2Len Stusek – Senior Manager, Partner, has been in healthcare IT/EDI since The last ten years he has served to lead both EDI Sales and Customer Service teams with Quadax as the Division achieved unprecedented growth and nearly 100% client retention.Pat Blech – Product Manager, is responsible for development, implementation and training of the company’s Denial Management suite of applications. Patrick is well- seasoned in client relations and a veteran at speaking on such topics as 5010 and Denial Management.
3While some are predicting the end of the world in the year 2012, rest assured that it will not be as a result of the transition to 5010.5010
4What worked, what didn't work and the residual fall-out of the 5010 transition. Many providers faced increased rejections. Where did they come from and recommendations for identifying and working those claims effectively.
5What is 5010? “When you arrive at a fork in the road, take it.” Yogi Berra
7Intended Purpose of 5010Provide the infrastructure on ICD-10 Diagnosis Codes and Present on Admission IndicatorsReduce redundancy and provide uniformity in transaction structure and usage of data contentReduce dependency on trading partner companion guides which many entities were forced to rely on with 4010A1
8270 & 271 TransactionsPrimary and Secondary insurance will now be identified5010 version allows for a search by Member ID, last name only or date of birth
9276 & 277 TransactionsClaim Status can be reported – Provider Level, Claim Level and Service Line LevelAddition of Account Number field, receive “cleaner” responses.
10999 File AcknowledgementPreviously each Medicare Administrative Contractor produces custom error reports that varied by jurisdictionThe Functional Acknowledgement 997 is being replaced by the 999 transactionThe TA1 and 999 reflect technical problems that must be addressed by the software preparing the EDI transmissionThe 999 is output from the Translator indicating either R (Rejected), E (Accepted with Errors), A (Accepted)Clearing houses and software vendors can use these transactions to produce reports tailored to their customers.
11277CA TransactionProprietary error reporting (277U, 277R ) will be replaced with the 277CA Claims Acknowledgement transactionClaim by claim reporting, accepted claims and returns claim number and rejected claims with the error codes indicated in one file.The 277CA reflects a data problem that must be addressed by resources in the Billing area; Billing staff will likely need reports (or work queues) to be produced using the 277CA transaction in order to identify claim corrections before resubmission.
135010 and the MACsMACs and CEDI will support the submission of 4010A1 and claim transactions in production starting April 5, 2011 through December 31, March 31, 2012.CMS grants HIPAA 5010 compliance leeway, MGMA asks for more (additional 90 days)
14Clearinghouse/Submitter role 4010 to for noncompliant providers5010 to standardization?5010 to 4010 for noncompliant payers
155010 – The Aftermath 837 issues/updates How do I navigate thru the “stuff”?835 issues updatesTips for post 5010 Denial ManagementFinal ThoughtsQuestions?
16From: MedicareEmailList@cgsadmin From: Sent: Monday, March 05, :17 PM To: Len Stusek Subject: Kentucky Part B News from CGSKentucky Part B News from CGSVersion 5010 – Where Are We Now? Centers for Medicare & Medicaid Services Webinar – Central Event Invitation: Please join the Centers for Medicare and Medicaid Services Regional Offices for an informative webinar on Version 5010 for healthcare providers, clearing houses, vendors and others. Read More...From: Sent: Monday, March 05, :36 PM To: Len Stusek Subject: Registration ConfirmationYou have registered for the following event:EVENT INFORMATIONCompany: CMSEvent Title: Version Where Are We Now? - Eastern WebinarEvent Date: Mar 6, 2012Event Time: 10:00 AM ETYou are not registered for the webinar. Webinar and phone line capacity have been reached. Check with the CMS website (www.cms.gov ) for future opportunities and information. Thank you!
