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  1. X Main Menu Main Menu • Thanks for taking the time to learn about changes in Medicaid billing as a result of HIPAA. This module will orient you to the changes and the next steps you must take in order to be compliant with HIPAA transaction and code sets requirements – and get paid for services! • Overview • Code Sets • Filing Options • Transactions • Eligibility Request / Response (270/271) • Referral / Authorization (278) • Claim Submission (837) • Claim Payment / Advice (835) • Claim Status Request / Response (276/277) • Tools and Processes • Resources • SC Medicaid Web-Based Claims Submission Tool Demo How to use this course: Proceed at your own pace through this module using the buttons at the bottom of the screen. goes to the Nextslide goes to the Previous slide returns tothe Main Menu exits the presentation and returns to the web site You may also access topics through links on the Main Menu.

  2. Overview Overview X

  3. Overview The Legislation • Why was HIPAA enacted? • HIPAA (Health Insurance Portability and Accountability Act) is a federal law enacted in 1996. • As health care became increasingly complex in the last decade, legislators recognized a need to make it easier for people to get insurance, to protect personal health information, and to reduce administrative costs while limiting fraud and abuse of the system. • Health Insurance Portability and Accountability Act(HIPAA) • Federal law enacted in 1996 • Designed to: • Provide better access to health insurance • Protect Personal Health Information (PHI) • Reduce administrative costs and limit fraud and abuse

  4. Overview How It Affects YOU • What is the impact of HIPAA? • The impact of of HIPAA is bigger than Y2K. It affects every aspect of health care operations. • HIPAA-mandated privacy regulations were effective April 14, 2003. Regulations standardizing transactions and code sets will be implemented October 16, 2003. • National standardization of transaction and codes sets is projected to result in significant time and cost savings. • Let’s examine how these changes affect your transactions with SC Medicaid. • Dimensions • Security • Privacy • Transactions • Code Sets • Cost • Larger effort than Y2K • Benefit • Significant time and cost savings, long-term • Protection of protected health information (PHI)

  5. Codes Code Sets X

  6. Codes Code Sets • How will codes change? • HIPAA mandates the standardization of medical and non-medical codes used in transactions. • Bottom line, with HIPAA, you will use only standard code sets (listed to the right). • SC Medicaid has cross-referenced (“crosswalked”) all local codes to national codes. This crosswalk may be accessed by visiting the SC Medicaid HIPAA web site: www.scdhhshipaa.org. • Medical • ICD-9-CM (diagnosis and procedures) • CPT-4 (physician procedures) • HCPCS (ancillary services/procedures) • CDT-2 (dental terminology) • NDC (national drug codes) • Non-medical • Gender, marital status, citizenship, etc. • Remittance Advice Codes (RARC) • Claim Adjustment Reason Codes (CARC)

  7. Codes Medical Code Crosswalk • How do I read the Medical Code crosswalk? • The medical code crosswalks are formatted as illustrated in the example to the right. • The local code currently used is located in the first column; the corresponding national code is located in the third column. Current Code New Code

  8. Filing Options Filing Options X

  9. Filing Options Filing Process(before 10/16/03) • Summary of the current process for claims submission to SC Medicaid. • Currently, providers submit claims to the Medicaid Management Information System (MMIS) in one of several ways: • Through a Clearinghouse or Billing Agency • Through the MCCS, via paper, or electronic media • Providers and clearinghouses currently use various different data formats for claims submission (in fact, there are about 400 different formats being used in the US!). All electronic transactions regulated by HIPAA must be standardized to meet ANSI X12 4010A formats, as specified in the Implementation Guide. These standards may be found at www.wpc-edi.com/hipaa/hipaa/_40.asp. Billing service/ Clearinghouse MMIS Tape, diskette, CD, etc. MCCS Paper MCCS

  10. Filing Options Filing Process (starting 10/16/03) • How will the filing process change? • Effective 10/16/03, all electronic claims must be submitted in HIPAA-compliant format. • Claims will go to an assigned EDI mailbox, then will travel through a Translator to the MMIS. The Translator serves to convert HIPAA-compliant formats into formats that can be accepted by the MMIS. • Providers will have two new options for submitting claims . . . Billing service/ Clearinghouse EDI Mailbox MMIS EDI Mailbox TRANSLATOR EDI Tapes, ZIP files, diskettes, CDs EDI Mailbox MCCS Paper MCCS

  11. Filing Options Web Filing • Web Filing! • Effective 10/16/03, providers may submit HIPAA-compliant claims via modem. • Additionally, SC Medicaid is pleased to provide a web-based claims submission tool for providers to use at no charge. If you have an ISP (internet service provider), you can submit claims this way. Billing service/ Clearinghouse EDI Mailbox Provider’s EDI software EDI Mailbox TRANSLATOR MMIS Tapes, ZIP files, diskettes, CDs EDI Mailbox MCCS EDI Mailbox Web Filing Paper MCCS

