Transcript What is HIPAA - Diverse Solutions

Main Menu
Thanks for taking the time to learn
about changes in Medicaid billing
as a result of HIPAA. This module
will orient you to the changes and
the next steps you must take in
order to be compliant with HIPAA
transaction and code sets
requirements – and get paid for
services!
How to use this course:
Main Menu
1. Overview
2. Code Sets
3. Filing Options
Proceed at your own pace through
this module using the buttons at
the bottom of the screen.
4. Transactions
 Eligibility Request / Response (270/271)
 Referral / Authorization (278)
goes to the Next slide
goes to the Previous slide
returns to the Main Menu
 Claim Submission (837)
 Claim Payment / Advice (835)
 Claim Status Request / Response (276/277)
5. Tools and Processes
exits the presentation and
returns to the web site
You may also access topics
through links on the Main Menu.
6. Resources
 SC Medicaid Web-Based Claims Submission
Tool Demo
Overview
Overview
Overview
Why was HIPAA enacted?
HIPAA (Health Insurance
Portability and Accountability Act)
is a federal law enacted in 1996.
As health care became
increasingly complex in the last
decade, legislators recognized a
need to make it easier for people
to get insurance, to protect
personal health information, and
to reduce administrative costs
while limiting fraud and abuse of
the system.
The Legislation
 Health Insurance Portability and
Accountability Act (HIPAA)
 Federal law enacted in 1996
 Designed to:
 Provide better access to health
insurance
 Protect Personal Health Information
(PHI)
 Reduce administrative costs and limit
fraud and abuse
Overview
What is the impact of HIPAA?
The impact of of HIPAA is bigger
than Y2K. It affects every aspect
of health care operations.
HIPAA-mandated privacy
regulations were effective April 14,
2003. Regulations standardizing
transactions and code sets will be
implemented October 16, 2003.
National standardization of
transaction and codes sets is
projected to result in significant
time and cost savings.
Let’s examine how these changes
affect your transactions with SC
Medicaid.
How It Affects YOU
 Dimensions
 Security
 Privacy
 Transactions
 Code Sets
 Cost
 Larger effort than Y2K
 Benefit
 Significant time and cost savings, longterm
 Protection of protected health
information (PHI)
Codes
Code Sets
Codes
How will codes change?
HIPAA mandates the
standardization of medical and
non-medical codes used in
transactions.
Bottom line, with HIPAA, you will
use only standard code sets
(listed to the right).
SC Medicaid has cross-referenced
(“crosswalked”) all local codes to
national codes. This crosswalk
may be accessed by visiting the
SC Medicaid HIPAA web site:
www.scdhhshipaa.org.
Code Sets
 Medical
 ICD-9-CM (diagnosis and procedures)
 CPT-4 (physician procedures)
 HCPCS (ancillary services/procedures)
 CDT-2 (dental terminology)
 NDC (national drug codes)
 Non-medical
 Gender, marital status, citizenship, etc.
 Remittance Advice Codes (RARC)
 Claim Adjustment Reason Codes (CARC)
Codes
How do I read the Medical Code
crosswalk?
The medical code crosswalks are
formatted as illustrated in the
example to the right.
The local code currently used is
located in the first column; the
corresponding national code is
located in the third column.
Medical Code Crosswalk
SC Medicaid
Local Procedure
Code Prior to
October 16, 2003
SC Medicaid Local
Procedure Code
Description Prior to
October 16, 2003
National
Procedure
Code Effective
October 16,
2003
National Procedure
Code Description
Effective October
16, 2003
Notes
These are the
codes from your
current program
manual.
These are the code
descriptions from
your current
program manual.
These are the
national codes
you will be
using.
This is the
description of the
national code.
This area will
give you code
specific
information
you will need
in order to bill
Medicaid.
Current Code
New Code
Filing Options
Filing Options
Filing Options
Filing Process
Summary of the current
process for claims submission
to SC Medicaid.
(before 10/16/03)
Currently, providers submit claims
to the Medicaid Management
Information System (MMIS) in one
of several ways:
 Through a Clearinghouse
or Billing Agency
 Through the MCCS, via
paper, or electronic media
Providers and clearinghouses
currently use various different data
formats for claims submission (in
fact, there are about 400 different
formats being used in the US!).
