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Medicare Fee For Service (FFS) 5010 Moving Into Production

Medicare Fee For Service (FFS) 5010 Moving Into Production. Purpose of Power Point. Testing Requirements OESS Announcement CMS Medicare FFS Announcement Calling EDI? Moving into production April 1, 2012. 5010 Transactions and Affected Business Processes.

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Medicare Fee For Service (FFS) 5010 Moving Into Production

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  1. Medicare Fee For Service (FFS)5010 Moving Into Production

  2. Purpose of Power Point • Testing Requirements • OESS Announcement • CMS Medicare FFS Announcement • Calling EDI? • Moving into production • April 1, 2012

  3. 5010 Transactions and Affected Business Processes • Claims (837 Institutional, Professional, COB, Dental, NCPDP) • Claim Status (276/277) • Claim Payment (835) • Enrollment (834) • Premium Payment (820) • Eligibility (270/271) • Referrals and Prior Authorizations (278) • Claims Acknowledgements (277CA) • Acknowledgement for Health Care Insurance (999)

  4. Medicare is ready. Are you? • Testing began in January 2011 • Processing 5010 claims since April 2011 • Over 2.4 million claims accepted last week • Test results returned within 3 business days • 835 Production Parallel files available upon request by contacting the EDI Hotline. • Results returned on a first come first served basis.

  5. Direct Submitters Testing Procedures • 25 claim minimum • Testing in errata version only • 100% syntax • 95% Medicare business rules • ISA14 highly recommended to = 1 • ISA15 must = T • Submitter is considered in test until approved by contractor

  6. Top 5010 Errors – Med B 837P • Billing provider not authorized for this submitter. • Payer's ID Number 2010BB.NM109 must be the same value as the Receiver's ID Number 1000B.NM109. • Other Insured's Adjustment Quantity; 2430.CAS04 must not be equal to zero. • Invalid Health Insurance Claim Number. • Invalid codes • Zip (can not be padded with 0s or 9s) • HCPCS • NDC • Rendering provider NPI same as Billing • SV101-7 code description required for NOC/NOS codes (revised list)

  7. Companion Guide • To assist trading partners and their business associates with exchanging transactions • Companion Guide provides technical and connectivity specification for the following: • 837 Health Care Claim Institutional • 837 Health Care Claim Professional • 835 Health Care Claim Payment Advice • 276/277 Status Inquiry and Response • Companion guides posted to: http://www.wpsic.com/edi/pdf/med_a_837i_companion.pdf http://www.wpsic.com/edi/pdf/med_b_837p_companion.pdf

  8. Clarification of OESS Announcement • CMS Office of E Standards (OESS) issued guidance “it would not initiate enforcement action,.. until 90 days after ” e.g. April 1, 2012 • The OESS is the compliance side of the CMS house and is in charge of enforcement of the HIPAA legislation.   • CMS-OESS is not the same as CMS Medicare Fee-For-Services.  

  9. CMS Medicare Fee For Service Announcement • Trading Partners that have tested and been approved for 5010 have 30 days to complete their cutover to production. • Trading Partners that have not started or completed testing of the new versions must submit their testing/transition plan and timeline to their Contractor within 30 days showing how they will complete their transition by March 31, 2012. • All transactions received after 4 pm cdst on March 30th must be in version 5010 by MACs.

  10. Some choose to wait…

  11. Contacting WPS’s Medicare EDI Hotlines? • Call volumes are up • Call durations are longer • Wait times are up • This affect billers, vendors, payers, and clearinghouses! • WPS Medicare EDI call volumes peaked the week ending January 13, 2012, but still high.

  12. Where are we at now on WPS’s Medicare EDI Hotlines? • Average/Max wait times last week: AvgMax J5A-EDI 1:26 13:06 J5B-EDI 0:25 15:23 Legacy A-EDI 0:55 8:55 Legacy B-EDI 2:06 19.31 • Normal Enrollment and ERA Processing times 7-10 business days • Calls, Enrollments, ERA requests, Voice Mails… are being responded to in the order which they were received.

