Transcript Medicare Fee For Service (FFS)
MAC J5 and J8 EDI ACT (April 10, 2014)
Participant Line: (800) 305-2862
Passcode: 84826714
Purpose of Power Point
Current issues Operating Rules HIPAA Security and Windows XP ICD-10 Preparedness, Nat’l Test Days, HR 4302 Monitor Your Business Go Green Upcoming EDI ACT 2014 Contacting EDI – New Toll Free Number
Current Med A Issues –
PCPrint - DLL error for Windows 8 users Has been reported to Shared System Maintainer. As a work around, users may run the program in “compatibility mode.” 999 and 277CA not received.
Current Med B Issues
Canadian and military zip codes.
Sporadic delays in sending responses (999, 277CAs or 835s) MREP issues for Windows 7 or 8 users
MSP Claims - 5010
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: http://www.wpsic.com/edi/files/msp5010A1.pdf
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.
Operating Rule Named for Eligibility and Claim Status
(effective 1/1/2013)
Phase 1 CORE 152 Phase 1 CORE 153 Phase 1 CORE 154 Phase 1 CORE 155 Phase 1 CORE 156 Phase 1 CORE 157 Phase 2 CORE 250 Phase 2 CORE 258 Phase 2 CORE 259 Phase 2 CORE 260 Phase 2 CORE 270
Eligibility and Benefit Real Time Companion Guide Eligibility and Benefit Connectivity Rule Eligibility and Benefit 270/271 Data Content Rule Eligibility and Benefit Batch Response Time Rule Eligibility and Benefit Real Time Response Time Rule Eligibility and Benefit System Availability Rule Claim Status Rule Eligibility and Benefit Normalizing Patient Last Name Rule Eligibility and Benefit 270/271 AAA Error Code Reporting Rule Eligibility and Benefit Data Content (270/271) Rule 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 Phase 3 CORE 350 Phase 3 CORE 360 Phase 3 CORE 370 Phase 3 CORE 380 Phase 3 CORE 382 Health Care Claim Payment/Advice (835) Infrastructure Rule Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule CORE-required Code Combinations for CORE-defined Business Scenarios EFT & ERA Reassociation (CCD+/835) Rule EFT Enrollment Data Rule 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 X12 835 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*8834567890*1391268299~ Example 835: TRN*1*8834567890*1391268299~
Ensure Proper Completion of ERA Form
(Rule 382)
:
DEG1 the address must match what is on file with Provider Enrollment.
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.
ICD-10 Impact
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.
ICD-10
ICD-10-CM will be used in all healthcare settings.
ICD-10-PCS will be used for facility reporting of hospital inpatient services.
Are you prepared for ICD-10?
Start now Ask your vendor and/or clearinghouse about their plans and timeframes implementing ICD-10 ICD-9 to ICD-10 analysis – identify: New, deleted and modified content Impact to business needs Training -Staff training Communicate and coordinate Test: internally and externally Know your vendor’s schedule Know your trading partner’s schedule Communicate within entire organization to insure all impacts identified early.
Identify contingencies It is your responsibility to be compliant.
If you fail to prepare, it will be your business and cash flow that will be affected!
Why ICD-10?
Improve accuracy and efficiency of coding Reduce training effort Improve communication with physicians Completeness - All substantially different procedures have a unique code Expandability - The structure of the system allows incorporation of new procedures as unique codes Standardize terminology - Includes definitions of the terminology used. While the meaning of specific words can vary in common usage, ICD-10 PCS defines a single meaning for each term used in the system.
ICD-10 Timeframes
NPRM Published August 22, 2008 with comments by October 21, 2008 Final rule Published January 16, 2009 Compliance date
OCTOBER 1, 2014
837I - ICD-10 on institutional claims with a discharge date, of October 1, 2014 or later 837P - ICD-10 codes on professional claims with a date of service October 1, 2014 or later HR 4302
May not adopt prior to October 1, 2015
House Resolution (HR)
4302
SEC. 212. DELAY IN TRANSITION FROM ICD–9 TO ICD–10 CODE SETS.
