Transcript Medicare Fee For Service (FFS) EDI ACT

Medicare Fee For Service (FFS)
EDI ACT
(June 14, 2012)
Purpose of Power Point
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5010 Status
Cutting off 4010
Moving Into Production
J8 Implementation
Contacting EDI
Important Dates
Medicare is ready. Are you?
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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.
WPS Medicare 5010 Statistics
Over 99.4% of all claim accepted are 5010 (as of
5/25/2012).
Contract
Submitter
Sending
5010 Accepted
Claims %
Provider %
Sending 5010
5010-835s Sent
Legacy A
730
99.1%
99.7%
49.36%
J5A
400
99.9%
98.5%
48.00%
J5B
1922
99.7%
99.7%
90.99%
IL
1051
99.6%
99.3%
91.96%
MI
529
98.0%
97.0%
95.73%
WI
555
99.9%
99.8%
87.53%
MN
277
99.8%
99.5%
94.52%
Direct Submitters Testing Procedures
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CMS recommends 25 claim minimum
Testing in errata version only
100% syntax
95% Medicare business rules
ISA14 highly recommended to = 1
ISA15 must = T
Submitter is considered in test until approved
by contractor
Top 5010 Errors – Med A 837I
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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
Top 5010 Errors – Med B 837P
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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
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Diagnosis Code (ICD-9)
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Zip (can not be padded with 0s or 9s)
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HCPCS
Anesthesia services require MJ qualifier, all other services UN qualifier
Other Insured's Adjustment Quantity; 2430.CAS must not be equal to
zero
Current Med A Issues
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277 - Claim Status Response - the STC01-1
(Claim Status Category Code) from the the
5010 277 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.
Current Med B Issues
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Canadian Beneficiary Address
Partial 835 (not a complete ISA-IEA)
Sporadic delays in sending responses
(999, 277CAs)
Getting 5010 – 835 Electronic
Remittance Advice
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835 Production Parallel files available upon request by
contacting the EDI Hotline.
Production 835 is generated based on how the receiver/provider
are set up
Not generated based on inbound claim format
When ready, we can “flip” the entire submitter from 4010 to
5010-835.
We can also “flip” on a provider by provider basis who gets
5010-835.
Request to switch from 4010 to 5010-835 should be done in
writing.
If a user doesn’t request to be flipped, they will automatically be
switched to 5010 effective July 1, 2012.
Getting 5010 – 276/277 Claim
Status Inquiry and Response
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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
Companion Guide
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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:
http://www.wpsic.com/edi/pdf/med_a_837i_companion.pdf
http://www.wpsic.com/edi/pdf/med_b_837p_companion.pdf
Cutting Off 4010
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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 will
receive message that the format is no longer
accepted.
835 receivers, who have not previously
converted to 5010 will be switched.
NO ADDITIONAL DELAYS!
Contingency Plans
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Approved vendor, billing services and
clearinghouse lists:
http://www.wpsic.com/edi/5010-Readiness.shtml
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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?
PC-Ace Pro32
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Providers may download PC-Ace Pro-32 software at the
link below to submit 5010 file formats:
http://www.wpsic.com/edi/pcacepro32.shtml
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.
Our Message to you…
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Move into 5010 production now!
Continue to work with your vendor and/or
clearinghouse
Monitor your business
It is your responsibility to be compliant
If you fail to prepare, it will be your
business and cash flow that will be
affected!
EDI Information For J8
Implementation
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.
J8 Contract Numbers
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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
July 23, 2012
MI-B
00953
08202
July 16, 2012
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 X12 837 claim files:
 ISA-08
 GS-03
 1000B/NM1-09 (40 qualifier)
J8 and 5010
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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:
http://www.wpsic.com/edi/5010Readiness.shtml
1500-5010 Crosswalk:
https://www.wpsic.com/edi/pdf/npi_1500_crosswalk.
pdf
J8 and Network Service Vendors
(NSV)
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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.
J8 and PC-Ace Pro32
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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 is working with the PC-Ace Pro32
vendor, SDI, to provide a patch which will
allow retention of history, beneficiary and
provider data.
J8 and MI Medicare B
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Current Michigan Medicare B submitters will
not need to change their current connectivity
to WPS;
Current Michigan B submitters will continue to
use their existing WPS submitter ID.
J8 and 5010 - Checklist for
Moving Into Production
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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…
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When you call have information available which will
help us identify your file and research your issue:
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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…
[email protected],
[email protected]
Go Green!!!
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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.
Medicare Remit Easy Print (MREP)
and PC Print Software
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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!
PWK Initiative Delayed
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Originally scheduled for April 2012
Change Requests (CRs):
7041, 7306, and 7330
Contractors continue to test.
Future EDI ACTs 2012
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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):
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Date
August 9, 2012
October 11, 2012
December 6, 2012
Dial In
800-305-2862
800-305-2862
800-305-2862
ID
11138602
11138603
11138604
Questions and Answers
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We want to hear from you…
Also visit our 5010 readiness site for
additional FAQs:
http://www.wpsic.com/edi/5010-Readiness.shtml
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J8 EDI Site:
http://www.wpsic.com/edi/med-macj8.shtml
EDI Addresses & Numbers
[email protected]
Medicare Part A Legacy A
(multiple states)
WPS Medicare EDI
PO Box 1602
Omaha, NE 68101
Fax: (402) 995-0606
Med A Hotline: (866) 734-6656
Medicare Part B Legacy
(Illinois, Michigan, Minnesota, Wisconsin)
WPS Medicare Electronic Data Services
912 N Pentecost Drive
Marion, IL 62959
Fax :
(618) 998-5170
Med B EDI Hotline: (877) 567-7261
[email protected]
Medicare J5 J8 MAC Part A & B
(Iowa, Kansas, Missouri, Nebraska)
(Indiana, Michigan)
WPS Medicare EDI
1717 West Broadway
Madison, WI. 53713
Fax:
(608) 223-3824
J5 Hotline:
(866) 503-9670
Important Dates
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4010 Cutoff
June 29, 2012, 4 pm cst
J8 Implementations
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MI-B
IN-A, MI-A
IN-B
Next EDI ACT
July 16,2012
July 23, 2012
August 20, 2012
August 9, 2012, 1 pm cst
Resources
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CMS 5010 and D.0 Webpage
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Educational Resources:
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5010 Technical Review Type 3 guides:
http://www.cms.gov/version5010andD0
http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
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X12: www.X12.org
Washington Publishing
www.WPC-EDI.com
WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml
CMS National Provider Calls:
http://www.eventsvc.com/palmettogba/