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Medicare Fee For Service (FFS) 5010 and Testing. Purpose of Today’s Call Discuss readiness Transactions and errata Testing requirements and procedures.

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Presentation on theme: "Medicare Fee For Service (FFS) 5010 and Testing. Purpose of Today’s Call Discuss readiness Transactions and errata Testing requirements and procedures."— Presentation transcript:

1 Medicare Fee For Service (FFS) 5010 and Testing

2 Purpose of Today’s Call Discuss readiness Transactions and errata Testing requirements and procedures Companion Guide Going into production

3 5010 and Affected Business Processes Claims (837 Institutional, Professional, COB, Dental, NCPDP) Claim Status (276/277) Claim Payment (835) Enrollment (834) Premium Payment (820) Eligibility (270/271) Referrals and Prior Authorizations (278) Claims Acknowledgements (277CA) Acknowledgement for Health Care Insurance (999)

4 5010 Errata

5 Medicare Implementation of 5010 Common 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

6 Medicare Implementation of 5010 Common 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

7 Medicare Implementation of 5010 Common 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

8 Timeline Current contractor activities January through March 2011 – translator level 1 and 2 testing (TA1 and 999s) April 2011: Errata testing – including translator level 1 and 2, Common Edit Module responses (277CA) including Medicare business rules, 835 testing April 2011 through December 31, 2011 – Testing/Migration Must be 5010 Errata ONLY by January 2012!!!

9 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

10 Compliance Dates Compliance deadlines were set per public comments CMS expects compliance deadlines to be met – no extensions Success will depend on starting early!

11 Ready, Set, Go… Don’t Wait to test or go into production! Short migration period Not just a Medicare issue CMS does not anticipate any delays to compliance date In order to receive the customer service and support you are accustomed to from your payers, vendors and clearinghouses it is important that you test early and go into production early.

12 Direct Submitters Testing Procedures 25 claim minimum Testing in errata version only 100% syntax 95% Medicare business rules ISA14 highly recommended to = 1 ISA15 must = T Submitter is considered in test until approved by contractor

13 Testing Continued Know your Trading Partners plan What is your Trading Partner doing to prepare?? Get on their schedule Review with your office what you need to do to implement 5010 Test what is applicable to you Know what needs to be changed

14 More testing information January 1, 2012 – Compliance Date CMS does not anticipate extensions to this deadline. Dual submission of 4010A1 and 5010 transactions are allowed until December 31, Test under your current submitter ID Consult with Software Vendor to confirm the 999 and 277CA will be returned in a readable format! The timeline for testing the errata version begins now. Make sure your updates are scheduled before the compliance date.

15 WPS is ready to test NOW! Testing has begun! We have already received and reviewed tests Test results returned within 3 business days

16 PC-Ace Pro32 Providers may download PC-ACE Pro-32 software at the link below to submit 5010 file formats: This free 5010 software may be downloaded and tested now Additional instruction regarding set up to follow and will be posed on above web site New PC-Ace users must test and go into production with 5010 errata version after April 2011

17 Companion Guide To assist trading partners and their business associates with exchanging transactions Companion Guide provides technical and connectivity specification for the following: 837 Health Care Claim Institutional 837 Health Care Claim Professional 835 Health Care Claim Payment Advice 276/277 Status Inquiry and Response Companion guides posted to:

18 Links to Edit Spreadsheets TransactionURL Link Professional Claim 837P Institutional Claim 837I Remittance 835 Claim Status 276/277

19 CMS National Provider Calls CMS will be hosting a variety of national education calls that will inform the provider community of the steps that they need to take in order to be ready for implementation. These calls will also give participants an opportunity to ask questions of CMS subject matter experts Delivery of a series of National Provider Calls – presentations, transcripts and audio files available at Next call, March 30, 2011, topic: 5010 National Call –Provider Testing and Readiness Registration for upcoming events:

20 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 calls (all times 1-2:30pm cst): Date Dial In ID May 12, July 14, September 8, November 10,

21 Our Message to you… Start preparing now! Work with your vendor and/or clearinghouse Know your vendor and clearinghouse schedule It is your responsibility to be compliant CMS expects compliance deadlines to be met – no extensions If you fail to prepare, it will be your business and cash flow that will be affected!

22 EDI Addresses & Numbers Medicare Part A Legacy A Medicare J5 MAC Part A & B (multiple states)(Iowa, Kansas, Missouri, Nebraska)WPS Medicare EDI PO Box West Broadway Omaha, NE 68101Madison, WI Fax: (402) Fax: (608) Med A Hotline: (866) J5 Hotline: (866) Medicare Part B LegacyMedicare Part B (Illinois, Michigan, Minnesota, Wisconsin)(EFT Only) WPS Medicare Electronic Data Services 912 N Pentecost Drive8120 Penn Ave. S., Suite 200 Marion, IL 62959Bloomington, MN Fax : (618) Fax: (952) Med B EDI Hotline:(877) Phone: (952) (952) (952)

23 Resources CMS 5010 and D.0 Webpage Educational Resources: Technical Review Type 3 guides: X12: Washington Publishing WPS 5010: CMS National Provider Calls:


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