  12. Transactions Transactions X

  13. Transactions Transactions • What are “transactions”? • Transactions in this context refers to EDI communications between the trading partner and the Translator. • HIPAA-regulated electronic transactions that affect you are listed to the right. • HIPAA-mandated formats may include changes on how units are reported, the number of digits in a date or medical record, etc. • Let’s review each of these transactions. • Eligibility Request/ Response (270/271) • Referral / Authorization (278) • Claim/Encounter (837) • Claim Payment / Advice (835) • Claim Status Inquiry / Response (276/277)

  14. Eligibility Request / Response Eligibility Request / Response X

  15. Eligibility Request / Response Eligibility Request / Response (270/271) • What are the eligibility transactions? • There are two transactions related to recipient eligibility, each with a unique transaction number. • The Eligibility Request (270) is sent by the provider • The Eligibility Response (271) is the answer sent by the MMIS • Because they are so tightly related, these are often referred to as the “270/271.” “Does s/he have insurance?” 270 Eligibility Inquiry 271 Eligibility Response MMIS Medicaid Management Information System

  16. Eligibility Request / Response Eligibility Request / Response (270/271) • How will I verify eligibility? • Currently, providers may check eligibility via the telephone, using the Interactive Voice Response System (IVRS), or through an eligibility vendor. These methods will remain. • The 270 transaction will allow providers to perform one or more eligibility inquiries using EDI software. The SC Medicaid Web-Based Claims Submission Tool will also provide for single eligibility checks via the Web. • Interactive inquiry • EDI – through current vendor • IVRS • New option – SC Medicaid Web-Based Claims Submission Tool • Batch Inquiry - new functionality • Transmit to EDI mailbox in HIPAA-compliant format

  17. Referral / Authorization Referral / Authorization X

  18. Referral / Authorization Referral / Authorization (278) • What is a referral/authorization transaction? • The 278 transaction, Referral/Authorization, answers the question, “Is this a covered service?” “Is this a covered service?” 278 – Referral/Authorization MMIS Medicaid Management Information System

  19. Referral / Authorization Referral / Authorization (278) • How will I obtain prior authorizations? • Effective 10/16/03, you will continue using the phone/fax method if attachments are involved. If, however, there are no attachments, you now will have the added option of sending the 278 electronically. • The response from the MMIS will be an acknowledgement of receipt of your request. The authorization number will be mailed or called in as it is today. • Referral / Authorization is sent electronically as a 278 • Process for sending required attachments will not change

  20. Claim Submission Claim Submission X

  21. Claim Submission Claim Submission (837) • Tell me about the claim submission transaction. • This transaction, known as the 837, contains all the data required for the professional, institutional and dental claim forms sent to SC Medicaid. • Claims may be submitted electronically via the 837, or by paper. “Please pay this claim” 837 Claim Submission MMIS Medicaid Management Information System

  22. Claim Submission Claim Submission (837) • What changes can I expect in the claims submission process? • The data you will be required to transmit will not change much. The 837 does expand the number of detail lines per claim. Also, the “other insurance” information has expanded from 2 to 10 carriers. • The 837 will be used also for void and replacement claims. A “void” is an action to eliminate a claim filed incorrectly. Once the void occurs, a replacement claim may then be submitted with the correct information. • Be aware that whether you void one or multiple claims, you will receive only one gross adjustment. • Three formats • Professional (CMS 1500) • Institutional (UB 92) • Dental (ADA Dental Claim Form 1999, Version 2000) • Report up to 10 insurance carriers • Also used for void and replacement claims

  23. Claim Submission Split Claims • How will the MMIS process these claims with increased detail lines? • Claims (with the exception of Institutional) that exceed the original limit of detail lines will be “split.” • That is, when a claim comes in with more detail lines than currently exist on the MMIS, it will be split into multiple claims, all identified by the same claim control number (CCN). For example, a Professional claim holds a maximum of 8 detail lines today. If a claim with 20 detail lines comes in, it will be split into three claims with 8, 8 and 4 detail lines, respectively. • Please note that split claims will not suspend. PROFESSIONAL CLAIM 20 detail lines 8 detail lines 8 detail lines MMIS 4 detail lines