175010 Early implementationDuring the week of December 5-9, 2011, National Government Services experienced processing issues with the new Part A Common Edit Module (CEM) which has resulted in a backlog of claims to be processed through the CEM. Some payers cut-over early without notice resulting in file rejects.Inbound sent in 5010 format but Outbound sent in 4010 format, due to mapping issue as per 5010 specs in Loop 2010AA Billing provider name, Ref Segment, Data Element 1H - CHAMPUS Identification Number is not required but it is essential in 4010 which cause this error “BILLING PROVIDER 2ND-ID IS INVALID”
18Top Problematic Payers Caresource to 4010 back to 5010OH Medicaid - MITS transition ahead of 5010MI MedicaidMI Blue CrossAetnaHealthplus (MI)Note – list does not include a WV specific payer!“If the world was perfect, it wouldn't be.” Yogi Berra
205010 issues - General Claims not making it to payers No visibility into claim statusIncreased rejectionsDelayed/missing remitsVague rejectionsDegradation of supportSome entities were reporting 10x production issues &8x volume increase in call center activity
215010 Issues post 1/1/2012Edits have been updated to accept LOB indicator of "FI" on 5010 FEP claims.Some payers had dark days where their system was down and did not provide notice. No files could be sent (837’s) or received (835’s)P55819_496 Submitter not approved for electronic claim submissions on behalf of this entityClaims containing Occ Code 50 will reject. This is a known issue and there is no established fix date (resolved 1/23/2012)
22WV Medicare B - has distributed both ANSI 835 files with "T" for Test and "P" for Production in the same file. Caused remit delay.Other varied and sporadic ERA (835) delays.Some providers were “unlinked” to established Clearinghouse with remits going to another.Rejection of secondary claims that contain negative dollar amounts - CMS has not issued a statement as to how to report claims paid by the primary payer with negative values, something that was acceptable under the guidelines.
23Invalid rejection of claims for NPIs not being registered with the submitter. The NPI issue was resolved by the various Medicares, affected files had to be resubmit, which resulted in payment delays due to the “ceiling” being reset.The FISS system added new DRG codes with the January release, however these were not included in the CEM reference file. FISS is aware of this issue and will be correcting under PAR ZFSZ6613. There is no scheduled release date for this issue at this time.*P56617 – National drug code or universal product number : Invalid for Payer.
24Crossover Claim Issues Important Information Concerning Medicare Outreach Efforts to Supplemental Payers Directing Their Payments to Incorrect Addresses Over the past several weeks, many physician/practitioner billing offices have notified their servicing A/B Medicare Administrative Contractor or Part B Carrier and the Centers for Medicare & Medicaid Services (CMS) that various supplemental payers have directed payment, arising from Medicare crossover claims, to incorrect payment addresses. The problem appears to have escalated as the supplemental payers have transitioned from receipt of crossover claims in version 4010 professional claims format to the version 5010A1 professional claims format. CMS believes it understands the full dimension of the problem and wishes to pass along those details to affected physician/practitioner billing offices through this article.
25CMS is not receiving similar complaints from institutional providers as tied to Pay-to Address information reported on HIPAA institutional production COB/crossover claims.
26Possible Cause #1:For HIPAA ANSI X12-N 837 version 4010A1 professional claims, Medicare's Part B claims processing system (Multi-Carrier System or MCS) usually only created the 2010AA loop, including the N3 and N4 segments. Since the HIPAA 4010A1 837 Professional Claims Implementation Guide had no prohibition against reporting Pay-to Address-related information—such as Lock-Box or P. O. Box address information, as retained within PECOS and the internal physician/practitioner files as the physician/practitioner’s “check or remittance address”—in the 2010AA N3 and N4 segments, the Part B claims system created 4010A1 837 professional outbound crossovers that only contained 2010AA loop address information.Under HIPAA 5010 requirements, Medicare must now create a 2010AB loop, with N3 and N4 segments, if the Pay-to Provider Address differs from the Bill-to Provider Address. This means that the address that most often used to be reflected in the 2010AA loop N3 and N4 address segments (which in reality was the Pay-to Address) now has to be reflected in the 2010AB N3 and N4 segments. Now, under HIPAA 5010, the address that Medicare reflects in the 2010AA N3 and N4 loops is truly the Bill-to Provider Address (or “master” and/or “physical address,” as captured within PECOS and the internal Medicare files).