All electronic transactions
regulated by HIPAA must be
standardized to meet ANSI X12
4010A formats, as specified in the
Implementation Guide. These
standards may be found at
www.wpcedi.com/hipaa/hipaa/_40.asp.
Billing service/
Clearinghouse
Tape, diskette, CD,
etc.
MCCS
Paper
MCCS
Filing Options
Filing Process
How will the filing process
change?
(starting 10/16/03)
Effective 10/16/03, all electronic
claims must be submitted in
HIPAA-compliant format.
Claims will go to an assigned EDI
mailbox, then will travel through a
Translator to the MMIS. The
Translator serves to convert
HIPAA-compliant formats into
formats that can be accepted by
the MMIS.
Providers will have two new
options for submitting
claims . . .
Billing service/
Clearinghouse
EDI
Mailbox
EDI
Mailbox
EDI
Tapes, ZIP files,
diskettes, CDs
MCCS
Paper
MCCS
EDI
Mailbox
Filing Options
Web Filing
Web Filing!
Effective 10/16/03, providers may
submit HIPAA-compliant claims
via modem.
Additionally, SC Medicaid is
pleased to provide a web-based
claims submission tool for
providers to use at no charge. If
you have an ISP (internet service
provider), you can submit claims
this way.
Billing service/
Clearinghouse
EDI
Mailbox
Provider’s EDI
software
Tapes, ZIP files,
diskettes, CDs
EDI
Mailbox
MCCS
EDI
Mailbox
Web Filing
Paper
EDI
Mailbox
MCCS
Transactions
Transactions
Transactions
Transactions
What are “transactions”?
Transactions in this context
refers to EDI communications
between the trading partner and
the Translator.
HIPAA-regulated electronic
transactions that affect you are
listed to the right.
HIPAA-mandated formats may
include changes on how units are
reported, the number of digits in a
date or medical record, etc.
Let’s review each of these
transactions.





Eligibility Request/ Response (270/271)
Referral / Authorization (278)
Claim/Encounter (837)
Claim Payment / Advice (835)
Claim Status Inquiry / Response (276/277)
Eligibility Request / Response
Eligibility Request /
Response
Eligibility Request / Response
What are the eligibility
transactions?
There are two transactions related
to recipient eligibility, each with a
unique transaction number.
Eligibility Request /
Response (270/271)
“Does s/he have insurance?”
 The Eligibility Request
(270) is sent by the provider
 The Eligibility Response
(271) is the answer sent by
the MMIS
Because they are so tightly
related, these are often referred to
as the “270/271.”
MMIS
Medicaid
Management
Information
System
Eligibility Request / Response
How will I verify eligibility?
Currently, providers may check
eligibility via the telephone, using
the Interactive Voice Response
System (IVRS), or through an
eligibility vendor. These methods
will remain.
The 270 transaction will allow
providers to perform one or more
eligibility inquiries using EDI
software. The SC Medicaid WebBased Claims Submission Tool
will also provide for single
eligibility checks via the Web.
Eligibility Request /
Response (270/271)
 Interactive inquiry
 EDI – through current vendor
 IVRS
 New option – SC Medicaid Web-Based
Claims Submission Tool
 Batch Inquiry - new functionality
 Transmit to EDI mailbox in HIPAAcompliant format
Referral / Authorization
Referral /
Authorization
Referral / Authorization
What is a referral/authorization
transaction?
The 278 transaction,
Referral/Authorization, answers
the question, “Is this a covered
service?”
Referral / Authorization (278)
“Is this a covered service?”
MMIS
Medicaid
Management
Information
System
Referral / Authorization
How will I obtain prior
authorizations?
Effective 10/16/03, you will
continue using the phone/fax
method if attachments are
involved. If, however, there are no
attachments, you now will have
the added option of sending the
278 electronically.
The response from the MMIS will
be an acknowledgement of receipt
of your request. The authorization
number will be mailed or called in
as it is today.
