Presentation on theme: "Medicare Fee For Service (FFS) EDI ACT (August 9, 2012)"— Presentation transcript:
1Medicare Fee For Service (FFS) EDI ACT (August 9, 2012)
2Purpose of Power Point 5010 Status Cutting off 4010 J8 Implementation Monitor Your BusinessGo GreenContacting EDI
3Medicare is ready. Are you? Testing began in January 2011Processing 5010 claims since April 2011Over 3.00 million claims accepted last weekTest results returned within 3 business days835 Production Parallel files available upon request by contacting the EDI Hotline.Results returned on a first come first served basis.
4WPS Medicare 5010 Statistics 100% of all claim accepted are 5010 (as of 7/27/2012). ContractSubmitter Sending5010 Accepted Claims %Provider % Sending 5010s SentJ5A412100%73.88%J8A109Legacy A71595.80%J5B201394.23%J8B57497.84%IL111594.89%WI58393.32%MN28596.76%
5Top 5010 Errors – Med A 837IInvalid information within the Payer Claim Filing IndicatorInvalid information within the Subscribers Contract/Member numberRelational field in error for service(s) renderedInvalid information within the HCPCSBilling Provider’s National Provider Identifier (NPI) and Billing Provider’s taxidDuplicate ST-SEInvalid information within the Subscribers Country codeClaim is out of balance within the Payers payment informationInvalid information within the Subscribers Postal/Zip codeInvalid information within the Attending Physicians Specialty/Taxonomy code
6Top 5010 Errors – Med B 837PBilling provider not authorized for this submitter (not linked, rendering NPI…)NPI Crosswalk Error - Billing provider NPI not related to TaxIDMissing or invalid Payer ID or Receiver IDInvalid Health Insurance Claim NumberSV101-7 code description required for NOC/NOS codesInvalid Billing NPIInvalid codesDiagnosis Code (ICD-9)Zip (can not be padded with 0s or 9s)HCPCSAnesthesia services require MJ qualifier, all other services UN qualifierOther Insured's Adjustment Quantity; 2430.CAS must not be equal to zeroIn 4010 world, invalid codes are returned as unprocessable, in 5010 world, they reject in the front end.We have a article regarding the requirement for SV101-7 which will be going out in E-News and posted to the Medicare web site codes for part B. Some obvious (ending in 99), some not.ANESTHESIA CLAIMS AND THE MJ QUALIFIER FOR MINUTES When billing your anesthesia claims the only time you can have the MJ qualifier for minutes is if you bill an anesthesia modifier. Examples of these would be the AA, QK, or QX modifiers; if you do not bill with any anesthesia modifier, then you will bill with the UN qualifier for units.
7Current Med A Issues277 - Claim Status Response - the STC01-1 (Claim Status Category Code) from the the flat file.835 - Electronic Remittance Advice – PLB0X-2 missing from FISS flat file which is failing compliance checking.MSP on DDE System - FISS mapping issue where primary payer name is not mapping to FISS.
8Current Med B Issues Canadian Beneficiary Address Partial 835 (not a complete ISA-IEA)Sporadic delays in sending responses (999, 277CAs)
9Getting 5010 – 835 Electronic Remittance Advice Production 835 is generated based on how the receiver/provider are set upNot generated based on inbound claim formatIf a user did not request to be flipped, they were automatically switched to 5010 effective August 1, 2012.Part A issues with 835 are scheduled for fix in early December.
10Getting 5010 – 276/277 Claim Status Inquiry and Response Testing is not required“Testing” is done using production dataISA05 must = ZZISA06 must = ZZISA14 highly recommended to = 1Be sure to have ISA15 = P
11Companion GuideTo assist trading partners and their business associates with exchanging transactionsCompanion Guide provides technical and connectivity specification for the following:837 Health Care Claim Institutional837 Health Care Claim Professional835 Health Care Claim Payment Advice276/277 Status Inquiry and ResponseCompanion guides posted to:
12Cut OffLast 4010 inbound transactions accepted must be received and processed by WPS, before 4 pm cst, June 29, 2012.4010 transactions received after 4 pm receive message that the format is no longer accepted.
13Contingency PlansApproved vendor, billing services and clearinghouse lists:PC-Ace Pro32Paper claim submission is not a contingency optionClearinghouse options? Step Up? Step Down?What are your contractual arrangements with vendor and/or clearinghouse? Other?Some services a clearinghouse may provide:4010 to 5010 translation (gap filling data)5010 to 4010 backward translationSeparating your transactions and sending the appropriate format to your payer.Again, keep in mind, if you are switching vendors or clearinghouses, these things take time.
14PC-Ace Pro32Providers may download PC-Ace Pro-32 software at the link below to submit 5010 file formats:This free 5010 errata software with instruction regarding set up posted on web siteNew PC-Ace users must testExisting PC-Ace users are not required to test.If you are a PC Ace user, be sure to back up and update your version. Once in version 2.32 you’ll automatically send in 5010.
16J8 Implementation Providers will not need to re-enroll for EDI claims submission or ElectronicRemittance Advice (ERA) provide you are:Currently an NGS EDI customer using one of the Network Service Vendors (NSVs), or;Currently a WPS submitter.
17J8 Submitter IDs Your submitter ID will NOT change. You should have received confirmation of WPS registration and temporary password.If you have not received confirmation of sub ID and temporary password, contact EDI immediately.
