Transcript NPI Testing To NPI Production Provider Realities Presented

Don’t Get
with 5010
Presented by
Gretchen Beicher
UW Medical Foundation
April 3, 2009
•Clinical practice organization for the faculty
physicians of UW School of Medicine and Public
Health
•The Medical Staff of over 60 clinical practice
locations throughout Wisconsin
•Largest academic, multi-specialty physician group
in Wisconsin
•837 = 87% -- > 837P <FQHC 837I < Dental 837D
•277K clm/mo Most are direct connections
•835 = 88.9% of payments posted
•270/271 – 11 connections
 Version 5010 835 - Payments
 Version 5010 270/271 – Eligibility
 Providers
 Payers
835 Remittance Advice
Claim Status code list has changed
significantly.
Claims Status Code location at CLP02 identify the
status of the entire claim as assigned by the payor.
Claim status code 4 - Denial definition changed
Codes removed from list
Notes added for clarifications.
835 Remittance Advice
Claims Status Codes
Provider
 Redefinition of Claims
Status 4 will make it
more difficult for the
provider to distinguish
between a true denial or
claims with high
deductible amounts.
 Claim Status Code 4
should only be used
when the patient cannot
be found on the payer
system.
Payer
 Payer should know
whether or not they are
primary. Multiple
coverages may make this
difficult to determine.
835 Remittance Advice
 Allows for the provision of a technical
contact and the payer’s website where
further policy information can be found.
 Not required.
835 Remittance Advice
Technical contact
Provider
 Would have to make
changes to accept and
store the information
 Would be great to have
the specific informational
policy without making a
phone call or researching
the web for a possible
match
Payer
 May lead to
procedure/workflow
changes for supporting
inquiries at the technical
level.
 Policy may need to be on
an unsecured website
which many payers do
not like
835 Remittance Advice
 Allows for Remit delivery data to be provided when both
the EFT and 835 are sent to a financial institution.

Not Required
Provider
 This is not widely used
but serves as an
opportunity for the
future.
Payer
 Would require
coordination with the
bank and some
programming changes to
provide the destination
information of the 835 to
the bank.
835 Remittance Advice
 Additional Clarity for Balancing
 Balancing does not change
Provider
 If interpretations are
correct of the 4010, this
can be considered an
enhancement.
 Some have experienced
invalid credit balances.
 The clarification of items
labeled “are and are not”
may help in reconciliation
issues with the payer.
Payer
 MUST review how they
balance the 835
currently against the
enhanced front matter
for balancing to ensure
that they are following
the rules of the
transaction set.
835 Remittance Advice
Claim Overpayment Recovery is Clarified
Providers may still elect to negotiate specific
methods in their contracts.
835 Remittance Advice
Overpayment
Provider
 It does help to know that
there is a reversal
 It is problematic because
method of recovery is
left to Trading Partner
Agreements.
 Provider does not have a
voice in recoup method.
Payer
 All payers should be
aware of the State laws
which may govern the
method that must be
used.
 Some states require the
payer to give the
provider an option upon
each occurrence.
835 Remittance Advice
 Remark Code Usage
 Situational
 Required when reason code is insufficient to
explain denial
835 Remittance Advice
RARC Usage
Provider
 Very beneficial in
reporting for the provider
so that an automated
determination can be
applied to the claim
 Will reduce call volume
and the need to call for
more information.
Payer
 This does require
programming changes
for some and
configuration set up for
other payers.
 Will reduce calls received
with requests for
clarification
The WEDI 835 SWG is creating a uniform list suggesting RARCs
to be used with CARCs and CARC definitions and clear scenariobased examples. www.wedi.org
270/271 Eligibility
5010 extends the definition of the subscriber
identifier to all downstream transactions.
 278, 837, 276/277, 835
Provider
 Simplifies software rules
needed for data capture,
storage and exchange
Payer
 Some payers already
assign unique IDs to
each family member
 Standardizes subscriber
programming across
transaction sets
 May require software
changes where payer
uses separate systems
for enrollment and claims
270/271 Eligibility
5010 requires eligibility response to include all
subscriber/dependant patient identifiers that a
payer requires on subsequent transactions
Provider

This could be the single
biggest advantage to the
providers. Currently many
providers require the
subscriber DOB on the 837,
but do not provider it in the
eligibility response for the
dependant leading to phone
calls, denied claims and
appeals. OR paper claims.
Payer
 This could be the most
difficult to achieve
requiring significant
programming effort
270/271 Eligibility
Patient Identifiers Con’t.
Provider
 Would require
programming to enable
upload and storage of
data to enable its later
submission on claims
 Where patient has
multiple coverages it
could require data
storage at the insurance
level rather than the
patient level
Payer
 May payers apply
different edit sets
between claims and
eligibility
 4010 requires only an
active or inactive
response. To include
more will require
programming.
270/271 Eligibility
New required alternate search options using
member ID and DOB or member ID and
name Provider

Payer
Some payers now require an
 Compliance with the
exact match to patient name.
Privacy Rule would
Example: Mary E. Smith claims
restrict response where
will deny if Mary Smith is
an exact match cannot
submitted. The alternative search
be found.
will enable providers to submit ID,
patient last name and DOB.
Where active coverage is found,
the response will provide the
name format the payer requires
on subsequent transactions
270/271 Eligibility
Alternate Search Con’t.
Provider
 As above some payers
require an exact DOB
match, yet may have the
DOB stored incorrectly.
A search using the ID,
last name and first would
provide the payer DOB.
Payer
 Significant software
modifications would be
required.
270/271 Eligibility

Additional Service Type Codes and Requirements.


45 New Service Type codes have been added.
New requirement: If information source receives a STC 30 or
one they do not support, 10 codes must be returned if they
are covered at the plan level.










1 – Medical
33 – Chiropractic
35 – Dental
47 – Hospital
86 – Emergency Services
88 – Pharmacy
98 – Professional Office Visit
AL – Vision
MH – Mental Health
UC – Urgent Care
270/271 Eligibility
Additional Service Codes Con’t
Provider
 Important in
environments where
physician and hospital
events are covered by
different insurers. A
generic STC 30 query to
a payer would require a
response of both 47
hospital and 98
physician if covered.
Lack of response on any
of the 10 could be
interpreted as no
coverage for the service
type.
Payer

Software modifications will
be required in order to
report the additional
information. Where
payers now are required
to provide a minimal
response (active or
inactive), patient
responsibility must now be
reported.
270/271 Eligibility
Additional Service Codes Con’t
Provider
 Ambiguity remains for
financial responsibility.
5010 does not
mandate content on
response to patient
responsibility. Benefits
remaining or used are
still unknown
Payer
 It means a lot more
digging into
benefits to
determine the
various types of
coverage and
report them at a
very high level.
270/271 Eligibility
Requires the return of PCP where applicable
Provider
Payer
 Excellent change – Provides us  Same as with the
with the contact needed to
requirements for
obtain a referral prior to the
additional service type
visit
reporting. Payers that in
4010 reported the
minimum (active/inactive)
will need software
programming effort to
report the additional data.
270/271 Eligibility
COB Information
Provider
 If patients have multiple

coverages, providers can
query to determine who is

primary.
 Where the coverage is
Medicare or Medicare providing
the third party MCO
information allows the provider
to search the MCO to locate
the patient in that system
Payer
COB information is not always
available or accurate
Programming changes are
again needed to report
complete information
Don’t Get
with 5010
DISCUSSION
Contact information:
Gretchen Beicher
[email protected]
608-829-5215