HIPAA EDI OUR EXPERIENCE

1. HIPAA & EDI OUR EXPERIENCE

2. BACKGROUND UWHC is a 500 bed complex academic medical center. > 600,000 ambulatory encounters and 20,000 admissions annually Siemans Invision mainframe HIS platform; Cirius claims scrubber Live with 837-4010A format direct to 8 payers;testing with 7 additional payers and 1 clearinghouse.

3. TOPICS OF DISCUSSION Your Trading Partners Testing services and certification Companion Documents Getting started: How we dealt with some problems How much testing is enough Moving to Production The 835 Wrap Up

4. YOUR TRADING PARTNERS Create a priority list of your partners: Which payers represent highest volume of claims? Which transactions are most important with which partners? Establish an EDI contact with each of your Trading Partners Create a checklist with each partner

5. TRADING PARTNER CHECKLIST Contact name � your new best friend until October 16th! Your own internal identifiers for this payer Mode of transmission agreed upon (FTP modem, Bulletin Board, Internet etc) Logins and passwords Encryption

6. CHECKLIST (CONT) Timetable for transmission and acceptance reports Create a log for transmission, acceptance and comments pertaining to this payer. The more �best friends� you have, the more important this becomes to keep everyone straight.

7. TESTING AND CERTIFICATION Subscribe to a nationally recognized Testing Agency. (We use Claredi) This provides you with credibility and identifies issues within your own data and it�s cheap! Prepare test files using production data in a test environment to submit to the testing service Don�t send a test file to a payer until you are certified

8. COMPANION DOCUMENTS Not all payers have companion documents. If not, they need to identify values they would like to see in the ISA and GS segments as well as any situational loops they require. Your testing agency will tell you if their requirements are compliant or not.

9. Problems/Solutions Loop 2400 SV2 � too much information! Based on the revenue code � if revenue code 0022, 0023 or 0024 you must send a ZZ in SV202-1 If you are passing a hcpc code, you must pass an HC in SV202-1 If you are passing a modifier, there has to be a separator between the hcpc and modifier(s)

10. PROBLEM Loop 2400 DTP If you are a Home Health Provider and sending a RAP claim to Medicare, they want to see the �Assessment Date� and not the service line date. Work with your HHA on how this date will be passed. Many will use the admission date field for this which can then be mapped to this loop.

11. PROBLEM Where do you put those valuable remarks you want the payer to see so you don�t have to fax or mail them something separately? (Remember this is an electronic solution) Use the 2300 Loop Billing Note and map form locator 84 to this loop so it is transparent to your billers but allows this information to pass.

12. PROBLEM E & M codes � if you are a hospital based provider and billing revenue code 510 your file is non-compliant without a CPT code for this revenue code. The current CPT language for E & M is defined for physician services. Send a letter of understanding to your trading partners that your are sending an E & M that represents Facility services and not professional.

13. HOW MUCH TESTING IS ENOUGH The larger the payer, the more testing you should do. Send each test file through your testing service prior to sending to the payer. The more you test, the greater likelihood of finding all those unique errors Don�t fix the claim, fix the cause: track the error back to the source data and find a way to prevent then from recurring

14. MOVING TO PRODUCTION Only the payer can set this date. Many have to test your data in two capacities, first run it through a front end translator and then through their claims adjudication system Some payers will forward your files through their own testing service which is why you want to make sure it is clean!

15. The 835 Remember, you are helping the payer by giving them an 837, ask for an 835 in return. This translates into FTE for you in batching and keying cash transactions. Use this in prioritizing your trading partners. In addition to the 835 ask the payer to send the funds through EFT so you are not sitting on transactions while a check is being mailed.

16. The 835 (cont) Research what steps you can build into the 835 process that will help your facility. We post the cash, compare the contractual allowance to that posted at time of billing and correct if necessary, move the balance to the next payer, generate a secondary claim form and EOB and post the ansi codes as remarks to the account.

17. The 835 (cont) Ask the payer to map their existing proprietary codes to the ansi codes. Knowing this up front will reduce calls back to the payer to translate after you are in production. Ask for the 835 test files to be of actual claims so you can look at production data for a comparison.

18. WRAP UP What have we learned? � The IG�s have to be read and not used to cure insomnia. I/S cannot own this � it is about claims and adjudication, not programming. Get certified � without this, you have no credibility; with it you have an internal testing resource Keep it simple! This is a solution, not a problem

19. Facts Trading partners really are �partners� work to benefit both sides; don�t agree to processes that require manual intervention � this is an electronic solution! Your vendor will not make you compliant! Your clearinghouse will not make you compliant!

20. CLOSING If you haven�t already done so, schedule a vacation starting October 17th. Don�t tell anyone where you are going! Computers and phones not allowed on this vacation! Good Luck!