Referral / Authorization (278)
 Referral / Authorization is sent electronically
as a 278
 Process for sending required attachments
will not change
Claim Submission
Claim Submission
Claim Submission
Tell me about the claim
submission transaction.
This transaction, known as the
837, contains all the data required
for the professional, institutional
and dental claim forms sent to SC
Medicaid.
Claim Submission (837)
“Please pay this claim”
Claims may be submitted
electronically via the 837, or by
paper.
MMIS
Medicaid
Management
Information
System
Claim Submission
What changes can I expect in
the claims submission
process?
The data you will be required to
transmit will not change much.
The 837 does expand the number
of detail lines per claim. Also, the
“other insurance” information has
expanded from 2 to 10 carriers.
The 837 will be used also for void
and replacement claims. A “void”
is an action to eliminate a claim
filed incorrectly. Once the void
occurs, a replacement claim may
then be submitted with the correct
information.
Be aware that whether you void
one or multiple claims, you will
receive only one gross
adjustment.
Claim Submission (837)
 Three formats
 Professional (CMS 1500)
 Institutional (UB 92)
 Dental (ADA Dental Claim Form 1999,
Version 2000)
 Report up to 10 insurance carriers
 Also used for void and replacement claims
Claim Submission
Split Claims
How will the MMIS process
these claims with increased
detail lines?
Claims (with the exception of
Institutional) that exceed the
original limit of detail lines will be
“split.”
That is, when a claim comes in
with more detail lines than
currently exist on the MMIS, it will
be split into multiple claims, all
identified by the same claim
control number (CCN). For
example, a Professional claim
holds a maximum of 8 detail lines
today. If a claim with 20 detail
lines comes in, it will be split into
three claims with 8, 8 and 4 detail
lines, respectively.
Please note that split claims will
not suspend.
PROFESSIONAL
CLAIM
20 detail lines
8 detail lines
8 detail lines
4 detail lines
Claim Submission
How will I know that a claim has
been split?
Split Claims
on the Remittance Advice
You will notice claim splitting when
you receive the remittance advice
(RA).
You will know that claims are
related by looking at the CCN. The
split claims will share the same
CCN; however, they will differ on
the 15th and 16th digits.
For Professional claims, the first
claim in the split will be denoted
by a 10; this number will be
incremented by 10 for the
remaining claims in the “split”.
Paper and Electronic RA (Professional)
xxxxxxxxxxxxxx10x
xxxxxxxxxxxxxx20x
xxxxxxxxxxxxxx30x
Paper and Electronic RA (Dental)
xxxxxxxxxxxxxx10x
xxxxxxxxxxxxxx30x
For Dental claims, the 15th and
16th digits will increase by
increments of 20.
The graphic to the right illustrates
this numbering system.
xxxxxxxxxxxxxx50x
Claim Payment / Advice
Claim Payment / Advice
Claim Payment / Advice
What is the claim payment /
advice transaction?
The 835 provides information on
how Medicaid is paying for
services billed on the 837 or by
paper claim. It reflects both paid
and denied services.
Claim Payment / Advice (835)
“Here is your payment”
Payments are made via check or
EFT, depending on the agreement
with the provider, and are
accompanied by an remittance
advice explaining payment or nonpayment reasons.
MMIS
Medicaid
Management
Information
System
Claim Payment / Advice
How will payment change?
Starting October 16th, automated
posting to accounts receivable will
be possible if your practice
management system allows that
function. The claim payment will
communicate claim adjudication,
and contain denials and partial
payments.
You may continue to receive
payment via check or EFT. You
will continue to receive the paper
RA and may also elect to receive
an electronic RA (835). The
electronic RA will contain the
national EOB codes, and the
paper RA will retain the current
codes.
Claim Payment / Advice (835)
 Allows for automated posting to accounts
receivable since payment is matched to
claims
 EFT option remains
 Codes
 National Explanation of Benefits (EOB)
codes on 835
– Claim Adjustment Reason Code
– Remittance Advice Remark Code
 Current edit codes remain on paper RA
Claim Status Request / Response
Claim Status
Request / Response
Claim Status Request / Response
What are the claims status
transactions?
Claim Status
Request / Response (276/277)
There are two transactions related
to claim status, each with a unique
transaction number.