27Conclusion tied to Possible Cause #1: Supplemental payers with Coordination of Benefits Agreements (COBA) may systematically still be reading the 2010AA N3 and N4 loops as the basis for determining where to direct their supplemental payments.
28Possible Cause #2:The physician/practitioner’s “check or remittance address,” as maintained by Medicare is no longer valid. As previously mentioned, the “check or remittance address” becomes the 2010AB N3 and N4 segments on outbound version 5010A1 837 professional crossover claims.Remedy for Possible Cause #2:If the address reflected in the 2010AB N3 and N4 segments is incorrect, the physician or practitioner will need to contact its servicing A/B MAC or carrier to have this information updated through appropriately established procedures.
29Possible Cause #3:There may be instances where the supplemental payer uses the address information that it maintains within its internal files as the basis for directing supplemental payments to a given physician or practitioner, and that information is out of date.Remedy for Possible Cause #3:The physician/practitioner’s billing office will need to address this matter with the supplemental payer directly for resolution.
30Crossover Claim Issues The COBC activates the following edits once COBA trading partners move into HIPAA 5010 or NCPDP D.0 production:N22226—“4010A1 production claim received, but the COBA trading partner is not accepting 4010A1 production claims.”N22230—“NCPDP 5.1 production claim received, but the COBA trading partner is not accepting NCPDP 5.1 production claims.”*To review the entire CR6658, visit on the CMS website.*To review the entire CR6664, visit on the CMS website.
31Crossover Claim Issues Breaking News – Friday, March 16thOur Part A claims processing system (FISS) maintainer has identified a situation whereby taxonomy codes reported on incoming version 5010A2 claims are not reliably mapping to outbound version 5010A2 COB/crossover claims. This issue is precipitating numerous problems for State Medicaid Agencies as well as a small number of commercial payers.
32Navigating the “stuff” If you have missing claimsClaim not showing up as accepted from a 277caContact Clearinghouse partnerClaim showing as sent to payer but no payer reporting backContact payer – if the payer has no information
33Navigating the “stuff” Check your provider enrollment and NPI information for correct reporting of Billing and Servicing provider information with each of your payers. Actively monitor CMS, payers and clearinghouse partner websites for news.‘In theory there is no difference between theory and practice. In practice there is.’ Yogi Berra
36Medicaid WorkshopsThe WV Bureau for Medical Services (BMS) and Molina Medicaid Solutions will be conducting seven (7) Provider Workshops throughout the state from March 26 – April 9, We are offering the workshops at various locations to accommodate as many providers as possible. All sessions are identical and include either a continental breakfast or an afternoon snack. Subjects will be discussed that affect a wide variety of provider types. Please join us at this year’s Provider Workshops so you and your staff are aware of new developments that may impact you. Below are the scheduled events.Martinsburg at Comfort Inn: March 26, :00 am – 1:00 pmMorgantown at Lakeview Resort: March 27, :00 am – 1:00 pmWheeling at Oglebay Park, Pine Room: March 28, :00 am – 1:00 pmHuntington at Big Sandy Arena: March 29, :00 pm – 4:00 pmCharleston at Charleston Civic Center: April 3, :00 am – 1:00 pmFlatwoods at Days Inn Hotel: April 5, :00 am – 1:00 pmBeckley at Tamarack: April 9, :00 pm – 4:00 pm
40Reporting ImpactClaim Status Category changes remove all “Not Advised” codes which includes pended claims. Removing the Pend/Suspend category codes on the 835 means that Plans/Payers will now have to report pended claims on the 277CA instead of the 835.New 5010 standards be implemented/delivered uniquely by HIS/PMS, clearinghouse and individual payers. The potential (reality) is increase is upfront edits at clearinghouse, increase in front end rejections based on tighter edits and reporting on 277ca and increase in 835 denials do rule changes, system changes and unintended consequences.
42HIS/PMS Ability to Support 5010 Does your host system have the ability to produce a 5010 formatted file?