  13. Checklist for Moving Into Production • Use the tools available to you to monitor your business • Identify contingencies • Read your 999 responses • Read your 277CA responses • Review your remittances • Monitor your cash flow • Identify and correct in a timely manner any issues identified. • Use these tools to monitor your business so when you call, you’ll already have an idea what the issue may be

  14. Help Us Help You… • When you call have information available which will help us identify your file and research your issue: • Submitter ID • NPI • ISA Control Number that was sent to WPS Medicare (this is especially important for clearinghouse customers. ISA13 is NOT Protected Health Information) • Claims Count • Date of Submission • Dollar Amount of submission • Other ways to contact EDI… EDIMediareA@WPSIC.com, EDIMedicareB@WPSIC.com

  15. Medicare Part A Statistics through 2/03/12 91.3% of all claim accepted are 5010

  16. Medicare Part B Statistics through 2/03/12 89.5% of all claim accepted are 5010

  17. Current Med A Issues • 277 - Claim Status Response - the STC01-1 (Claim Status Category Code) from the the 5010 277 flat file. • 835 - Electronic Remittance Advice – PLB0X-2 missing from FISS flat file which is failing compliance checking. • MSP on DDE System - FISS mapping issue where primary payer name is not mapping to FISS.

  18. Current Med B Issues • Canadian Beneficiary Address • Delays in getting claims into adjudication system • Presence of 2000C/PAT not rejecting correctly • Partial 835 (not a complete ISA-IEA) • Duplicate 835s

  19. Getting 5010 – 835 Electronic Remittance Advice • 835 Production Parallel files available upon request by contacting the EDI Hotline. • Production 835 is generated based on how the receiver/provider are set up • Not generated based on inbound claim format • When ready, we can “flip” the entire submitter from 4010 to 5010-835. • We can also “flip” on a provider by provider basis who gets 5010-835. • Request to switch from 4010 to 5010-835 should be done in writing. • If a user doesn’t request to be flipped, they will automatically be switched to 5010 effective March 31, 2012.

  20. Getting 5010 – 276/277 Claim Status Inquiry and Response • Testing is not required • “Testing” is done using production data • ISA05 must = ZZ • ISA06 must = ZZ • ISA14 highly recommended to = 1 • Be sure to have ISA15 = P

  21. Part A Check 14th digit of DCN = 7. Ex: 21200100627607 Part B Check your ICN regions. RRYYJJJCCCCCC Ex: 1012001123450 5010 EMC 4010 EMC IL/IA 09 10 02 MI/MO 18 19 11 WI/KS 28 29 22 MN/NE 38 39 32 How can I tell if I am 5010?Check your remittance advice.

  22. PC-Ace Pro32 • Providers may download PC-Ace Pro-32 software at the link below to submit 5010 file formats: http://www.wpsic.com/edi/pcacepro32.shtml • This free 5010 errata software with instruction regarding set up posted on web site • New PC-Ace users must test • Existing PC-Ace users are not required to test.

  23. Contingency Plans • Approved vendor, billing services and clearinghouse lists: http://www.wpsic.com/edi/5010-Readiness.shtml • PC-Ace Pro32 • Paper claim submission is not a contingency option • Clearinghouse options? Set Up? Set Down? • What are your contractual arrangements with vendor and/or clearinghouse? • Other?

  24. Future EDI ACTs 2012 • 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. • 2012 calls (all times 1-2:30 pm cst): Date Dial In ID • April 12, 2012 800-305-2862 11138600 • June 14, 2012 800-305-2862 11138601 • August 9, 2012 800-305-2862 11138602 • October 11, 2012 800-305-2862 11138603 • December 6, 2012 800-305-2862 11138604

  25. Cutting Off 4010 • Last 4010 inbound transactions accepted must be received and processed by WPS, before 4 pm cdst, March 30, 2012. • 4010 transactions received after 4 pm will receive message that the format is no longer accepted. • 835 receivers, who have not previously converted to 5010 will be switched.

  26. Our Message to you… • Move into production now! • Continue to work with your vendor and/or clearinghouse • Monitor your business • It is your responsibility to be compliant • If you fail to prepare, it will be your business and cash flow that will be affected!

  27. Questions and Answers • We want to hear from you… • Also visit our 5010 readiness site for additional FAQs: http://www.wpsic.com/edi/5010-Readiness.shtml

  28. 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) 995-0606 Fax: (608) 223-3824 Med A Hotline: (866) 734-6656 J5 Hotline: (866) 503-9670 Medicare Part B Legacy (Illinois, Michigan, Minnesota, Wisconsin) WPS Medicare Electronic Data Services 912 N Pentecost Drive Marion, IL 62959 Fax : (618) 998-5170 Med B EDI Hotline: (877) 567-7261

  29. Resources • CMS 5010 and D.0 Webpage http://www.cms.gov/version5010andD0 • Educational Resources: http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys • 5010 Technical Review Type 3 guides: • X12: www.X12.org • Washington Publishing www.WPC-EDI.com • WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml • CMS National Provider Calls: http://www.eventsvc.com/palmettogba/

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