Presentation on theme: "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."— Presentation transcript:
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! Main Menu 1.OverviewOverview 2.Code SetsCode Sets 3.Filing OptionsFiling Options 4.TransactionsTransactions Eligibility Request / Response (270/271) Referral / Authorization (278) Claim Submission (837) Claim Submission (837) Claim Payment / Advice (835) Claim Status Request / Response (276/277) 5.Tools and ProcessesTools and Processes 6.ResourcesResources SC Medicaid Web-Based Claims Submission Tool Demo 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 Next slide goes to the Previous slide returns to the Main Menu exits the presentation and returns to the web site You may also access topics through links on the Main Menu.
The Legislation Why was HIPAA enacted? HIPAA (Health Insurance Portability and Accountability Act) is a federal law enacted in 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. Overview 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
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, Regulations standardizing transactions and code sets will be implemented October 16, 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. Overview 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)
Code Sets 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: 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) 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. Codes SC Medicaid Local Procedure Code Prior to October 16, 2003 SC Medicaid Local Procedure Code Description Prior to October 16, 2003 National Procedure Code Effective October 16, 2003 National Procedure Code Description Effective October 16, 2003 Notes These are the codes from your current program manual. These are the code descriptions from your current program manual. These are the national codes you will be using. This is the description of the national code. This area will give you code specific information you will need in order to bill Medicaid. Current Code New Code
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 X A formats, as specified in the Implementation Guide. These standards may be found at edi.com/hipaa/hipaa/_40.asp. Tape, diskette, CD, etc. Billing service/ Clearinghouse MCCS Paper MCCS 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... EDI Mailbox Tapes, ZIP files, diskettes, CDs EDI Billing service/ Clearinghouse EDI Mailbox EDI Mailbox MCCS Paper MCCS 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. EDI Mailbox Tapes, ZIP files, diskettes, CDs Web Filing Provider’s EDI software Billing service/ Clearinghouse EDI Mailbox EDI Mailbox MCCS EDI Mailbox Paper MCCS Filing Options
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) Transactions
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.” Eligibility Request / Response 270 Eligibility Inquiry 271 Eligibility Response “Does s/he have insurance?” MMIS Medicaid Management Information System
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 Eligibility Request / Response
Referral / Authorization
Referral / Authorization (278) What is a referral/authorization transaction? The 278 transaction, Referral/Authorization, answers the question, “Is this a covered service?” Referral / Authorization 278 – Referral/Authorization “Is this a covered service?” MMIS Medicaid Management Information System
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 Referral / Authorization
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. Claim Submission MMIS Medicaid Management Information System “Please pay this claim” 837 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 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. Claim Submission PROFESSIONAL CLAIM 20 detail lines PROFESSIONAL CLAIM 20 detail lines 8 detail lines 4 detail lines
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 15 th and 16 th 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 15 th and 16 th digits will increase by increments of 20. The graphic to the right illustrates this numbering system. Claim Submission Paper and Electronic RA (Professional) xxxxxxxxxxxxxx10x xxxxxxxxxxxxxx20x xxxxxxxxxxxxxx30x Paper and Electronic RA (Professional) xxxxxxxxxxxxxx10x xxxxxxxxxxxxxx20x xxxxxxxxxxxxxx30x Paper and Electronic RA (Dental) xxxxxxxxxxxxxx10x xxxxxxxxxxxxxx30x xxxxxxxxxxxxxx50x Paper and Electronic RA (Dental) xxxxxxxxxxxxxx10x xxxxxxxxxxxxxx30x xxxxxxxxxxxxxx50x
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. MMIS Medicaid Management Information System 835 Claim Payment “Here is your payment” Claim Payment / Advice
Claim Payment / Advice (835) How will payment change? Starting October 16 th, 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 Claim Payment / Advice
Claim Status Request / Response
Claim Status Request / Response (276/277) MMIS Medicaid Management Information System 277 Claim Status Response 276 Claim Status Inquiry Claim Status Request / Response 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.”
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 Claim Status Request / Response
Tools and Processes
transaction 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. EDI Mailbox Tapes, ZIP files, diskettes, CDs EDI Mailbox EDI Mailbox MCCS Paper MCCS 997 Billing service/ Clearinghouse 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 Finally, test sending claims using your chosen method before 10/16/03. This test will need to be scheduled in advance by calling 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 Tools and Processes
Call or 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 It contains the most current information about instructor-led training events and national codes. Questions may be ed to If you wish to speak to a person, call SC Medicaid HIPAA Provider Outreach at and one of our friendly representatives will assist you. SC Medicaid SC Medicaid HIPAA Provider Outreach Statewide Training Sessions Online Training Testing Resources Implementation Guide CMS
Resources Check your Understanding
Resources 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! 1.HIPAA is designed to simplify healthcare administrative processes. True. 2.TPA stands for third-party agreements. False (Trading Partner Agreement) 3.Transactions and Code Sets are a part of the Administrative Simplification process. True 4.Providers who bill on the CMS 1500 are exempt from HIPAA regulations. False. Everyone must be compliant! 5.An EDI transaction is the filing of a claim using the CMS False. It is the electronic exchange of information. Self-Test
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. 5.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 is the transaction that requests eligibility. False. 837 is the Claim Submission transaction. 7.SC Medicaid created the Health Insurance Portability and Accountability Act of False. HIPAA is a federal law. 8.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! 9.Clearinghouses are required to comply with all HIPAA deadlines. True. Self-Test (cont.)
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! Where next?
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.
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. 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.
1. LIST MANAGEMENT The Recipient List – Add/View screen 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!
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 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.
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.
Claims Submission Once you have completed your claims, submitting them is an easy task. Simply click ‘Claims Submission’ 3. CLAIMS SUBMISSION
The Claims Submission screen appears. 1.Type the Contact Information in the fields provided. 2.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. 3.Click the SUBMIT button to send the claims. 3. CLAIMS SUBMISSION
This message appears to let you know the claims have been sent. You may click the batch ID to view the details of your submission.
If you are interested in this tool... You need: Computer with ISP and Internet connection –Speed depends on computer and connection. Pentium II equivalent is recommended. Login ID and Password –Assigned when you register and sign TPA Complete a Web Interest Form to learn more!Web Interest Form For more information: or
Where next? Main Menu See demo again! EXIT presentation and return to web site