county level • Data integrity check process same as PY18, but

improved* hospital list • Time and distance measurements same as PY18 • Continue collecting network data via the template

as part of the certification process • Continue researching use of machine readable

(MR) data for use in the future *Augmenting American Hospital Associate data with state department of insurance (DOI) hospital data

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Machine Readable Requirements

• Issuers are required to publish provider and formulary data on websites – Must be complete and accurate – Must be in a machine readable (MR) format as specified by HHS – HHS specifies JavaScript Object Notation (JSON) format

• Must update MR information at least once monthly – Must provide that MR information to HHS/CMS

• 45 CFR 156.122(d)(1) - (2) and 156.230(c)

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MR Compliance Activities

• CMS monitors compliance with the MR requirements – Review of issuer websites – Track compliance during compliance reviews – Track compliance during Post - Certification Assessment (PCA)

process

• Resolution of MR Compliance Issues – Technical Assistance – Notice of Non - Compliance

• Issuers can MR questions in the UserVoice platform – https://cms-provider-directory.uservoice.com/– Also contains Knowledge Base documents

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https://cms-provider-directory.uservoice.com/


Questions

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machine readable and consumer support tools

Documents