Medicare Fee For Service (FFS)

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