43HIS/PMS Ability to Support 5010 New FieldsUB041500Additional Diag Code Fields (25)Additional Diag Codes Fields (25)Additional Surgical Codes Fields (25)Other Insured RelationshipAdditional Occurrence Span FieldsAdditional Line Detail Fields (prescription date, purchased svc, purchased svc amount, purchased npi)Additional Physician DetailAddition of Pay To AddresssService + Facility Tax FieldsLine Control NumberRemaining Patient Liability
44HIS/PMS Ability to Support 5010 4010 or print image may require staff manually populate 5010 required data
45HIS/PMS Ability to Support 5010 4010 or print image may require staff manually populate 5010 required dataBilled information may deviate from information stored in Host SystemTime consuming labor cost
46HIS/PMS Ability to Support 5010 Inability to produce 5010 source file may ultimately result in clearing house payer rejectionMay result in future processing issues as wellNo support for ICD10
47Clearing House/Vendors Ability to Support 5010 Does your clearinghouse have the ability to accept a 5010 formatted file?
48Clearing House/Vendors Ability to Support 5010 Will your vendor actively track which payers do/do not accept 5010 and transmit required format?5010 enforcement period begins July 01, 2012 for most health plans5010 enforcement period begins January 01, 2013 for all “Small” health plans
49Clearing House/Vendors Ability to Support 5010 Failure to transmit required ANSI 837 version may result in entire FILE REJECTIONS
50Clearing House/Vendors Ability to Support 5010 Clearing House/Vendors should remain current on all payer specific guidelines to minimize rejectionsSee CMS MLN Matters® Number: SE1137Vendors should accommodate payer specific scenarios during transition time period to minimize any payment delays for providers as opposed to defending a standard.
51Clearing House/Vendors Ability to Support 5010 CMS MLN Matters® Number: SE1137As COBA supplemental payers move into production on the 5010A1 and A2 claim formats, CMS requires that they continue to accept their “pre-HIPAA 5010” production Version 4010A1 claims for 14 full calendar days after their cut-over to the new claim formats.Vendors should accommodate payer specific scenarios during transition time period to minimize any payment delays for providers as opposed to defending a standard.
52Clearing House/Vendors Ability to Support 5010 CMS MLN Matters® Number: SE1137For a limited timeframe (likely 30 days after a supplemental payer cuts over to Version 5010 for crossover claims receipt), providers, physicians, and suppliers will need to file the affected claims directly with their patients’ supplemental payers.Vendors should accommodate payer specific scenarios during transition time period to minimize any payment delays for providers as opposed to defending a standard.
53CMS MLN Matters® Number: SE1137 During the 90 day non-enforcement period (January 1, 2012—March 31, 2012), Medicare will have the systematic capability to convert incoming claim formats in accordance with external supplemental payer specifications concerning production claims format. That is, Medicare will have the ability to:Take incoming claims submitted by the provider community in hardcopy (paper) format or Version 4010A1 or NCPDP 5.1 batch claim formats and convert them to HIPAA Version 5010A1 or 5010A2 claim formats, as appropriate, or NCPDP D.0 batch claim formats for those COBA supplemental payers that already have cut-over to exclusive receipt of Version 5010 COB claims in production; andTake incoming claims submitted by the provider community in the Version 5010A1 or 5010A2 or NCPDP D.0 batch claim formats and convert them to HIPAA Version 4010A1 claim formats or NCPDP 5.1 COB batch claim format for those supplemental payers that have not cut-over to production use of the HIPAA Version 5010 COB claim formats or NCPDP D.0 batch claim format.Vendors should accommodate payer specific scenarios during transition time period to minimize any payment delays for providers as opposed to defending a standard.
54Clearing House/Vendors Ability to Support 5010 Failure to monitor payer guidelines and claim processing habits may result in file rejections, claim rejections, suspensions or denials!Vendors should accommodate payer specific scenarios during transition time period to minimize any payment delays for providers as opposed to defending a standard.
55Payer Edits Updated to Require 5010 Data Discharge Hour Prohibited on OP ClaimsICN# Required on XX7 + XX8 bill typesLegacy numbers prohibited when NPI is presentProvider + Pay-To zip must be 9 digits
56Payer Edits Updated to Require 5010 Data Payers will reject claims if 5010 specific fields are not provided or complete!
