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Medicare Fee For Service (FFS) 5010 and 837P. Purpose of Today’s Call Highlight differences Provide update on Medicare FFS activities Discuss Errata as.

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Presentation on theme: "Medicare Fee For Service (FFS) 5010 and 837P. Purpose of Today’s Call Highlight differences Provide update on Medicare FFS activities Discuss Errata as."— Presentation transcript:

1 Medicare Fee For Service (FFS) 5010 and 837P

2 Purpose of Today’s Call Highlight differences Provide update on Medicare FFS activities Discuss Errata as it relates to 837 transactions and Medicare FFS Emphasis on preparation

3 What was adopted under HIPAA 5010? Version 5010 of the X12 standards General Changes Implementation Guides (IG) are now referred to as Technical Review Type 3 (TR3) Front matter in guides more consistent across transactions “Situational” rules further clarified Ambiguities in 4010A1 rolls corrected (ex “should” replaced with “must”) “If not required, do not send.”

4 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)

5 Differences in 5010 Billing Provider (2010AA) prohibits use of PO Box Zip codes (N403) requires 9 digit zip Added Pay to Plan loop (2010AC) SBR loops allow for 8 additional iterations Removed Responsible Party and Credit/Debit card loops (2010BC and 2010BD) Modification to DTP (Date) segments Modifications to AMT (Amount) segments

6 Differences in 5010 cont’d Expansion of number of diagnosis codes to 12 HI segment allows for ICD-10 Added Ambulance Drop off and Pick Up loops Added Anesthesia Related Procedure HI segment Added Condition Code HI segment Added freeform narrative note at line level Removed Purchased Service loop (2310C), loop sequence restructured and reused

7 Differences in 5010 cont’d Added PWK segment in 2400 loop Deleted Home Oxygen Therapy CR5 REF Oxygen Flow Rate Addition of two new QTY segments for Ambulance Patient Count and Obstetric Unit Anesthesia Count

8 837P Errata The Standards Development Organizations have made corrections to the 5010 and D.0 versions of certain transactions. The Errata versions replace the Base versions for HIPAA compliance. Per the Federal Register (Vol. 75, No. 197, October 13, 2010, 62684–62686 [2010–25684] found at HIPAA compliance will require the implementation of the Errata versions and the Base versions for those transactions not affected by the Errata. Compliance with the Errata must be achieved by the original regulation compliance date of January, Medicare FFS will implement the Errata versions to meet HIPAA compliance requirements.

9 837P Errata Changed various N4 (City, State Zip) from required to situational Added Property and Casualty Patient Identifier segment (2010CA) Changed 2010BA/NM108 & NM109 to situational Changed situational rule for LIN and added values in LIN02 to capture product number/device identifier Medicare does not anticipate any impact to 5010 implementation or compliance dates.

10 837P Errata Comparison (example) LoopSegmentElementDescription of change ISARemoved Segment Repeat (had '1') GSRemoved Segment Repeat (had '1') GS08Version number changed to '005010X222A1' ST03Version number changed to '005010X222A1' 2010BANM108Changed from required to 'Situational' 2010BANM109Changed from required to 'Situational' 2010BAN4Segment changed from required to 'Situational' 2010BBN4Segment changed from required to 'Situational' 2010CAREFNew segment added for 'Property and Casualty Patient Identifier' 2330AN4Segment changed from required to 'Situational' 2330BN4Segment changed from required to 'Situational' 2410LIN02Additional qualifiers added (EN,EO,HI,ON,UK,UP) 2410LIN03Element name changed to 'National Drug Code or ‘Universal Product Number’ 2420EN4Segment changed from required to 'Situational' GERemoved Segment Repeat (had '1') IEARemoved Segment Repeat (had '1')

11 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 Standardized Error Handling TA CA Receipt, Control and Balancing Claim Number Assignment

12 Medicare Implementation 5010 Up to 12 diagnosis codes Changes to core processing system Increase quantity from to NPI validation PWK implementation (CR 7041) Medicare Secondary Payer (MSP) balancing edits

13 Timelines Target DateActivity Dec 2010 Achieve Level 1 compliance (Covered entities have completed internal testing and can send and receive compliant transactions) Jan 2011 Begin Level 2 testing period activities (external testing with Trading Partners and move into production; dual 4010A/5010 processing mode) Begin initial ICD-10 compliance activities (Gap analysis, design, development, internal testing) April 2011 Medicare FFS will implement the Errata versions to meet HIPAA compliance requirements. Jan 1, /D.0 Compliance Date for all covered entities.

14 Are you preparing for 5010? Start now Ask your vendor and/or clearinghouse about their plans and timeframes implementing A1 to 5010 gap analysis – identify: New content Deleted content Modified content Impact to business needs 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.

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

16 Our Message to you… Start preparing now! Work with your vendor and/or clearinghouse. 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!

17 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 January 13, March 10, May 12, July 14, September 8, November 10,

18 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 Legacy (Illinois, Michigan, Minnesota, Wisconsin)(EFT) 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)

19 Resources CMS 5010 and D.0 Webpage Educational Resources: Service_Systems.asp 5010 Technical Report Type 3 guides: X12: Washington Publishing WPS 5010: HIPAA Version 5010: Fourteenth National Provider Call January 19, :00 – 2:30 cst. Go and register at


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