 The Claim Status Request
(276) is sent by the provider
 The Claim Status
Response (277) is the
answer sent by the MMIS
Because they are so tightly
related, these are often referred to
as the “276/277.”
MMIS
Medicaid
Management
Information
System
Claim Status Request / Response
How will I check the status of a
claim?
Checking claim status will be
faster and easier. The 276
transaction allows providers to
check the status of more than one
claim at a time.
The 277 will indicate where the
claim is in the cycle (in receipt or
not found, ready for payment,
need more information, paid).
The response will also enable
Medicaid to request additional
information from the provider
regarding the claim. This more
efficient process should reduce
the incidence of duplicate claim
filing.
Claim Status
Request / Response (276/277)
 New electronic option
 Multiple claim status can be checked in
one transmission
 Replies indicate claim status:
 Claim in receipt, or not found
 Ready for payment cycle
 Needs more information
 Already paid/processed
Tools and Processes
Tools and Processes
Tools and Processes
Exchange of Data
How data will flow effective
October 16, 2003?
As discussed earlier, electronic
transactions exchanged between
providers and the MMIS will pass
through a Translator.
An electronic mailbox will hold
both inbound and outbound
transactions. Each time a
transaction is sent by a provider,
the Translator will send to the
mailbox a 997 (Acknowledgment)
that will tell the provider if the
transaction format (not content)
was compliant and has been
forwarded to the MMIS. If the
transaction is not format
compliant, the 997 message will
explain why.
Providers will be responsible for
checking regularly for outbound
transactions from Medicaid.
Billing service/
Clearinghouse
transaction
EDI
Mailbox
997
EDI
Mailbox
EDI
Tapes, ZIP files,
diskettes, CDs
Paper
MCCS
MCCS
EDI
Mailbox
Tools and Processes
What must providers do – and
by when?
First, choose a method for your
practice to submit HIPAAcompliant claims. You may choose
more than one method.
Second, sign a Trading Partner
Agreement. You can get a copy
by visiting our web site
www.scdhhshipaa.org.
Finally, test sending claims
using your chosen method before
10/16/03. This test will need to be
scheduled in advance by calling
1-888-289-0709.
Next Steps to 10/16/03
 Choose your method of submission
 South Carolina Medicaid Web-Based
Claims Submission Tool
 EDI (HIPAA-compliant software)
 Paper
 Tapes, diskettes, CDs and Zip Files
 Clearinghouse/Billing Agency
 Sign a Trading Partner Agreement
 Test
Resources
Resources
Resources
I have more questions! Where
can I go for answers?
Listed to the right are a variety of
links and phone numbers where
you can get additional information.
The most comprehensive web site
about HIPAA and SC Medicaid is
www.scdhhshipaa.org. It
contains the most current
information about instructor-led
training events and national
codes.
Questions may be emailed to
[email protected]. If you
wish to speak to a person, call SC
Medicaid HIPAA Provider
Outreach at 1-888-289-0709 and
one of our friendly representatives
will assist you.
Call or E-mail for HELP!
 SC Medicaid
 www.scdhhshipaa.org
 SC Medicaid HIPAA Provider Outreach
1-888-289-0709
 www.dhhs.state.sc.us
 Statewide Training Sessions
 Online Training
 Testing Resources
 www.hipaadesk.com
 www.claredi.com
 Implementation Guide
 www.wpc-edi.com/hipaa/HIPAA_40.asp
 CMS
 www.cms.gov
Resources
Check your
Understanding
Resources
What have you learned?
Self-Test
Click the hippo to bring up a
question.
See if you know the answer. Then
click again to see if you answered
correctly.
1. HIPAA is designed to simplify healthcare administrative processes.
Good luck!
2. TPA stands for third-party agreements.
True.
False (Trading Partner Agreement)
3. Transactions and Code Sets are a part of the Administrative
Simplification process.
True
4. Providers who bill on the CMS 1500 are exempt from HIPAA
regulations.
False. Everyone must be compliant!
5. An EDI transaction is the filing of a claim using the CMS 1500.
False. It is the electronic exchange of information.
Keep going . . .
