MAC J5 and J8 EDI ACT (August 14, 2014) Participant Line: (800) Passcode:

Purpose of Power Point Current issues ICD-10 Update Reminder MSP Claims ERA Myth Busting Go Green Operation Rules Connectivity Misconceptions PC-Ace Monitor Your Business Upcoming EDI ACT 2014 Contacting EDI – Toll Free N umbers

Current Med A Issues – PCPrint Update: Current version Version and above, are not compatible with Windows XP. Part A providers using Windows XP should continue to use version of PC Print until they are able to upgrade to a newer version of Windows. The “Find” function in PCPrint is not working in version and after. A fix for this is anticipated in October Sporadic delays in sending responses (999, 277CA, 277 or 835s)

Current Med B Issues Foreign and military zip codes. Foreign zips can be alpha-numeric zips and not currently loaded to CEM. Military zips code set not currently loaded to CEM. CEM Edits Require: 2010BA.N403 must be a valid postal/zip Code when N404 equals US or blank. 2010BA.N404 must be a valid 2 character Country Code. Valid alpha-2 Country Code reference must be available for this edit. (from Part 1 of ISO 3166) Example: N3*POSTFACH 88~ N4*MARLIX**7074*CH~ Sporadic delays in sending responses (999, 277CA, 277 or 835s) MREP issues for Windows 7 or 8 users

ICD-10 Update ICD-10 is the biggest change in standard healthcare coding systems in decades. ICD-10 will impact every system, process and transaction that contains or uses a diagnosis code. This past March, the Centers for Medicare & Medicaid Services (CMS) conducted a successful ICD-10 testing week. This testing week allowed an opportunity for testers and CMS alike to learn valuable lessons about ICD-10 claims processing. CMS anticipates additional testing for trading partners.

ICD-10 Update SE1410 – alerts providers that on October 1, 2015, all Medicare claims submissions of diagnosis codes will change from the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) to the 10th Edition (ICD-10-CM). Factors affect how ICD-10-CM must be used: The claim “From” date (episode start date); The Outcome and Assessment Information Set (OASIS) assessment completion date (OASIS item M0090 date); and The claim “Through” date. Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf

Reminder MSP Claims MSP claims are not an ASCA (Administrative Simplification Compliance Act) exception and must be sent electronically. Avoid front end rejections, delays and Unprocessable rejections: When determining the beneficiary’s insurance coverage, it is important to determine the correct insurance type code. Always give the MSP insurance type code. Other Insured's Adjustment Quantity; 2430/CAS must not be equal to zero. Primary paid amount should not exceed the billed amount. Primary paid amounts at the claim level should agree with the amounts submitted at the line level. Instructions:

ERA Myth Busting I was unaware of the ERA. Tell me more about EDI and ERA. Goal – We want to educate on the benefits of ERA. I'm not really sure. If it is something you need to sign up for we may not have been informed. Fact – ERA is optional, at this time, but provides several benefits to your business. Because paper is more reliable than electronic remittance. It also allows me to track internal errors. I am able to follow our patients better who have cross over claims, as our cross over claims do not always get processed by the state and this way we assure that happens on a weekly basis. I am in need of the paper EOB when I post the primary EOB to send to the other plan and I make those copies at the time of primary posting. Fact – Paper and ERA contain the same information. Per HIPAA, the data content of paper cannot be greater then that of the electronic transaction (xref ). Cost of vendor retrieval of ERAs. I do not know how to receive ERA. Fact – You can download directly from WPS or through a clearinghouse (clearinghouse charges apply). You can also use free products such as PCPrint or MREP for your ERA. Fact – Products like PCPrint and MREP as well as vendor product, have many useful reports.

ERA Myth Busting It is difficult enough with depositing directly to the account. I get an stating a deposit has been made to our account then, I have to hunt and review all of my Medicare clients to see where the money should go. Fact – Operating Rules (370) reassociation requires the EIN and Check # be on both ERA and EFT. ERA did not come faster, harder to read without printing and did not import into PCAce the reimbursements, so not streamlining or improving efficiency of office staff. Fact – ERA is avaliable next business day after a claim finalizes. Fact – PCPrint and MREP provide many beneficial reports, some of which are formatted the same as the paper remit. We use PC-Ace to submit our electronic claims. Using ERA with that system has never been explained to us. Fact – EDI Helpdesk staff are available to help. Not sure, do not know how to set up. Fact – PCPrint and MREP user guides provide clear, concise intructions.

Facts. You too can Go Green!!! Go Green!!! Even if you don’t post electronically you can take advantage of 835. ERA has same content as SPR. Over 78% of all remittances are sent electronically in format. Download directly from WPS. Operating Rule 370 ensures EFT and ERA reassociation. PcPrint and MREP are free and easy to use. You can download MREP and PcPrint from:

Medicare Remit Easy Print (MREP) and PcPrint Software  MREP for Part B; PC Print for Part A  Will 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!

Operating Rules Affordable Care Act (ACA) defines operating rules as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.” Operating rules address gaps in standards, help refine the infrastructure that supports electronic data exchange and recognize interdependencies among transactions. Goal: Create as much uniformity in the implementation of electronic standard as possible. Goal: Create as much uniformity in the implementation of electronic standard as possible.

