Presentation on theme: "GE Healthcare 5010: Cynthia Klain April 2011. Agenda Who are we? 5010 Background Payer Readiness and Testing Areas of Impact Processing Strategy Questions?"— Presentation transcript:
GE Healthcare 5010: Cynthia Klain April 2011
Agenda Who are we? 5010 Background Payer Readiness and Testing Areas of Impact Processing Strategy Questions?
GE Centricity ® EDI Services A full service EDI solution dedicated to improving your revenue cycle through service and automation. Delivering Value With Integrated Transactions: Eligibility - 270/271 Claims Status – 276/277 Referrals Electronic Claims Electronic Remit - 835
GE Centricity ® EDI Services Healthcare Transactions per month: Customers 4 GE Centricity PMs (Practice, Group, Business, Enterprise) ~16 million Claims/month ~$6 Billion in gross charges!!/month ~15 Million Remits/month ~5.5 Million Eligibility/month
5010/ICD-10 Timeline Enforcement Date January 1, 2012 Compliance Date January 1, Implementation Date October 1, ICD-10 June 18, 2010: Centricity EDI Services is ready for 5010 April 1, 2011; payers should be ready to test with errata. Only ~30% are ready Claims with Date of Services on October 1, 2013 or after will utilize ICD-10!
270/271 Eligibility Inquiry & Response 837 Professional and Institutional Claim 835 Remittance Advice 276/277 Claim Status Request & Response 837 Dental claims 278 Referral/ Authorization Request & Response Transactions that are Changing with X A1 X
5010 Overview Whos affected? Customers Centricity EDI Trading Partners Payers Mandate Overview The X transactions replace the 4010 HIPAA transactions and are needed to accommodate ICD-10 codes and address other identified issues with 4010 ChangesImpact New Data Elements/RecordsNew Storage locations/Processing/Screens and Updated Segments Translations Scripts/Tools/PM Update Data requirementsUpdated Edits/rejections Updated Adjudication SystemsNew Edits/Billing processes
PAYER READINESS AND TESTING
Update on Payer Readiness Target DateActivity May 2010Centricity EDI began Trading Partner Readiness Calls -Repeated calls every 30 days to 90 days Summer 2010 Continued Payer Calls, but received very little information. One payer indicated readiness soon; Highmark (PA BCBS) August – December 2010 Began testing with Highmark (PA BCBS) -Tested various billing specialties & input formats (4010 & 5010). -Mid-Oct = Highmark Production! All payers contacted for 5010 readiness April of 143 payers indicate readiness to test, but all require testing in April with the Errata Version Currently TESTING with our top 30 claim payers Currently PRODUCTION with Kansas Medicaid, Highmark BCBS and Emdeon. Production approved with several others (GA Medicaid, most Noridian payers) Testing with CMS/Medicare Eligibility in the next few weeks Q3 2011Most payers available for testing
Trading Partner Readiness Outreach When can we begin testing 5010 with you? (for each transaction 837P, 837I, 835, 270&271) Is 5010 testing required? When (what date) is 5010 transaction mandated? (for each transaction type 837P, 837I, 270) If we send a 5010 claim file (837) will we be able to get the 5010 remit back (835)? When will the 5010 remit (835) be available? Will 5010 testing be only for compliance or will it also test payer specific edits? Will we be getting reports back after testing 5010? Will you be ready to test and go live on 5010 across all transactions at the same time? (837, 835, 270&271) If not at the same time, what is the schedule? Are you planning to allow dual submissions of 4010 and 5010 at the same time or will it be a hard cutover only to 5010 claim submissions? Will there be any transmission/connection changes to how we technically send you are claims? Will there be any enrollment or re-enrollment required before submitting 5010? Will we be able to test the 270 and get 271 transaction back? How will you be communicating when you cutover or mandate the 5010 transaction? (website, letter, , etc.) Will you be changing the length of any of the fields in the 835 (ERA) (policy #, check #, ICN) When we go live with 5010 will you be replacing the 997 report with the 999 report? Will there be any other changes to reports or new reports? Are you mandating with implementation of 5010 that the Billing Provider Address(2010AA N3) no longer be a PO Box and that it MUST be a street address? Will the providers need to complete re-enrollment if they are currently sending the PO Box and need to start sending the street address?
