Transcript Preparation for 005010 - Hipaa Collaborative of Wisconsin

EDI
Session 1
Avoiding a Wipeout!
Spring Conference
April 4, 2008
Gary Beatty
President
EC Integrity, Inc
Vice-Chair ASC X12
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HIPAA Adopted Versions
◦ 004010 - May 2000
◦ 004010 Addenda – October 2002
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HIPAA Deadlines
◦ October 16, 2002 – Original Implementation
◦ October 16, 2003 – ASCA Extended Implementation
◦ Contingency Plans
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DSMO
◦ Processed over 1000 change requests
◦ ~500 changes since 004010

X12
◦ Has processed additional industry change requests
since 004010
◦ IG’s are now Technical Report Type 3 – TR3
 005010 – First X12 TR3
 9 - TR3’s for the current HIPAA adopted transactions
 10 – Additional TR3’s for possible HIPAA adoption
 Acknowledgements
 Health Care Claim Attachments
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X12
◦ Continuous TR3 development cycle
◦ Learning from past experiences
◦ More industry coordination – DSMO
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National Uniform Billing Committee (NUBC)
National Uniform Claim Committee (NUCC)
Dental Content Committee (DeCC)
Health Level 7 (HL7)
National Council for Prescription Drug Programs (NCPDP)
X12 Public Comment Period
NPRM Comment Period
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Business value for change
◦ Increasing inability of 004010 to support industry
business needs.
◦ Ability to synchronize current HIPAA transactions
with health care claim attachment transactions
◦ Added flexibility
 Moved some codes to external code lists
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ICD-10 Support
◦ Added capability to communicate
 ICD-10-CM Diagnosis
 ICD-10-PCS Procedure Codes
◦ Improves the capture of information about the
increasingly complex delivery of health care.
◦ Greater coding accuracy and flexibility
 opportunities for detailed record-keeping and
enhanced documentation to support accurate
payment.
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Aesthetics
◦ Table of Contents
 Reformatted for consistency across all TR3’s
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Content
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Consistency between TR3’s
Greater flattening of Segments (single functionality)
Added new business functions
Modified existing business function for efficiency
Front Matter improvements
Alignment with HIPAA Privacy Rules
Uniform content for Subscribers, Members, and
Dependents
◦ Removed ambiguity
 Removed “Should”, “Could”, “May”
 Replace with:
 Form A —“Required when <explicit condition statement>. If
not required by this implementation guide, may be provided
at the sender’s discretion but cannot be required by the
receiver.”
 Form B —“Required when <explicit condition statement>. If
not required by this implementation guide, do not send.”
 Situations:
 More definitive
 Closed loopholes to prevent
 Payer-specific requirements due to the TR3 not restricting data
 Providers from sending data beyond the minimum necessary
needed for the business function –which would require
explanatory documentation
◦ Clarified mechanism to communicate National
Provider Identifier (NPI)
◦ Allows code set changes to occur rapidly using
X12’s Code Maintenance Request and HIPAA nonmedical code set adoption processes –as dictated
by real-time evolving business needs
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270/271
◦ Added enhanced and highly specific search
requirements for matching individuals covered by
health plans: subscribers, members, dependents
◦ Added much more detailed eligibility, coverage, or
benefit responses
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Plan and benefit begin dates
Plan name
Primary care physician (if applicable)
Other health plans (if known)
10 high level benefits
All demographic information needed to identify the
individual in all other subsequent EDI transactions
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837
◦ Modified subscriber and patient hierarchy
◦ Added National Provider Identifier (NPI) reporting
rules
◦ Clarified use of Pay-To Provider
◦ Made provider type definitions consistent
◦ Clarified Coordination of Benefit reporting rules
◦ Clarified drug claim reporting rules
◦ Clarified Medicaid subrogation processing rules
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835
◦ Removed “Not Advised“ code value usage language
◦ Refined reversal and correction instructions;
particularly for
 Prompt pay discounts
 Interest
◦ Added new segments to communicate
 Health Care Policy
 Remittance Delivery Method
◦ Enhanced claim status definitions
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276/277
◦ Improved consistency of subscriber and dependent
identification data
◦ Improved capabilities for processing prescription
claims
 Added use of prescription numbers
 Added use of NCPDP reject / payment codes
◦ Enhanced capabilities to communicate patient,
provider, and payer control / tracking numbers
◦ Expanded capabilities to send more complete and
detailed status information
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278
◦ Restructured to support patient and service event
level requests
◦ Enabled service level to support Institutional,
Professional and Dental detailed segments
◦ Clarified patient condition segments
◦ Added medical service reservation: Medicaid
◦ Allowed for multiple reject reason codes
◦ Added support for
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Reconsideration requests
Subscriber and dependent mailing addresses
Transport
Other UMO
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834
◦ Clarified the differences and uses of
 Change Update
 Full File Replacement
 Full File Audit
◦ Added new control totals for
 Employee Total
 Dependent Total
 Transaction Total
◦ Added codes to specify reason for Medicare
eligibility
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834
◦ Added capabilities to communicate
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Class of Contract
Service Contract Number
Medical Assistance Category
Program Identification Numbers
◦ Added ability to indicate patient confidentiality and
alternate information delivery addresses
◦ Added capabilities to report individual financial
amounts related to the member’s responsibility;
including Medicaid Spend Down amounts

820
◦ Added ability to apply adjustments to
 Entire transaction –not just individual members
 Past payments
◦ Added the capability to communicate additional
deductions
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Service
Promotion
Allowance
Charge
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Detailed TR3 Changes Documentation
◦ Summary in Appendix D of each 005010 TR3
◦ Body of each 005010 TR3
Function
Enrollment
Premium Payment
Eligibility
Services Review
Professional Claim
Institutional Claim
Dental Claim
Claim Status
Claim Payment
Standard
834
820
270/271
278
837P
837I
837D
276/277
835
TR3
005010X220
005010X218
005010X279
005010X217
005010X222
005010X223
005010X224
005010X212
005010X221

All TR3’s are approved for publication
◦ Available at:
www.x12.org
◦ Copyright changes

Federal rule making process to adopt 005010
◦ Draft Proposed Regulation
◦ Internal Clearance
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 CMS
 DHHS
 OMB
Publish NPRM for public comment (? Days)
Draft Final Regulation
Respond to comments (in Final Regulation)
Internal Clearance
 CMS
 DHHS
 OMB
◦ Publish Final Regulation (publication date)
 30/60 day Congressional Review (effective date)
 2 Years for industry to implement (compliance date)

Claim Attachments
◦ 277 Request for Additional Information
◦ 275 Patient Information
 HL7 Clinical Document Architecture
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Acknowledgements
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999 Implementation Acknowledgment
TA1/TA3 Interchange Acknowledgments
824 Application Advice
277 Health Care Claim Acknowledgment
269 Health Care Benefit Coordination
Verification Request and Response

Be Proactive not Reactive
◦ Do not wait for the NPRM to review 005010 TR3’s
◦ If you need more time ask for an extension
WEDI X12 Pre-conference Forum: HIPAA X12 005010 Transaction
Enhancements
Held in conjunction with the 17th Annual WEDI National Conference
Monday, May 19, 2008
Hyatt Regency Baltimore on the Inner Harbor
Thank you !
Questions
Gary Beatty
President
EC Integrity, Inc
Vice-Chair ASC X12