Presentation on theme: "Transactions, Code Sets and Identifiers (NPI) Update"— Presentation transcript:
1 Transactions, Code Sets and Identifiers (NPI) Update The Privacy SymposiumThe Sixteenth National HIPAA SummitCambridge, MATransactions, Code Sets and Identifiers (NPI) UpdateJim Whicker, CPAMIntermountain HealthcareDirector of EDI, A/R ManagementChair, WEDIAAHAM EDI Liaison
2 NPI – Our Experiences Claims processing ok Unexpected rejections Concern for some providers as not all segments fully NPI onlyUnexpected rejectionsPayer CrosswalksInability to handle provider who practices in multiple locations835’s processing mostly without incidentSome payers have difficulty with paper and crossover claimsClearinghouse/Payer creating loops and segments not on outbound claim then rejecting claim for non compliance!
3 National Provider ID - NPI Additional Issues:Provider required to submit NPI on bill even when referring doc has no NPI/Unable to obtainMedicare Transmittal 235 made recommendations, but has since been rescinded without alternativeProvider NPPES and IRS name mismatchRequirement to Update 855 documents with CMS and wait to update NPPES until AFTER CMS updates internal systems.Interaction issue between NPPES and PECOSCMS has processing issues for certain institutional bill types hitting the right area internally for payment.
4 "You really don't need my driver's license officer "You really don't need my driver's license officer...I have an NPI, a 10-digit, intelligence-free, numeric identifier."Cartoon by Dave Harbaugh
5 NPRM – 5010, D.0, and ICD-10Information released for public view Friday, August 15Publication in Federal Register August 22, 2008Comments Due October 21, 2008For 5010 and D.0Industry internal review for changes – begin September 2008Internal/External Testing by April 2009CMS expects to have full compliance by April, 2010Short process for review of comments and posting of final rule?For ICD-10Industry begin design and documentation June 2009Industry build and internally test system changes December 2009Test with trading partners July 2010 – October 2011Full compliance October 2011Still no Attachments final rule, nor plans for a National Payer IDRecommendation to adopt Acknowledgements, Standard ID Card
6 5010? Why? Current transactions are over 6 years old More than 500 industry requested changes via DSMOMany more industry requested changes via ASC X12Addresses problems encountered with 4010A1Improvements to implementation instructionsMore consistent implementations by trading partnersShould reduce Companion Guide TP requirements
7 Upgrade not a HIPAA “Do-over” Change analysis will require a thorough review of all transaction TR3sAnalysis is X12 to X12Less complicated than with round 1Changes are not a 100% changeSome transactions changed very littleOther transactions changed moderatelyOthers had significant changes (claims)
8 General changes to all transactions More standardized front matterAddressed industry needs missing from 4010Clarified intent where previously ambiguousClarified, Added, or Deleted code values and qualifiers:To address industry requestsTo reduce confusion from similar or redundant valuesTR#’s (Implementation Guides) “Free” for 4010, Must be purchased for 5010
9 837 – Health Care Claims (I, P, D) Fixed significant industry problems:Improved front matter explanation of COB reporting and balancing logicAdded COB crosswalk – and examplesSection added to explain allowed and approved amountsSubscriber/patient hierarchy modified837I Provider types were redefined in conjunction with the NUBC code set
10 837 – Health Care Claims (cont’d) Improved rules and instructions for reporting provider roles and use of NPIAdded front matter sections to:Explain Medicaid subrogationPay-to Plan informationExplain reporting of drug claimsPOA Moved to a specific segment rather than “Kludged”Capability to do ICD-10837 Professional - Anesthesia minutesAmbulance “Pick-up” information addedDental – easier to coordinate benefits between dental and medical plansStart/Stop dates for crowns/bridgesAllows for Tooth numbers with International systems
11 835 – Claims Payment/Remittance Many improvements are in the Front MatterTighter business rules to eliminate options and codesAllows compatibility with claims sent under version 4010 for transitionAdded Health Care Medical Policy – via payer URLClaim status has clearer guidance to report how a claim was adjudicatedBetter instructions for handling reversals and corrections; interest payments and prompt pay discountsLimits use of denial claim status to specific business caseAdvanced payments and reconciliationSecondary payment reporting considerations section revised
12 834 - Enrollment/Disenrollment 820 – Premium Payments834:Allow usage of ICD-10 for reporting pre-existing condittionsPrivacy issues addressedAdded codes to explain coverage changesClarifies usage of coverage dates820:Ability to report additional deductions from paymentsMethod used to deliver remittanceSimplifies and clarifies when adjustments to previous payments are needed
13 270/271 – Eligibility Clarified instructions for sending inquiries: When subscriber is patientWhen dependent is patientNewly required response informationWhen a patient has active benefit coverage, the health plan must report:Beginning effective eligibility date, Plan name, and the Benefit effective dates if different from the overall coverage.All demographic information needed by the health plan on subsequent transactions must be reported, primary care provider if available, and other payers if known.
14 270/271 – Eligibility Required alternate search options When payers are unable to find member eligibility information using all the data elements of the primary search, health plans must support inquiries with:Member ID, Last name only, and Date of Birth to help eliminate false negatives.This was a controversial requirement, and was just modified during the June trimester meeting, changes to the TR3 (Implementation Guide) will be forthcoming to reflect this modification.
15 270/271 – Eligibility (cont’d) Nine categories that must be reportedMedical CareChiropractic CareDental CareHospitalEmergency ServicesPharmacyProfessional Visit – OfficeVisionMental HealthUrgent Care
16 270/271 – Eligibility (cont’d) Clear requirements for reporting patient responsibility with a monetary amount or percentageAdded 38 new service type codes
17 276/277 – Health Care Claim Status Eliminated sensitive patient information that was unnecessary for business purposeAdded Pharmacy related data segments and the use of NCPDP Payment Reject CodesIncreased Claim Status segment repeat to > 1 for more detailed status informationAdded more examples to clarify instructions
18 278 – Referral Certification and Authorization Little implementation due to constraints under 4010Added segments for reporting key patient conditionsAdded/expanded support for various business needsExpanded usage for authorizations