Top 30 Payer Testing Status 16 of the 30 have major or minor delays. Were tracking when we can move to PRODUCTION, since test and production are often not the same. We are testing both 5010 and upconverted LIVE with some upconverts! Team meets weekly to track status, identify new payers to test, discuss issues. 143 unique connections.
AREAS OF IMPACT
High to Medium Impact IssueWhat is this?Work AroundWhat to do NOW! PO Box in the Billing Provider and Service Location Loops PO BOX address are no longer allowed in these fields. A physical street address must be sent. Send the physical address! Weve also had some success with POBOX and P0B0X. Know what you are submitting! Look for WARNINGS and ALERTS as we do more end to end testing. Zip+4 is required in the Pay-To-Provider Loop The 5010 specification requires the zip+4 in some loops Send the zip+4! Weve also has some success with a default value of 9998 Know what you are submitting! Look for WARNINGS and ALERTS as we do more end to end testing. Subscriber Definition changes If the dependent has a unique member ID, then this is submitted in the subscriber loop (the patient loop is not used TBD – Dependent on payer interpretation Know what you are submitting
Medium to Low Impact IssueWhat is this?Work AroundWhat to do NOW! Place of Service = HOME If the Place of Service is HOME, this must be the physical street address of the patient. Send the physical address! Weve also had some success with POBOX and P0B0X. Front desk protocol check – are you capturing the street address? Look for WARNINGS. Anesthesia ClaimsShould be reported only as minutes Submit correctlyKnow what you are submitting. Ambulance BillingNow requires physical pick-up/drop off address Submit correctly. TBD on how payers will do this (ex: mile marker 25?) Know what you are submitting. Workers Comp Claims Several new fields required Submit correctly.Know what you are submitting
Electronic Claims Strategy Payer Ready to Test Assumptions/Clarifications - Centricity EDI Can translate X TO X most of the time -Centricity EDI Can translate X TO X all the time -After your CPS upgrade, Centricity EDI does not need to make customer set up changes to accept updated versions of Inputs. -Centricity EDI will begin sending X transactions to payers as payers are ready and/or mandate it Centricity EDI Alerts internal teams. Begins 5010 certification process with various input and claims types for a sub-set of customers As payer mandate date approaches, Centricity EDI begins sending X for all customers Process is Complete Validation Receipt of file (reports) Payment
Electronic Remit Strategy New Mandate Identified 1 st 5010 ERA file is received Is Customer able to process x (835)? Y N Centricity EDI Translates Incoming file to X Customer is upgraded Centricity EDI begins sending customer X files Process is Complete Centricity EDI alerts internal teams
Eligibility Strategy -Assumptions/Clarifications - Centricity EDI Can translate X TO X most of the time for BOTH 270 and 271 -Centricity EDI Can translate X TO X all the time -After your CPS upgrade, Centricity EDI does not need to make customer set up changes to accept updated versions of Inputs. -Centricity EDI will begin sending X transactions to payers as payers are ready and/or mandate it Payer Ready to Test Centricity EDI Alerts internal teams. Begins 5010 certification process with various input and claims types for a sub-set of customers As payer mandate date approaches, Centricity EDI begins sending X for all customers Process is Complete Validation Receipt of 271
Summary Get ready for CPS v10! Impacted Areas: Know what your sending! Look for WARNINGS and ALERTS (Centricity EDI Users). Look for additional monthly updates and webinars. Prepare for a few hiccups. Payers are delayed in testing.
Useful Resources ICD-10 Resources General Information Resources Government Bills – legislation HHS Web Site – regulatory html Workgroup for Electronic Data Interchange (WEDI) Washington Publishing ANSI X12