Lesson 3 Testing the 837

1. Lesson 3 Testing the 837

2. Lesson 3 Topics • Set Up RPMS • Input Provider Taxonomy Codes • Set Up Location file • Set Up Insurer file • Populating RPMS for Error-Free Claims • Test Mode • Production Mode

3. Section 3: Testing the 837 • Set Up RPMS • Input Provider Taxonomy Codes • Set Up Location file • Set Up Insurer file • Populating RPMS for Error-Free Claims • Test Mode • Production Mode

4. What Is Provider Taxonomy Code? • Each provider must have specific code assigned to him/her in RPMS • Code must be entered into RPMS • OR entire 837 transaction will be rejected by insurer • Codes are called Provider Taxonomy Codes • Each code is unique alphanumeric identifier, ten characters in length • Example: 207PE0004X Adult Day Care

5. Find the Right Code

6. Taxonomy Code Updates • Published twice a year • July 1st (becomes effective October 1st) • January 1st ( becomes effective April 1st) • OIT provides updates to be installed into RPMS under AUT namespace • This means that Taxonomy updates are maintained separately

7. Provider Taxonomy code list indicates specialty categories for: Individuals Groups of individuals Non-individuals Provider Taxonomy is divided into 2 different groups: Individual or group codes Classifies type of provider or group Non-Individual taxonomies Classifies healthcare facilities, agencies, nursing units, and suppliers and various vendors Taxonomy Code List Structure

8. Taxonomy Code List Structure (cont’d) • Each of 2 groups on code list is structured into 3 distinct "Levels": • Level I, Provider Type (major grouping of service(s) or occupation(s)) • Level II, Classification (more specific service or occupation related to the Provider Type) • Level III, Area of Specialization (more specialized area of the Classification in which a provider chooses to practice or make services available) • See example of levels on next screen

9. Example of Levels

10. Tip • Providers may have more than one Taxonomy code associated to them • When determining what code or codes to associate with a provider, review the requirements of the trading partner with which the code(s) are being used

11. Input the Code • Codes must be added manually using: • VA Fileman • User Management options in Kernel Menu • For help or access, see site manager or system manager • Codes located in PRV segment, piece4 • One-time procedure

12. Input Individual or Group Codes – General • Enter codes in VA Fileman/New Person file • Set up codes for all billable providers, including secondary providers (e.g., RN’s, Pharmacists) that facilities may have on a claim • Start by inputting most common providers

13. Input Individual or Group Codes - General (cont’d) • Enter Level II description • For example • If provider is an Emergency Room Physician, enter ‘Emergency’ into RPMS and system will display the following: Physicians (M.D. and D.O.) Physician/Osteopath Emergency Medicine

14. Input Individual or Group Codes - General (cont’d) • System is case-sensitive when entering Provider Taxonomy • Provider name is correctly entered with lowercase letters • For more specific categories, such as SPORTS MEDICINE, enter ‘Sports’ • System will attempt to locate all Sports Medicine providers

15. Input Individual or Group Codes - General (cont’d) • For specific steps to add Provider Taxonomy, go to: • Manually Adding Provider Taxonomy http://www.ihs.gov/AdminMngrResources/HIPAA/documents/HIPAA_Adding_Taxonomy_Codes.pdf • Quick Reference Guide to 837 and 835 Transactions and Code Sets

16. Input Non-Individual Taxonomies - General • Enter information in VA Fileman/ Location file • Will need to enter: • Location name • Classification of facility • Set up codes for all billing locations

17. Input Non-Individual Taxonomies – General (cont’d) • To determine facility classification, may choose to use RPMS Provider Taxonomy Crosswalk http://www.ihs.gov/AdminMngrResources/HIPAA/documents/TAXONOMY_crosswalk_document.xls • For standard I/T/U Location Taxonomy codes, scroll down to Non-Individual (Facility) Taxonomy Code section

18. Input Non-Individual Taxonomies – General (cont’d) • For specific steps to add Provider Taxonomy, go to: • Manually Adding Provider Taxonomy http://www.ihs.gov/AdminMngrResources/HIPAA/documents/HIPAA_Adding_Taxonomy_Codes.pdf • Quick Reference Guide to 837 and 835 Transactions and Code Sets

19. Important Points About Taxonomy Codes • Crosswalk: • Crosswalk was built into RPMS 3rd Party Billing to alleviate sites from having to populate numerous locations • See Provider/Location Taxonomy AUT Patch v98.1, Patch 13 •  Billing and Claims Editor • Provider and location taxonomy codes may be used right after entered • User will not see codes in claim editor • Access Provider Inquiry (PRTM) option in Table Maintenance to view codes

20. Section 3: Testing the 837 • Set Up RPMS • Input Provider Taxonomy Codes • Set Up Location file • Set Up Insurer file • Populating RPMS for Error-Free Claims • Test Mode • Production Mode

21. Set Up Location File • Location files must be set up on a one-time basis • Step must be completed for each location that is to be billed; required for 837 • Step provides physical street address to your claims   • If facility is already testing 837 format with other Insurers, this step may already be complete

22. Set Up Location File (cont’d) • For specific steps to set up location file, go to one of the following: • Quick Reference Guide to 837 and 835 Transactions and Code Sets • Trailblazers Medicare Part A: Testing and Production Procedures • Trailblazers Medicare Part B: Testing and Production Procedures

23. Section 3: Testing the 837 • Set Up RPMS • Input Provider Taxonomy Codes • Set Up Location file • Set Up Insurer file • Populating RPMS for Error-Free Claims • Test Mode • Production Mode

24. Set Up Insurer Files • Set up each insurer in Insurer file • Enter trading partner’s name • Enter trading partner’s Associate Operator (AO) control number • This is insurer’s electronic identification • All sites use the same number for an insurer • Enter Electronic Media Claims (EMC) submitter identification • This is login number and password assigned by a particular insurer to a particular facility • Found in the Companion Guide or provided by insurer • Facility cannot test electronic claims submission process without EMC number

25. Set Up Insurer Files (cont’d) • For specific steps to set up Insurer file, go to one of the following: • Quick Reference Guide to 837 and 835 Transactions and Code Sets • Trailblazers Medicare Part A, Testing and Production Procedures • Trailblazers Medicare Part B, Testing and Production Procedures

26. Section 3: Testing the 837 • Set Up RPMS • Set Up Location file • Set Up Insurer file • Input Provider Taxonomy Codes • Populating RPMS for Error-Free Claims • Test Mode • Production Mode

27. Populating RPMS for Error-Free Claims • Enter data correctly or claim will be rejected • If data element is mandatory, it must have data in it • Data elements must be entered exactly as prescribed • No special characters or punctuation allowed • Data elements for a patient must be entered the same way at every location

28. Examples • Ft. Defiance • Entered as Ft Defiance or Fort Defiance • P.O. Box • Entered as PO Box • 5-21-05 • Entered as 05212005 • 610-555-0123 • Entered as 6105550123

29. Common Data Problems • See Common Errors That Cause an 837 Claim to Be Rejected in “Quick Reference Guide to 837 and 835 Transactions and Code Sets”

30. Section 3: Testing the 837 • Set Up RPMS • Input Provider Taxonomy Codes • Set Up Location file • Set Up Insurer file • Populating RPMS for Error-Free Claims • Test Mode • Production Mode

31. Two Levels of Testing • Level 1: HIPAA Compliance Testing • Level 2: Insurer Testing • Important • Even if you pass Level 1 testing and file is accepted initially, • you could still fail Level 2 testing with insurer. • You MUST pass both levels of testing.

32. Level 1 HIPAA Compliance Testing – 6 Types • Integrity Testing • Validates basic syntactical integrity of EDI file • Implementation Guide Requirements Testing • Involves requirements imposed by HIPAA Implementation Guide, including validation of data element values specified in Guide

33. Level 1 HIPAA Compliance Testing – 6 Types (cont’d) • Balancing Testing • Verification that summary-level data is numerically consistent with corresponding detail level data, as defined in HIPAA Implementation Guide • Inter-Segment Situation Testing • Validates inter-segment situations specified in HIPAA Implementation Guide (e.g., for accident claims, an Accident Date must be present)