  24. Claim Submission Split Claims on the Remittance Advice • How will I know that a claim has been split? • You will notice claim splitting when you receive the remittance advice (RA). • You will know that claims are related by looking at the CCN. The split claims will share the same CCN; however, they will differ on the 15th and 16th digits. • For Professional claims, the first claim in the split will be denoted by a 10; this number will be incremented by 10 for the remaining claims in the “split”. • For Dental claims, the 15th and 16th digits will increase by increments of 20. • The graphic to the right illustrates this numbering system. Paper and Electronic RA (Professional) xxxxxxxxxxxxxx10x xxxxxxxxxxxxxx20x xxxxxxxxxxxxxx30x Paper and Electronic RA (Dental) xxxxxxxxxxxxxx10x xxxxxxxxxxxxxx30x xxxxxxxxxxxxxx50x

  25. Claim Payment / Advice Claim Payment / Advice X

  26. Claim Payment / Advice Claim Payment / Advice (835) • What is the claim payment / advice transaction? • The 835 provides information on how Medicaid is paying for services billed on the 837 or by paper claim. It reflects both paid and denied services. • Payments are made via check or EFT, depending on the agreement with the provider, and are accompanied by an remittance advice explaining payment or non-payment reasons. “Here is your payment” 835 Claim Payment MMIS Medicaid Management Information System

  27. Claim Payment / Advice Claim Payment / Advice (835) • How will payment change? • Starting October 16th, automated posting to accounts receivable will be possible if your practice management system allows that function. The claim payment will communicate claim adjudication, and contain denials and partial payments. • You may continue to receive payment via check or EFT. You will continue to receive the paper RA and may also elect to receive an electronic RA (835). The electronic RA will contain the national EOB codes, and the paper RA will retain the current codes. • Allows for automated posting to accounts receivable since payment is matched to claims • EFT option remains • Codes • National Explanation of Benefits (EOB) codes on 835 • Claim Adjustment Reason Code • Remittance Advice Remark Code • Current edit codes remain on paper RA

  28. Claim Status Request / Response Claim Status Request / Response X

  29. Claim Status Request / Response Claim Status Request / Response (276/277) • What are the claims status transactions? • There are two transactions related to claim status, each with a unique transaction number. • The Claim Status Request (276) is sent by the provider • The Claim Status Response (277) is the answer sent by the MMIS • Because they are so tightly related, these are often referred to as the “276/277.” 276 Claim Status Inquiry 277 Claim Status Response MMIS Medicaid Management Information System

  30. Claim Status Request / Response Claim Status Request / Response (276/277) • How will I check the status of a claim? • Checking claim status will be faster and easier. The 276 transaction allows providers to check the status of more than one claim at a time. • The 277 will indicate where the claim is in the cycle (in receipt or not found, ready for payment, need more information, paid). • The response will also enable Medicaid to request additional information from the provider regarding the claim. This more efficient process should reduce the incidence of duplicate claim filing. • New electronic option • Multiple claim status can be checked in one transmission • Replies indicate claim status: • Claim in receipt, or not found • Ready for payment cycle • Needs more information • Already paid/processed

  31. Tools and Processes Tools and Processes X

  32. TRANSLATOR Tools and Processes Exchange of Data • How data will flow effective October 16, 2003? • As discussed earlier, electronic transactions exchanged between providers and the MMIS will pass through a Translator. • An electronic mailbox will hold both inbound and outbound transactions. Each time a transaction is sent by a provider, the Translator will send to the mailbox a 997 (Acknowledgment) that will tell the provider if the transaction format (not content) was compliant and has been forwarded to the MMIS. If the transaction is not format compliant, the 997 message will explain why. • Providers will be responsible for checking regularly for outbound transactions from Medicaid. transaction Billing service/ Clearinghouse EDI Mailbox 997 MMIS EDI Mailbox EDI Tapes, ZIP files, diskettes, CDs EDI Mailbox MCCS Paper MCCS

  33. Tools and Processes Next Steps to 10/16/03 • What must providers do – and by when? • First, choose a method for your practice to submit HIPAA-compliant claims. You may choose more than one method. • Second, sign a Trading Partner Agreement. You can get a copy by visiting our web site www.scdhhshipaa.org. • Finally, test sending claims using your chosen method before 10/16/03. This test will need to be scheduled in advance by calling 1-888-289-0709. • Choose your method of submission • South Carolina Medicaid Web-Based Claims Submission Tool • EDI (HIPAA-compliant software) • Paper • Tapes, diskettes, CDs and Zip Files • Clearinghouse/Billing Agency • Sign a Trading Partner Agreement • Test