Operating Rule Named for Eligibility and Claim Status (effective 1/1/2013) Phase 1 CORE 152 Eligibility and Benefit Real Time Companion Guide Phase 1 CORE 153 Eligibility and Benefit Connectivity Rule Phase 1 CORE 154 Eligibility and Benefit 270/271 Data Content Rule Phase 1 CORE 155 Eligibility and Benefit Batch Response Time Rule Phase 1 CORE 156 Eligibility and Benefit Real Time Response Time Rule Phase 1 CORE 157 Eligibility and Benefit System Availability Rule Phase 2 CORE 250 Claim Status Rule Phase 2 CORE 258 Eligibility and Benefit Normalizing Patient Last Name Rule Phase 2 CORE 259 Eligibility and Benefit 270/271 AAA Error Code Reporting Rule Phase 2 CORE 260 Eligibility and Benefit Data Content (270/271) Rule Phase 2 CORE 270 Connectivity Rule

EFT and ERA Operating Rule Impacts 835 Infrastructure CARC/RARC combinations EFT ERA Reassociation Electronic Enrollments for EFT and ERA

EFT and ERA Operating Rules Named (effective 1/1/2014) Phase 3 CORE 360 Health Care Claim Payment/Advice (835) Infrastructure Rule Phase 3 CORE 350 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule Phase 3 CORE 360 CORE-required Code Combinations for CORE-defined Business Scenarios Phase 3 CORE 370 EFT & ERA Reassociation (CCD+/835) Rule Phase 3 CORE 380 EFT Enrollment Data Rule Phase 3 CORE 382 ERA Enrollment Data Rule

CARC/RARC Operating Rules 4 Business Scenarios Defined (Rule 360) Specific combinations of CARC and RARC are allowed for each business scenario. Scenario #1: Additional Information Required - Missing/Invalid/Incomplete Documentation Scenario #2: Additional Information Required – Missing/Invalid/Incomplete Data from Submitted Claim Scenario #3: Billed Service Not Covered by Health Plan Scenario #4: Benefit for Billed Service Not Separately Payable

EFT ERA Reassociation (Rule 370) Reassociation is the process of matching an Electronic Remittance Advice (ERA) in the ASC X format to the associated Electronic Funds Transfer (EFT). EFT must match 835 transaction. Reconcile actual cash received to check amounts in the 835 PRIOR to posting to patient accounting system. Bank need to ensure the “7 record” is sent to provider (typically sent upon request only). Example EFT: 705TRN*1* * ~ Example 835: TRN*1* * ~

Ensure Proper Completion of ERA Form (Rule 382) : DEG1 the address must match what is on file with Provider Enrollment. DEG2 Medicare must be listed in Assigning Authority DEG2 Medicare PTAN must be listed in other identifier DEG2 Valid WPS submitter id/trading partner ID DEG3 Provider contact information must be someone from the provider’s office (not a biller, billing service or clearinghouse). DEG7 NPI is required DEG8 is required if using a clearinghouse. DEG10 Mark the submission information - ex: New Enrollment, Change Enrollment, Cancel Enrollment.

Connectivity Misconceptions WPS took over some years ago and submitting electronic claims went from pulling them up through the internet back to a bulletin board system (BBS). I asked WPS why they did this and they claimed it couldn't change until CMS OK'd it. Fact - CMS Internet policy (ref IOM Chapter 24 Guidance/Guidance/Manuals/Downloads/clm104c24.pdf) prohibits the transmission of protected health data between providers and other parties who are not Medicare contractors over the Internet unless it is authenticated and encrypted…Unless otherwise approved, A/B MACs, DME MACs and CEDI are only permitted to accept EDI transactions via the Internet when explicitly directed by CMS. We still have to transfer electronic claims through a dial up connection. Every other electronic submission I use is through the internet. I asked WPS about it and they said dial up is safe. Fact: Dial up technology is proven secure. WPS also offers secure FTP (sFTP) via Networl Service Vendor (NSV) in addition to BBS.

WPS Connectivity Options Dial Up Bulletin Board System (BBS). Network Service Vendor (NSV) into Medicare EDI Gateway (MEG) Ability Network ClaimShuttle Cortex EDI, Inc ECC Technologies' RAPID Network Episode Alert LLC eSolutions, Inc. McKesson Carebridge MedXpress Nebo Systems, Inc. Optimum Management

Contingency Plans Approved vendor, billing services, clearinghouse and Network Service Vendor (NSV) lists: PC-Ace Pro32 Clearinghouse options? What are your contractual arrangements with vendor and/or clearinghouse? Paper claim submission is not a contingency option Other?

PC-Ace Pro32 Providers 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 site. New PC-Ace users must test. Existing PC-Ace users are not required to test. Import 277CA or 835 into readable reports. A common piece of providers’ contingency plans! Current version 2.54

Monitor Your Business!!! Use the tools available to you to monitor your business Identify contingencies Read your 999 responses Read your 277CA responses Review your remittances Monitor your cash flow Identify 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.

Help Us Help You… Before you call, have information available which will help us authenticate you and research your issue: Submitter ID NPI ISA Control Number that was sent to WPS Medicare (this is especially important for clearinghouse customers. ISA13 is NOT Protected Health Information) Claims Count Date of Submission Dollar Amount of submission Other ways to contact EDI…

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Future EDI ACTs 2014 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 1-2:30 pm cst): Date October 9, 2014(800) December 11, 2014(800) More in 2015!!!

Questions and Answers We want to hear from you… If you have additional questions, you can also send an to: Also visit our EDI site for additional information:

EDI Addresses & Numbers MAC J5, J8 Part A & B (Iowa, Kansas, Missouri, Nebraska and J5 National) (Indiana, Michigan) WPS Medicare EDI 1717 West Broadway Madison, WI Fax: (608) New Single Point of Contact Numbers!!! J5 Single Point Of Contact (SPOC):(866) opt 1 J8 Single Point Of Contact (SPOC): (866) opt 1

Resources CMS 5010 and D.0 Webpage Educational Resources: Technical Review Type 3 guides: X12: Washington Publishing WPS Medicare EDI: NACHA: CAQH CORE: