837 Professional and Institutional Changes 4010A1 to 5010

1. 837 Professional and Institutional Changes4010A1 to 5010 Presented by John Bock

2. 5010 Objectives • Provide clear direction as to NPI usage and Provider Structure • Eliminate, or at least minimize, ambiguity • Eliminate redundancies • Close 4010 Loopholes • Minimize need for trading partner companion guides • TR3 Development Requirements

3. NPI and Provider Structure • 4010A1 Implementation • Allows for a significant amount of flexibility in provider structure • Results in major challenge for both providers and payers

4. Consistent Structure – The Problem Defined ABC Hospital System Payer A enrolls at the system level and requires the Billing Provider be ABC Hospital System. Hospital A Hospital B Payer B enrolls at the hospital level and requires the Billing Provider to be the individual hospital.

5. Consistent Structure – The Problem Defined (Cont) Payer A enrolls at the group level and requires the Billing Provider be XYZ Group Practice XYZ Group Practice Site A with multiple physicians Site B with multiple physicians Payer B enrolls at the Site level and requires the Billing Provider to be the individual site. Payer C enrolls the individual physicians and requires the Billing Provider to be the physician. The Group is considered a Pay-to and must be reported as such.

6. Billing Provider • The 4010A1 versions allowed service bureaus and clearinghouses to be reported in the Billing Provider Loop. This is not allowed in 5010. The Billing Provider must be a provider. • All payer specific secondary identifiers have been removed from the Billing Provider loop.

7. Billing Provider (Cont) • The remaining identifiers in the Billing Provider Loop are: • license numbers • tax identification numbers • UPIN (837P only). • The Billing Provider address must be a street address.

8. Payer Specific Identifiers • Billing Provider payer specific identifiers have been moved to the Payer Loop. • The Billing Provider has also been added to the COB loops to enable clear reporting of payer specific identifiers. • Payer specific qualifiers have been removed from all provider loops in favor of a standard generic qualifier (G2).

9. The Billing Provider’s NPI • In professional and dental claims, the Billing Provider must be an individual when the provider is an unincorporated entity and not eligible for an organization NPI. In all other situations, the Billing Provider must be the organization.

10. The Billing Provider’s NPI (Cont) • If a covered healthcare provider has created subparts, the Billing Provider must always be the most granular level of enumeration. • This is the NPI which is then sent to all payers.

11. Service Location and the NPI • The NPI is not allowed within the service location loops for health care providers except when the service location is not part of the Billing Provider’s organization (e.g. outside lab services, physician hospitalist services, etc)

12. Pay-to Provider • The affect of the 4010A1 Billing Provider definition is the Pay-to Provider can be a service provider or service location. This resulted in a high level of confusion and varied implementation. In the 5010 versions, it is simply an alternate address to direct payment.

13. Pay-to Provider (Cont) • As the Pay-to Provider is simply an alternate address for payment and correspondence to be directed, there are no applicable identifiers. • This loop is where lock-box or PO Box addresses are to be reported.

14. Other Providers • The NPI of individual providers is required when the role of the provider can be influenced by the Billing Provider. These include; Attending, Rendering, Supervising, Operating, Other Operating. • Provider roles where the NPI is only required when known include; Referring, Purchased Service, Ordering

15. Other Providers (Cont) • Replaced the ambiguity of the mysterious “Other Provider” in the 837I with specific loops for the Referring, Rendering, and Other Operating Provider Loops. Each with its own specific definition and usage requirements. • Added support for payer specific line level provider identifiers.

16. Other Structure Changes • Drug information • Revised loop structure to ensure only one way for compound drugs to be reported. • Subscriber/Patient Information • Revised the rules for subscriber reporting to be in sync with the eligibility transaction • Oxygen Therapy Information • The various segments needed to complete the CMN for Oxygen services has been consolidated into the FRM Segment.

17. Other Structure Changes (Cont) • Payer Specific Referral and Prior Authorization Numbers • Developed a structure that is more efficient and robust than was done in 4010. • Added the Pay-to Plan loop to support the Medicaid (and other payer) Subrugation process

18. Other Structure Changes (Cont) • Loop and Segment Repeats • Segments and loops with repeat possibilities were reviewed for appropriateness. In cases where the number of repeats was deemed excessive or illogical, the count was changed. Examples are: • Accident Date reduced from 10 to 1 • Acute Manifestation Date from 5 to 1 • Line Adjustment Information (CAS) from 99 to 5

19. Data Requirements Review • Several data elements, segments and loops were eliminated as they were deemed no longer necessary. These include, but are not limited to: • Responsible Party Information • Credit/Debit Card Information • Home Care Plan Information • Many COB related amounts which can be calculated or derived based upon other data within the claim

20. Data Requirements Review (Cont) • On the other hand, additional data elements were added as a result of requests submitted either directly to X12 or through DSMO change requests. Examples of these include; • Ambulance pick-up and drop-off addresses • EPSDT (837I) • Condition Codes (837P) • Present on Admission Indicator (837I) • Support for ICD-10 CM and ICD-10 PCS

21. Data Requirements Review (Cont) • In the name of clarity, many segments were “flattened” out. This means segments with multiple qualifiers and purposes were split out into their own distinct segment representation. This allows for clear rules to be written for each piece of information. Examples of this include: • Referral/Prior Authorization Number • Principal, Admitting, E-Code, and Patient Reason for Visit Diagnosis Information

22. Data Requirements Review (Cont) • Situational Rules clarified and tightened. • Rules were modified as necessary to clearly state when the data is required. • The rules also state when the data is not to be sent. • Informational notes were painstakingly separated from rule notes for clarity.

23. 004010A1 Note Structure • Notes:1. In the case where the patient is the same person as the subscriber, the property and casualty claim number is placed in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is placed in Loop ID-2010CA. This number should be transmitted in only one place. • 2. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 4.2, Property and Casualty, for additional information about property and casualty claims. • 3. Not required for HIPAA (The statutory definition of a health plan does not specifically include workers’ compensation programs, property and casualty programs, or disability insurance programs, and, consequently, we are not requiring them to comply with the standards.) but may be required for other uses.

24. 005010 Note Structure • Situational Rule: Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send. • TR3 Notes: 1. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims. • 2. This segment is not a HIPAA requirement as of this writing.

25. Consistency • Consistency efforts have long been a challenge in developing the Implementation Guides. Thanks to the creation of new tools and a database design, consistency within a single IG and across all of the 5010 837 IGs is a tremendous improvement. • Significant effort was expended on the part of both X12 and the NUBC to ensure the UB04 and the 5010 837I are as in sync as possible.

26. Education and Examples • “Front Matter” instruction has been added to provide direction and clarify many high level concepts. These sections include: • Extensive COB instruction • How to create a COB claim from a paper remit • How to balance a COB claim • How receivers are to calculate the allowed amount of the prior payer • Acknowledgments

27. Education and Examples (Cont) • Inpatient and Outpatient designations • Other definitions • NPI Usage Within the 837 • Receiver direction to take an ignore, don’t reject attitude towards situational or redundant data they do not use • Example transactions have been updated, created, and verified to be current.

28. Questions?

29. Contact Information • John Bock • jbock@prodigy.net