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Medicare Fee For Service (FFS) EDI ACT (August 9, 2012)

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Presentation on theme: "Medicare Fee For Service (FFS) EDI ACT (August 9, 2012)"— Presentation transcript:

1 Medicare Fee For Service (FFS) EDI ACT (August 9, 2012)

2 Purpose of Power Point 5010 Status Cutting off 4010 J8 Implementation
Monitor Your Business Go Green Contacting EDI

3 Medicare is ready. Are you?
Testing began in January 2011 Processing 5010 claims since April 2011 Over 3.00 million claims accepted last week Test results returned within 3 business days 835 Production Parallel files available upon request by contacting the EDI Hotline. Results returned on a first come first served basis.

4 WPS Medicare 5010 Statistics 100% of all claim accepted are 5010 (as of 7/27/2012).
Contract Submitter Sending 5010 Accepted Claims % Provider % Sending 5010 s Sent J5A 412 100% 73.88% J8A 109 Legacy A 715 95.80% J5B 2013 94.23% J8B 574 97.84% IL 1115 94.89% WI 583 93.32% MN 285 96.76%

5 Top 5010 Errors – Med A 837I Invalid information within the Payer Claim Filing Indicator Invalid information within the Subscribers Contract/Member number Relational field in error for service(s) rendered Invalid information within the HCPCS Billing Provider’s National Provider Identifier (NPI) and Billing Provider’s taxid Duplicate ST-SE Invalid information within the Subscribers Country code Claim is out of balance within the Payers payment information Invalid information within the Subscribers Postal/Zip code Invalid information within the Attending Physicians Specialty/Taxonomy code

6 Top 5010 Errors – Med B 837P Billing provider not authorized for this submitter (not linked, rendering NPI…) NPI Crosswalk Error - Billing provider NPI not related to TaxID Missing or invalid Payer ID or Receiver ID Invalid Health Insurance Claim Number SV101-7 code description required for NOC/NOS codes Invalid Billing NPI Invalid codes Diagnosis Code (ICD-9) Zip (can not be padded with 0s or 9s) HCPCS Anesthesia services require MJ qualifier, all other services UN qualifier Other Insured's Adjustment Quantity; 2430.CAS must not be equal to zero In 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.

7 Current Med A Issues 277 - 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.

8 Current Med B Issues Canadian Beneficiary Address
Partial 835 (not a complete ISA-IEA) Sporadic delays in sending responses (999, 277CAs)

9 Getting 5010 – 835 Electronic Remittance Advice
Production 835 is generated based on how the receiver/provider are set up Not generated based on inbound claim format If 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.

10 Getting 5010 – 276/277 Claim Status Inquiry and Response
Testing is not required “Testing” is done using production data ISA05 must = ZZ ISA06 must = ZZ ISA14 highly recommended to = 1 Be sure to have ISA15 = P

11 Companion Guide To assist trading partners and their business associates with exchanging transactions Companion Guide provides technical and connectivity specification for the following: 837 Health Care Claim Institutional 837 Health Care Claim Professional 835 Health Care Claim Payment Advice 276/277 Status Inquiry and Response Companion guides posted to:

12 Cut Off Last 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.

13 Contingency Plans Approved vendor, billing services and clearinghouse lists: PC-Ace Pro32 Paper claim submission is not a contingency option Clearinghouse 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 translation Separating 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.

14 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. 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.

15 EDI Information For J8 Implementation

16 J8 Implementation Providers will not need to re-enroll for
EDI claims submission or Electronic Remittance Advice (ERA) provide you are: Currently an NGS EDI customer using one of the Network Service Vendors (NSVs), or; Currently a WPS submitter.

17 J8 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.

18 J8 Contract Numbers Submitters will need to change their current contract number (receiver ID) on the weekend of the specified cutover: Workload Current Code New J8 Code Cutover Date IN-A 00130 08101 July 23, 2012 IN-B 00630 08102 August 20, 2012 MI-A 00452 08201 MI-B 00953 08202 July 16, 2012

19 J8 - Important X12 837 Data Element Change
The new contract codes (receiver ID) will need to be placed in the following data elements within your MAC J8 X claim files: ISA-08 GS-03 1000B/NM1-09 (40 qualifier) 2010BB/NM1-09 (Part B Only)

20 J8 - Important X12 835 Data Element Change
The new contract codes (receiver ID) will be reported in the following data elements within your MAC J8 X12 835 Electronic Remittance Advice: ISA-06 GS-02 1000A/REF02 (2U qualifier)

21 J8 and 5010 CMS 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

22 J8 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.

23 J8 and PC-Ace Pro32 WPS 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.

24 J8 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.

25 Monitor Your Business!

26 Checklist for Moving Into Production (5010 and J8)
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. Use all the tools available. Monitor your business. Watch the ERA and SPR’s from your other insurers on cross over claims.

27 Help Us Help You… When you call have information available which will help us identify your file 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…

28 Go 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.

29 Medicare Remit Easy Print (MREP) and PC Print 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!

30 PWK Initiative Delayed
Originally scheduled for April 2012 Change Requests (CRs): 7041, 7306, and 7330 Contractors continue to test.

31 Future 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 ID October 11, December 6, 2012 Schedule to be announced.

32 Questions and Answers We want to hear from you…
Also visit our 5010 readiness site for additional FAQs: J8 EDI Site:

33 EDI Addresses & Numbers
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 EDI Omaha, NE West Broadway Fax: (402) Madison, WI Med A Hotline: (866) Fax: (608) J5 Hotline: (866) Medicare Part B Legacy (Illinois, Minnesota, Wisconsin) WPS Medicare Electronic Data Services 912 N Pentecost Drive Marion, IL 62959 Fax : (618) Med B EDI Hotline: (877) Here is our EDI contact information. If you choose to EDI at either: or we 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.

34 Important Dates 4010 Cutoff June 29, 2012, 4 pm cst J8 Implementations
MI-B July 16,2012 IN-A, MI-A July 23, 2012 IN-B August 20, 2012 Next EDI ACT August 9, 2012, 1 pm cst

35 Resources CMS 5010 and D.0 Webpage
Educational Resources: 5010 Technical Review Type 3 guides: X12: Washington Publishing WPS 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.

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