57Updated Payer EDI + Editing Systems with 5010 Conversion
58Updated Payer EDI + Editing Systems with 5010 Conversion Many payers are updating Editing, EDI Systems + Processes in Line with 5010 ConversionConversions are directly resulting in:increases in rejected, suspended and denied claimsErroneous/missing claim status updates
59Updated Payer EDI + Editing Systems with 5010 Conversion CMS will be making system improvements concurrent with the 5010/D.0 changes. These improvements include:Implementing standard acknowledgement and rejection transactions across all jurisdictions;Improving claims receipt, control, and balancing procedures;Increasing consistency of claims editing and error handling;Returning claims needing correction earlier in the process; andAssigning claim numbers closer to the time of receipt
60Updated Payer EDI + Editing Systems with 5010 Conversion Medicare Conversion to 277CA Response ReportsMedicare - Proprietary error reporting will be replaced with the 277CA Claims Acknowledgement transaction across all MACS
61Updated Payer EDI + Editing Systems with 5010 Conversion Medicare CEMThe CEM software will perform Medicare specific edits, CMS-selected IG edits and produce the following: CMS flat files for accepted transactions, with claim numbers assigned, A 277CA for each accepted or rejected claim, The 277CA for an accepted claim will contain the claim number
62Updated Payer EDI + Editing Systems with 5010 Conversion Collateral DamageClaim RejectionsClaim SuspensionsDelayed Processing TimesMissing Claim Status Responses
63Updated Payer EDI + Editing Systems with 5010 Conversion Collateral DamageExample RejectionRejection Message Returned - INFORMATION SUBMITTED INCONSISTENT WITH BILLING GUIDELINESResponse Time – 15 DaysResolution – Edit is erroneously affecting claims at the MACS. The edit will be relaxed with a system upgrade in April
64Updated Payer EDI + Editing Systems with 5010 Conversion Collateral DamageExample RejectionRejection Message Returned - FISS REASON CODE 10139: DATA ELEMENTS ON THE EMC CLAIMS RECORD EXCEEDED THE FIELD SIZE FOR THE CORRESPONDING UB-92 ON-LINE CLAIMS FORMAT. THEREFORE, AMPERSANDS WERE MOVED TO THE ASSOCIATED FIELD.Response Time – 30+ DaysResolution – Edit is erroneously suspending claims in FISS. Initial explanation detailed that invalid characters were populated in claim file. MACS advised this is an issue with FISS and are working on a resolution
65Support Limitations with 5010 Conversion Per MGMA letter to CMS regarding 5010 issues: “Protracted call hold times (most typically 1-2 hours) when attempting to contact MACs for further explanation of unpaid and rejected claims”Some Vendor support has declined due to influx of 5010 related issues
67Consider All Available Sources of Payment Delay Pre-Bill ErrorsPayer Rejections(277 Files)Payer Remits (ANSI 835)
68Consider All Available Sources of Payment Delay A majority of 5010 related issues occur pre-adjudication
69Consider All Available Sources of Payment Delay HIS/PMS + Clearinghouse EditsRejection Message Returned - Claim contains a non compliant P.O Box format per 5010 requirementsResolution – Host system must be updated to supply compliant address information or staff must manually update
70Consider All Available Sources of Payment Delay Payer Front-End RejectionsRejection Message Returned - ACK/REJECT INVAL INFO - entity street address - billing providerResolution – Billing provider address must be a street address or physical location. PO BOX should be sent in the pay to address if needed
71Consider All Available Sources of Payment Delay Medicare FISS RejectionRejection Message Returned : DATA ELEMENTS ON THE EMC CLAIMS RECORD EXCEEDED THE FIELD SIZE FOR THE CORRESPONDING UB-92Resolution – MAC’s and FISS working to resolve this issue
72Consider All Available Sources of Payment Delay Remittance DenialsRejection Message Returned – 15 -The authorization number is missing invalid or does not apply to the billed services or providerResolution – MAC claim processing system not reading the entire auth number from 837 file
73Consider All Available Sources of Payment Delay Remittance DenialsRejection Message Returned – 18 –Duplicate Claim/ServiceResolution – 5010 file transmission issues between payer + clearinghouse may result in duplicate file transmissions
74Workflow System Engine Identify + WorkflowOnce identified, all rejections should be automatically workflowed to staff worklists for timely review and follow-upWorklist AWorklist BWorklist CWorklist DRejection SourceWorkflow System Engine
75Report 5010 Denial ImpactProviders should report 5010 related rejection/denials to better understand the impact of 5010 conversion and to support resulting assumptions with live data
76Report 5010 Denial Impact Letter from MGMA to CMS Version 5010 Issues and ConcernsPhysician practices have reported numerous problems across various areas of the United States stemming from the transition to Version The most frequently reported problems have involved:Issues with practice management and/or billing systems that showed no problems during the testing phase with their MAC, but once the practice moved into production phase, found their claims being rejectedIssues with secondary payersRejections due to various address issues (pay-to address being stripped/lost from claims; pay to address can no longer be the same as billing address; no PO Box address)Crosswalk NPI numbers not being recognized“Lost” claims with MACsCertain "not otherwise specified" claims being denied due to not having a description on the claim (CMS sent a notice of correction of this issue Jan. 27, 2012)Unsuccessful claims processing (with no reason cited for rejection) despite using a “submitter” that was approved after successful testing with CMSConcerns list would be exponentially more effective if data figures were provided and examples were easily accessible
77Report 5010 Denial ImpactStep 1: Gather listings of Rejections/Denials from all available sources and identify specific codes related to 50105010 relatedNon-5010 related
78Report 5010 Denial ImpactStep 2: Identify Root Cause (Responsible Party) For 5010 Related Rejections + DenialsThis may be time consuming, but end result will be worthwhile
79Report 5010 Denial Impact Rejection/Denial Root Cause Provider Pre- Bill Edit “non-compliant P.O Box format per 5010 requirements”ProviderPre-Bill Edit “non-compliant patient relation codeVendor (HIS)Payer Rej “ACK/REJECT INVAL INFO - entity street address - billing providerVendor (Clearinghouse)Payer Rej “INFORMATION SUBMITTED INCONSISTENT WITH BILLING GUIDELINESPayerRemittance Denial “15 - The authorization number is missing invalid or does not apply to the billed services or provider”Remittance Denial “ 18 – Duplicate Claim/Service”
80Report 5010 Denial ImpactPre- Bill Edit “non-compliant P.O Box format per 5010 requirements” – PROVIDERPre-Bill Edit “non-compliant patient relation code” – Vendor (HIS)Payer Rej “ACK/REJECT INVAL INFO - entity street address - billing provider” – Vendor (Clearinghouse)Payer Rej “INFORMATION SUBMITTED INCONSISTENT WITH BILLING GUIDELINES – PayerRemittance Denial “15 - The authorization number is missing invalid or does not apply to the billed services or provider” - Payer
81Report 5010 Denial ImpactStep 3: Format and compile data into meaningful reports
82Report 5010 Denial ImpactOnce rejection/denial data is identified and categorized, it can be used to:More accurately gauge resource and financial impact of 5010 claim processing issuesIdentify sources causing greatest impactQuickly produce live examples to backup assumptions (Data is King)
83Report 5010 Denial Impact CMS Financial Preparation Advice https://www.cms.gov/ICD10/Downloads/SmoothTransition.pdfEstablish a line of credit. Providers should work with their financial team to establish or increase a line of credit to cover potential cash flow disruptions. A line of credit will help a provider’s practice prepare for potential delays and denials in payer claims reimbursements due to noncompliant Version 5010 transactions being submitted. A practice should also evaluate its cash reserves.
84Questions?‘”f you ask me anything I don't know, I'm not going to answer.”“I wish I had an answer to that because I'm tired of answeringthat question. Yogi Berra
85Thank you!I just want to thank everyone who made this day necessary. Yogi BerraICD - 10