The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.
CMS is assessing the impact of HR 4302, and we’ll communicate more information as we receive it.
ICD-10 FAQs
http://www.wpsmedicare.com/j5macparta/claims/icd-10/index.shtml
http://www.wpsmedicare.com/j5macpartb/claims/icd-10/index.shtml
http://www.wpsmedicare.com/j8macparta/claims/icd-10/index.shtml
http://www.wpsmedicare.com/j8macpartb/claims/icd-10/index.shtml
Are you ready for ICD-10?
ICD-10 codes are 3-7 characters long. Have you contacted your vendor to ensure that your billing software will accommodate ICD-10 codes? When will you be ready to send a ICD-10 test to your payer or clearinghouse?
Have your staff been trained on ICD-10?
Do you know when your payer will be ready to test ICD-10? Do you know when your payer will be ready to receive production ICD-10 claims?
CMS Announces Testing Days
CR8465 Allow trading partners access to MACs for testing with real-time help desk support.
Front End (999/277CA) testing only.
Submit ICD-10 codes on claims.
Register in advance via site or email.
March 3-7, 2014 More expected…
Results Nat’l Test Days
Limited End-to-End Testing
As a result of the industry interest and demand… Medicare is able to provide some limited end-to-end testing, which includes 835 generation.
CR 8602
Volunteering for End-to-End
Limited # of testers (16 - J5 and 16 - J8 each).
Cross-section of large/small providers, geographic area, provider type, bill type… WPS participating with other MACs to “share” national clearinghouses.
Contingency Plans
Approved vendor, billing services, clearinghouse and Network Service Vendor (NSV) lists: http://www.wpsic.com/edi/files/medicare_connection.pdf
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: 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.
Import 277CA or 835 into readable reports.
A common piece of providers’ contingency plans!
Current version 2.52
New 1500 (02/12)
Paper billing – NOT A CONTINGENCY! ASCA Rules still apply.
Does your billing software need updating in order to accommodate the new form (02/12)?
Do your printer settings need to be modified? Item - 14 multiple date field, requires date qualifier.
Item – 21 ICD-9 or ICD-10 indicator, up to 12 diagnosis.
Item 24E must use the appropriate alpha (A-L) diagnosis code pointers.
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…
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… [email protected]
WPS Connectivity Options
Dial Up Bulletin Board System (BBS).
Network Service Vendor (NSV) into Medicare EDI Gateway (MEG).
Go Green!!!
Go Green!!!
Even if you don’t post electronically you can take advantage of 835.
Over 78% of all remittances are sent electronically in 5010-835 format.
PcPrint and MREP are free and easy to use.
You can download MREP and PcPrint from: http://www.wpsic.com/edi/tools.shtml
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!
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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. 2014 calls (all times 1-2:30 pm cst): Date June 12, 2014 August 14, 2014 October 9, 2014 December 11, 2014 (800) 305-2862 (800) 305-2862 (800) 305-2862 (800) 305-2862 84826906 84826989 84826999 84827004
Questions and Answers
We want to hear from you… If you have additional questions, you can also send an email to: [email protected]
Also visit our EDI site for additional information: http://www.wpsic.com/edi/
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. 53713 Fax: (608) 223-3824
New Single Point of Contact Numbers!!!
J5 Single Point Of Contact (SPOC):
(866) 518-3285 opt 1
J8 Single Point Of Contact (SPOC):
(866) 234-7331 opt 1
Important Dates
June 12, 2014 EDI ACT
Resources
CMS 5010 and D.0 Webpage http://www.cms.gov/version5010andD0 Educational Resources: http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
5010 Technical Review Type 3 guides: X12: www.X12.org
Washington Publishing www.WPC-EDI.com
WPS Medicare EDI: www.wpsic.com/edi/med_index.shtml
NACHA: www.nacha.org
, www.electronicpayments.org
CAQH CORE: www.caqh.org