Transcript 5010 Moving Into Production Presentation

Medicare Fee For Service (FFS)
5010
Moving Into Production
Purpose of Power Point
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Testing Requirements
OESS Announcement
CMS Medicare FFS Announcement
Calling EDI?
Moving into production
April 1, 2012
5010 Transactions and
Affected Business Processes
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Claims (837 Institutional, Professional, COB, Dental, NCPDP)
Claim Status (276/277)
Claim Payment (835)
Enrollment (834)
Premium Payment (820)
Eligibility (270/271)
Referrals and Prior Authorizations (278)
Claims Acknowledgements (277CA)
Acknowledgement for Health Care Insurance (999)
Medicare is ready. Are you?
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Testing began in January 2011
Processing 5010 claims since April 2011
Over 2.4 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.
Direct Submitters Testing Procedures
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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 B 837P
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Billing provider not authorized for this submitter.
Payer's ID Number 2010BB.NM109 must be the same value as
the Receiver's ID Number 1000B.NM109.
Other Insured's Adjustment Quantity; 2430.CAS04 must not be
equal to zero.
Invalid Health Insurance Claim Number.
Invalid codes
 Zip (can not be padded with 0s or 9s)
 HCPCS
 NDC
Rendering provider NPI same as Billing
SV101-7 code description required for NOC/NOS codes (revised
list)
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
Clarification of OESS
Announcement
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CMS Office of E Standards (OESS) issued
guidance “it would not initiate enforcement
action,.. until 90 days after ” e.g. April 1,
2012
The OESS is the compliance side of the CMS
house and is in charge of enforcement of the
HIPAA legislation.
CMS-OESS is not the same as CMS Medicare
Fee-For-Services.
CMS Medicare Fee For Service
Announcement
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Trading Partners that have tested and been
approved for 5010 have 30 days to complete
their cutover to production.
Trading Partners that have not started or
completed testing of the new versions must
submit their testing/transition plan and
timeline to their Contractor within 30 days
showing how they will complete their
transition by March 31, 2012.
All transactions received after 4 pm cdst on
March 30th must be in version 5010 by MACs.
Some choose to wait…
Contacting WPS’s Medicare
EDI Hotlines?
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Call volumes are up
Call durations are longer
Wait times are up
This affect billers, vendors, payers, and
clearinghouses!
WPS Medicare EDI call volumes peaked the
week ending January 13, 2012, but still high.
Where are we at now on
WPS’s Medicare EDI Hotlines?
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Average/Max wait times last week:
Avg
J5A-EDI
1:26
J5B-EDI
0:25
Legacy A-EDI
0:55
Legacy B-EDI
2:06
Max
13:06
15:23
8:55
19.31
Normal Enrollment and ERA Processing times 7-10 business
days
Calls, Enrollments, ERA requests, Voice Mails…
are being responded to in the order which they were received.
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]
Medicare Part A Statistics
through 2/03/12 91.3% of all claim accepted are 5010
Contract
# of Submitters
Approved
Submitter Sending
5010 Accepted Claims %
Legacy Part A
705
651
93.9%
J5A
403
356
85.7%
Medicare Part B Statistics
through 2/03/12 89.5% of all claim accepted are 5010
Contract
# of Submitters
Approved
Submitter Sending
5010 Accepted Claims %
IL
900
841
96.4%
MI
521
425
74.5%
WI
586
464
81.4%
MN
243
243
98.7%
J5B
1845
1464
96.1%
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
Delays in getting claims into
adjudication system
Presence of 2000C/PAT not rejecting
correctly
Partial 835 (not a complete ISA-IEA)
Duplicate 835s
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 March 31, 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
How can I tell if I am 5010?
Check your remittance advice.
Part A
Check 14th digit of DCN = 7.
Ex: 21200100627607
Part B
Check your ICN regions.
RRYYJJJCCCCCC
Ex: 1012001123450
EMC
5010 EMC
IL/IA 09
MI/MO 18
WI/KS 28
MN/NE 38
4010
10
02
19
11
29
22
39
32
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.
Contingency Plans
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Approved vendor, billing services and
clearinghouse lists: http://www.wpsic.com/edi/5010Readiness.shtml
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PC-Ace Pro32
Paper claim submission is not a contingency
option
Clearinghouse options? Set Up? Set Down?
What are your contractual arrangements with
vendor and/or clearinghouse?
Other?
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
April 12, 2012
June 14, 2012
August 9, 2012
October 11, 2012
December 6, 2012
Dial In
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
ID
11138600
11138601
11138602
11138603
11138604
Cutting Off 4010
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Last 4010 inbound transactions accepted
must be received and processed by WPS,
before 4 pm cdst, March 30, 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.
Our Message to you…
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Move into 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!
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
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 MAC Part A & B
(Iowa, Kansas, Missouri, Nebraska)
WPS Medicare EDI
1717 West Broadway
Madison, WI. 53713
Fax:
(608) 223-3824
J5 Hotline:
(866) 503-9670
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/