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Medicare Fee For Service (FFS)

Medicare Fee For Service (FFS). 5010 and 837I. Purpose of Today’s Call. Highlight significant differences between the 4010A1 837I and the 5010 837I Provide update on Medicare FFS activities Discuss the 837I Errata. What was adopted under HIPAA 5010. Version 5010 of the X12 standards

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Medicare Fee For Service (FFS)

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  1. Medicare Fee For Service (FFS) 5010 and 837I

  2. Purpose of Today’s Call • Highlight significant differences between the 4010A1 837I and the 5010 837I • Provide update on Medicare FFS activities • Discuss the 837I Errata

  3. What was adopted under HIPAA 5010 • Version 5010 of the X12 standards • General Changes • Implementation Guides (IG) are now referred to as Technical Review Type 3 (TR3) • Front matter was revised to be more consistent across transaction types (e.g. claim, eligibility, claim status) • “Situational” rules further clarified and updated to specify when an element is required or not allowed. • Ambiguities in 4010A1 rules were corrected; “should” was replaced with “must” in many cases. • If not required…do not send.

  4. Differences in 5010 • Billing Provider (2010AA) prohibits use of PO Box • Billing provider address (2010AA) and Service facility address (2310E) require a 9 digit zip code • SBR loops allow for 8 additional iterations • Removed Responsibility Party and Credit/Debit card loops (2010BC and 2010BD)

  5. Differences in 5010 cont’d • Modifications to DTP (Date) segments • Modifications to AMT (Amount) segments • Patient Status Code (CL103) usage required • POA indicator moved from the K3 segment to the HI segment • Added a ‘not otherwise classified’ (NOC) procedure code description • The Unit Rate (SV206) is changed to ‘Not Used’

  6. Medicare Implementation of 5010Common Edits and Enhancement Module (CEM) • Standardized Claim Editing • One set of edits per line of business • Consistent editing • Consistent results for transaction exchange Standardized Error Handling • TA1 Interchange Acknowledgement • High level report of the ISA-IEA • Complete file failure

  7. Medicare Implementation of 5010Common Edits and Enhancement Module (CEM) cont’d • 999 • Replaces the 997 transaction • Communicates X12 and IG syntax violations • Can result in all claims being returned (unless 999E) 277CA (claims acknowledgement) • Used to communicate the status of individual claims (accepted or rejected) • Replaces proprietary reports

  8. Medicare Implementation of 5010Common Edits and Enhancements Module (CEM) cont’d • Receipt, Control, and Balancing • System of internal checks and balances • Flags out of balance situations Claim Number Assignment • Immediate assignment of DCN to accepted claims • DCN will be included in the acknowledgments • Allows faster access to status inquiry/IVR

  9. Medicare FFS Business Changes • Increased adjudication capability of ‘other’ diagnosis codes from 8 to 24 • Increased adjudication capability of ‘other’ procedure codes from 5 to 24 • Updated the core processing system to accept 7 byte diagnosis codes • Updated the NPI validation in the front end • Implemented the PWK segment • Added MSP balancing edits

  10. 837I Errata • Proposed Errata Content • Change of various N4 (City State Zip) segments from REQUIRED to SITUATIONAL • Addition of a Property and Casualty Patient Identifier segment in the 2010CA loop (Patient Name) • Change 2010BA NM108 & NM109 (Subscriber Primary Identifier) to SITUATIONAL – required when a “person”

  11. 837I Errata cont’d • Change the Admission Type Code (CL101) from SITUATIONAL to REQUIRED • Change to situational rule for the LIN segment (Drug Identification) and code values in LIN02 segment to capture product number/device identifier • Medicare does not anticipate any impact to 5010 implementation or compliance dates.

  12. Submitter Testing Procedures • 25 claim minimum • ISA15 must = T for testing • 100% syntax • 95% Medicare business rules • Submitter is considered in test until approved by contractor

  13. Timelines

  14. Are you preparing for 5010 • Start now • Ask your vendor and/or clearinghouse about their plans and timeframes implementing 5010 • Communicate and coordinate • Test: internally and externally • Know your vendor’s schedule • Know your trading partner’s schedule • Communicate within entire organization to insure all impacts identified early

  15. Compliance Dates • Compliance deadlines were set per public comments • CMS expects compliance deadlines to be met – no extensions • Success will depend on starting early!

  16. Future EDI ACTs 2011 • These teleconferences are to address your EDI questions. • No reservations are required. • Who should attend? Providers, billing staff, vendors and clearinghouses with Medicare EDI questions. • 2011 calls (all times 1-2:30pm cst): Date Dial In ID • January 13, 2011 800-305-2862 23338581 • March 10, 2011 800-305-2862 23353257 • May 12, 2011 800-305-2862 23353258 • July 14, 2011 800-305-2862 23353259 • September 8, 2011 800-305-2862 23353260 • November 10, 2011 800-305-2862 23353261

  17. EDI Addresses & Numbers EDIMedicareA@WPSIC.comEDIMedicareB@WPSIC.com Medicare Part A Legacy A Medicare J5 MAC Part A & B (multiple states) (Iowa, Kansas, Missouri, Nebraska) WPS Medicare EDI WPS Medicare EDI PO Box 1602 1717 West Broadway Omaha, NE 68101 Madison, WI. 53713 Fax: (402) 351-6188 Fax: (608) 223-3824 Med A Hotline: (866) 734-6656 J5 Hotline: (866) 503-9670 Medicare Part B LegacyMedicare Part B Legacy (Illinois, Michigan, Minnesota, Wisconsin) (EFT) WPS Medicare Electronic Data Services WPS Medicare Electronic Data Services 912 N Pentecost Drive 8120 Penn Ave. S., Suite 200 Marion, IL 62959 Bloomington, MN 55431 Fax : (618) 998-5170 Fax: (952) 885-2899 Med B EDI Hotline: (877) 567-7261 Phone: (952) 885-2811 (952) 885-2881 (952) 885-2882

  18. Resources • CMS 5010 and D.0 Webpage http://www.cms.gov/version5010andD0 • Educational Resources: http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Systems.asp • 5010 Technical Report Type 3 guides: • X12: www.X12.org • Washington Publishing www.WPC-EDI.com • WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml

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