  34. Resources Resources X

  35. Resources Call or E-mail for HELP! • I have more questions! Where can I go for answers? • Listed to the right are a variety of links and phone numbers where you can get additional information. • The most comprehensive web site about HIPAA and SC Medicaid is www.scdhhshipaa.org. It contains the most current information about instructor-led training events and national codes. • Questions may be emailed to info@scdhhshipaa.org. If you wish to speak to a person, call SC Medicaid HIPAA Provider Outreach at 1-888-289-0709 and one of our friendly representatives will assist you. • SC Medicaid • www.scdhhshipaa.org • SC Medicaid HIPAA Provider Outreach 1-888-289-0709 • www.dhhs.state.sc.us • Statewide Training Sessions • Online Training • Testing Resources • www.hipaadesk.com • www.claredi.com • Implementation Guide • www.wpc-edi.com/hipaa/HIPAA_40.asp • CMS • www.cms.gov

  36. Resources Check your Understanding X

  37. Resources Self-Test • What have you learned? • Click the hippo to bring up a question. • See if you know the answer. Then click again to see if you answered correctly. • Good luck! • HIPAA is designed to simplify healthcare administrative processes. True. • TPA stands for third-party agreements. False (Trading Partner Agreement) • Transactions and Code Sets are a part of the Administrative Simplification process. True • Providers who bill on the CMS 1500 are exempt from HIPAA regulations. False. Everyone must be compliant! • An EDI transaction is the filing of a claim using the CMS 1500. False. It is the electronic exchange of information.

  38. Self-Test (cont.) • Keep going . . . Click the hippo again to bring up the next question. See if you know the answer. Then click again to see if you answered correctly. • Trading Partner Agreements apply to providers filing claims electronically only. False. All entities wishing to conduct electronic transactions with SC Medicaid must sign an agreement. • 837 is the transaction that requests eligibility. False. 837 is the Claim Submission transaction. • SC Medicaid created the Health Insurance Portability and Accountability Act of 1996. False. HIPAA is a federal law. • The South Carolina Medicaid Web-Based Claims Submission Tool requires the purchase of software for use. False. Providers access the free application online via the Internet! • Clearinghouses are required to comply with all HIPAA deadlines. True.

  39. Where next? • Where do I go next? • To review sections of this module, click the home button to return to the Main Menu. • To see samples of the web-based claims submission tool, click the DEMO icon. • To visit the SCHIPAA web site and download codes or companion guides, click the last button. • To exit this presentation, just close this window! • Thanks for taking this course – and best wishes on your journey to HIPAA compliance! DEMO WEB SITE

  40. South Carolina Medicaid WEB-BASED CLAIMS SUBMISSION TOOL X

  41. This screen will appear when you type in the web address. The MAIN MENU lists all the familiar tasks of claims submission. Let’s explore the different options available from the Main Menu. X

  42. 1. LIST MANAGEMENT List Management Tired of typing the same codes and names over and over each time you complete a new claim form? List Management lets you build your own frequently-used lists of codes and patient information. So, instead of typing a patient name or procedure code, you can just select it from a list. One click -- and the correct code is in the field! To build a list, click List Management on the Main Menu. X

  43. 1. LIST MANAGEMENT A submenu of lists appears. Select the list you want to build. We will click “Recipient” in order to add a patient to the list. X

  44. TheRecipient List – Add/Viewscreen appears. To add patient information, type in the fields provided (top half of screen) and click SUBMIT. The name is added to your list. To edit patient information, just click the EDIT button by the patient’s name on the Recipient Information list (lower half of the screen) and make the changes. It’s that simple! 1. LIST MANAGEMENT X

  45. 2. CLAIMS ENTRY Claims Entry When you click the Claims Entry option, you will be given the choice to enter a Dental, CMS 1500, or UB 92 claim. For example, to complete a professional claim, we’ll select CMS 1500. X

  46. 2. CLAIMS ENTRY The CMS 1500 Results screen will appear. All claims you have keyed, but not yet submitted, will be listed. You can view, edit, copy or delete one of these claims by clicking the radio button next to it and then clicking the desired action button (Add, Edit, Copy, View, History, Delete). Create a new claim by clicking the ADD button. X

  47. 2. CLAIMS ENTRY The CMS 1500 screen will appear -- an online claim form. Complete the fields as you would normally. Then save your work by clicking the SAVE button. NOTE: Wherever you see an ellipses icon (see green box), there is a list from which you can select information (and save keystrokes!). In this case, the ellipses indicate the existence of a Recipient List. X

  48. 3. CLAIMS SUBMISSION Claims Submission Once you have completed your claims, submitting them is an easy task. Simply click ‘Claims Submission’ X

  49. 3. CLAIMS SUBMISSION • The Claims Submission screen appears. • Type the Contact Information in the fields provided. • Then select the type of claims you are submitting from the list at the bottom of the screen (only one claim type may be submitted at a time). In this example, we have two CMS 1500 claims to be submitted. We clicked the radio button next to CMS 1500 to select them. • Click the SUBMIT button to send the claims. X

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