Click the hippo again to bring up
the next question. See if you
know the answer. Then click
again to see if you answered
correctly.
Self-Test (cont.)
5. Trading Partner Agreements apply to providers filing claims
electronically only.
False. All entities wishing to conduct electronic
transactions with SC Medicaid must sign an
agreement.
6. 837 is the transaction that requests eligibility.
False. 837 is the Claim Submission transaction.
7. SC Medicaid created the Health Insurance Portability and
Accountability Act of 1996.
False. HIPAA is a federal law.
8. The South Carolina Medicaid Web-Based Claims Submission Tool
requires the purchase of software for use.
False. Providers access the free application online via the
Internet!
9. Clearinghouses are required to comply with all HIPAA deadlines.
True.
Where do I go next?
To review sections of this
module, click the home button
to return to the Main Menu.
To see samples of the webbased claims submission
tool, click the DEMO icon.
To visit the SCHIPAA web
site and download codes or
companion guides, click the
last button.
To exit this presentation, just
close this window!
Thanks for taking this course –
and best wishes on your journey
to HIPAA compliance!
Where next?
This screen will appear when you
type in the web address.
The MAIN MENU lists all the
familiar tasks of claims submission.
Let’s explore the different options
available from the Main Menu.
1. LIST MANAGEMENT
List Management
Tired of typing the same codes
and names over and over each
time you complete a new claim
form?
List Management lets you build
your own frequently-used lists
of codes and patient
information. So, instead of
typing a patient name or
procedure code, you can just
select it from a list. One click -and the correct code is in the
field!
To build a list, click List
Management on the Main
Menu.
1. LIST MANAGEMENT
A submenu of lists
appears.
Select the list you want to
build.
We will click “Recipient” in
order to add a patient to
the list.
1. LIST MANAGEMENT
The Recipient List – Add/View screen
appears.
To add patient information, type in the fields
provided (top half of screen) and click
SUBMIT. The name is added to your list.
To edit patient information, just click the EDIT
button by the patient’s name on the
Recipient Information list (lower half of the
screen) and make the changes.
It’s that simple!
2. CLAIMS ENTRY
Claims Entry
When you click the Claims
Entry option, you will be given
the choice to enter a Dental,
CMS 1500, or UB 92 claim.
For example, to complete a
professional claim, we’ll select
CMS 1500.
2. CLAIMS ENTRY
The CMS 1500 Results
screen will appear.
All claims you have keyed,
but not yet submitted, will be
listed. You can view, edit,
copy or delete one of these
claims by clicking the radio
button next to it and then
clicking the desired action
button (Add, Edit, Copy,
View, History, Delete).
Create a new claim by
clicking the ADD button.
2. CLAIMS ENTRY
The CMS 1500 screen will
appear -- an online claim
form.
Complete the fields as you
would normally. Then save
your work by clicking the
SAVE button.
NOTE: Wherever you see
an ellipses icon (see green
box), there is a list from
which you can select
information (and save
keystrokes!).
In this case, the ellipses
indicate the existence of a
Recipient List.
3. CLAIMS SUBMISSION
Claims Submission
Once you have completed your
claims, submitting them is an
easy task.
Simply click ‘Claims Submission’
3. CLAIMS SUBMISSION
The Claims Submission
screen appears.
1. Type the Contact
Information in the fields
provided.
2. Then select the type of
claims you are submitting
from the list at the bottom
of the screen (only one
claim type may be
submitted at a time). In
this example, we have two
CMS 1500 claims to be
submitted. We clicked the
radio button next to CMS
1500 to select them.
3. Click the SUBMIT button to
send the claims.
3. CLAIMS SUBMISSION
This message appears to let you
know the claims have been sent.
You may click the batch ID to
view the details of your
submission.
If you are interested in this tool. . .
You need:
 Computer with ISP and Internet connection
– Speed depends on computer and connection.
Pentium II equivalent is recommended.
 Login ID and Password
– Assigned when you register and sign TPA
Complete a Web Interest Form to learn more!
For more information: 1-888-289-0709 or [email protected]
Where next?
Main Menu
See demo again!
EXIT presentation and
return to web site