18J8 Contract NumbersSubmitters will need to change their current contract number (receiver ID) on the weekend of the specified cutover:WorkloadCurrent CodeNew J8 CodeCutover DateIN-A0013008101July 23, 2012IN-B0063008102August 20, 2012MI-A0045208201MI-B0095308202July 16, 2012
19J8 - Important X12 837 Data Element Change The new contract codes (receiver ID) will need to beplaced in the following data elements within yourMAC J8 X claim files:ISA-08GS-031000B/NM1-09 (40 qualifier)2010BB/NM1-09 (Part B Only)
20J8 - Important X12 835 Data Element Change The new contract codes (receiver ID) willbe reported in the following dataelements within your MAC J8 X12 835Electronic Remittance Advice:ISA-06GS-021000A/REF02 (2U qualifier)
21J8 and 5010CMS expects trading partners to transition to 5010 transactions;WPS can assist with any 5010 transition issues;Visit the WPS EDI 5010 readiness website at:Crosswalk https://www.wpsic.com/edi/pdf/npi_1500_crosswalk.pdf
22J8 and Network Service Vendors (NSV) WPS is working with the NSV to ensure there is no disruption in service to electronic providers;Your current connectivity through an NSV will remain in place, therefore, connectivity via bulletin board system is not required;You can use your current submitter IDs for J8.
23J8 and PC-Ace Pro32WPS also utilizes PC-Ace Pro32 as the free, Medicare supplied billing software;Different versions of PC-Ace Pro32 are used by other payers;WPS has an upgrade which will allow retention of history, beneficiary and provider data. J8 providers will need to run the upgrade on or after your respective cutover date in order to transition to the new Part B J8 MAC contractor codes.
24J8 and MI Medicare B MI-B transition date was July 16, 2012. Michigan Medicare B submitters did not need to change their current connectivity to WPS;Michigan B submitters will continue to use their existing WPS submitter ID.
26Checklist for Moving Into Production (5010 and J8) Use the tools available to you to monitor your businessIdentify contingenciesRead your 999 responsesRead your 277CA responsesReview your remittancesMonitor your cash flowIdentify and correct in a timely manner any issues identified.Use these tools to monitor your business so when you call, you’ll already have an idea what the issue may be.Use all the tools available. Monitor your business. Watch the ERA and SPR’s from your other insurers on cross over claims.
27Help Us Help You…When you call have information available which will help us identify your file and research your issue:Submitter IDNPIISA Control Number that was sent to WPS Medicare(this is especially important for clearinghouse customers. ISA13 is NOT Protected Health Information)Claims CountDate of SubmissionDollar Amount of submissionOther ways to contact EDI…
28Go Green!!!Go Green!!!Even if you don’t post electronically you can take advantage of 835.PC Print and MREP are free and easy to use.
29Medicare Remit Easy Print (MREP) and PC Print Software MREP for Part B; PC Print for Part AWill enable physicians and suppliers to view and locally print a Medicare Part B / DMERC HIPAA compliant 835 file in a format that mirrors the Medicare Standard Paper Remittance Advice (SPR).Eliminates physical filing and storage space needs.Print remit same day as 835 is available.Print and forward claims for other payers.Quick and easy access to claim information.No waiting for mail.Several useful reports.Save time and money.It’s FREE!
30PWK Initiative Delayed Originally scheduled for April 2012Change Requests (CRs):7041, 7306, and 7330Contractors continue to test.
31Future EDI ACTs 2012 Date Dial In ID 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.2012 calls (all times 1-2:30 pm cst):Date Dial In IDOctober 11,December 6,2012 Schedule to be announced.
32Questions and Answers We want to hear from you… Also visit our 5010 readiness site for additional FAQs:J8 EDI Site:
33EDI Addresses & Numbers EDIMedicareA@WPSIC.com EDIMedicareB@WPSIC.com Medicare Part A Legacy A Medicare J5, J8 MAC Part A & B(multiple states) (Iowa, Kansas, Missouri, Nebraska)WPS Medicare EDI (Indiana, Michigan)PO Box WPS Medicare EDIOmaha, NE West BroadwayFax: (402) Madison, WIMed A Hotline: (866) Fax: (608)J5 Hotline: (866)Medicare Part B Legacy(Illinois, Minnesota, Wisconsin)WPS Medicare Electronic Data Services912 N Pentecost DriveMarion, IL 62959Fax : (618)Med B EDI Hotline: (877)Here is our EDI contact information.If you choose to EDI at either: orwe want to remind you that CMS prohibits the sending or receiving of Protected Health Information (PHI) over the internet, so if you choose to EDI, be sure to not include any PHI.
34Important Dates 4010 Cutoff June 29, 2012, 4 pm cst J8 Implementations MI-B July 16,2012IN-A, MI-A July 23, 2012IN-B August 20, 2012Next EDI ACT August 9, 2012, 1 pm cst
35Resources CMS 5010 and D.0 Webpage http://www.cms.gov/version5010andD0 Educational Resources:5010 Technical Review Type 3 guides:X12:Washington PublishingWPS 5010:CMS National Provider Calls:Lastly, here are some resources for 5010 as well as ICD-10.We will have more information in our Enews and Communiqué. You are encourage to sign up for Enews and watch notifications on related EDI topics.To sign up, go to the wpsmedicare website and select the appropriate line of business for Part A or Part B, enter your address in the yellow box located in the upper right hand corner and select ‘subscribe’. From there you will have a link from which you can follow directions.