34. Level 1 HIPAA Compliance Testing – 6 Types (cont’d) • External Code Set Testing • Validates code set values for HIPAA mandated codes defined and maintained outside HIPAA Implementation Guides • Examples: • Local Procedure Codes for which states were given waivers • NDC Drug Codes • Claim Adjustment Reason Codes • Claim Status Codes • Claims Status Category Codes • Remittance Remarks Advice Codes • Last four codes/updates published by Washington Publishing Company; OIT updates them

35. Level 1 HIPAA Compliance Testing – 6 Types (cont’d) • Product Type or Line of Service Testing • Validates specific requirements defined in HIPAA Implementation Guide for specialized services such as durable medical equipment (DME)

36. Level 2 Insurer Testing • Trading partner-specific testing • Involves testing coding and transaction requirements that are required by insurer but that are not specifically determined by HIPAA • These requirements will be found in insurer’s Companion Guide

37. Ready to Begin Level 2 Testing? • Required software installed. (See Lesson 2) • Trading Partner Agreement and EDI forms in place. (See Lesson 2) • RPMS set-up complete and correct. (See this lesson) • Have tested for HIPAA compliance. (See this lesson) • Have complied with insurer’s requirements in Companion Guide. (See this lesson)

38. What Does It Mean For You? Financial Management Officer:“Ah, we thought we were done! . . . The ultimate benefit is a cleaner process that puts money back into the facility.”

39. Testing Process #1 • Choose bills for initial test batch • Bills should include variety of visit types that you already bill to insurer • E.g., Institutional, Professional, Dental • If appropriate, include variety of locations • See Companion Guide for how many bills to include in test batch • At least 3 of each type • See Companion Guide for file naming conventions; max 16 characters

40. Testing Process #2 • Check each bill carefully to make sure that it is correctly populated • Mandatory fields are filled in • Data entered adheres to 837 conventions

41. Testing Process #3 • Set EMC Test Indicator to identify file as test file • In 3P, go to Add/Edit Insurer (EDIN) • Select INSURER: Indicate insurer you are testing • EMC TEST INDICATOR: change value to “T”

42. Testing Process #4 • On each claim, change mode of export • Go to Claim Editor. • EDTD>EDCL. • Desired ACTION: enter “E” (Edit). • Desired FIELDS: Enter “7”. • Mode of Export: Enter “??”. • Select appropriate form: 837 UB or 837 1500

43. Testing Process #5 • Submit different batches for each 837 format • Once claims (3 or more) of one 837 format are approved, export batch in usual process via RPMS Pub Directory

44. Testing Process #6 • Once you submit batch via FTP or your usual process: • E-mail insurer that file has been submitted • Request verification from insurer that file was received • Consult local or Area IT if you have problems • Wait for response or error report from insurer • If no word within 24 hours, call insurer contact to find out status of file

45. Testing Process #7 • If you receive error report, make fixes locally • Either by Business Office or Patient Registration, depending on error • If you can’t figure out how to fix error, consult with local or Area IT contact • Once fixes made, resubmit claims to insurer • Repeat process until claims pass with no errors

46. Testing Process #8 • After initial claims go through with no errors, prepare a larger batch (@ 25 claims) of each 837 format • Test these claims following steps in Testing Process #2 - #7 •  NOTE: See Lesson 4 for how to read error reports and make corrections

47. Testing Realities • Testing process may be lengthy • Testing time varies by: • Time you put into it • Insurer • Process used • Number of claims that have to be tested • If clearinghouse involved, another level of preparation and testing is required • May also be more labor intensive

48. Testing Realities (cont’d) • If claims have errors, they will not be paid until they are corrected • If testing involves several locations and/or insurers, there are more possibilities for errors • Monitor each batch submitted and provide timely corrections

49. Testing Tips • Evaluate staffing before you begin testing • Demands on staff time will increase • Anticipate this and assign adequate resources • For example: • Cleaning up patient database may require a massive effort • You now have a double workload in Billing Office: • Maintaining regular claims process so payments continue • Creating and submitting test files

50. Be as prepared as you can but don’t delay testing The sooner you jump in, the sooner you will be through it Keep everyone informed of progress being made in testing process through e-mail group Insurer contacts OIT contacts Area contacts Service Unit contacts More Testing Tips