Medicare Fee For Service (FFS)
5010 Are you ready???
Welcome and Purpose of Today’s Call
Transactions and errata Testing requirements and procedures Know your readiness status Going into production
5010 Transactions and Affected Business Processes
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)
Companion Guide
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
Timeline – 50 DAYS LEFT!!!
Current contractor activities April 2011 through December 31, 2011 – Testing/Migration Must be 5010 Errata ONLY by January 2012!!! Last Day for 4010, December 30, 2011 before 4 pm cdst. Are you ready?
Compliance Date
Compliance deadlines were set per federal rule CMS expects compliance deadlines to be met – no extensions Success will depend on starting early!
WPS is ready NOW! Are you?
Testing began in January 2011 Submitters are in production NOW Test results returned within 3 business days when able 835 Production Parallel files available upon request by contacting the EDI Hotline. Results returned on a first come first served basis.
Are you prepared for 5010?
Do you know your vendor’s schedule? Do you know your trading partner’s schedule? Has you vendor or clearinghouse tested and been approved? Have you tested and been approved? Have you moved into production?
Ready, Set, Go…
Don’t Wait to test or go into production! Migration period ending soon, only 50 days left! Not just a Medicare issue – this affects all payers vendors and clearinghouses CMS fee for service does not anticipate any delays to compliance date CMS regulatory agency does no In order to receive the customer service and support you are accustomed to from your payers, vendors and clearinghouses it is important that you test early and go into production early.
If you choose to wait…
Direct Submitters Testing Procedures
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
Testing FAQs
Testing under your current sub ID Advanced registration is not required Know what needs to be changed Test what is applicable to you 5010 Top 10 Submission Errors
http://www.wpsic.com/edi/5010-Readiness.shtml
Valid 9 digit zip codes in billing and facility loops.
More testing information
January 1, 2012 – Compliance Date
CMS does not anticipate extensions to this deadline.
Test under your current submitter ID. Submitters are considered in test until approved by WPS. Consult with Software Vendor to confirm the 999 and 277CA will be returned in a human readable format! The timeline for testing the errata version begins now. Make sure your updates are scheduled before the compliance date. Dual submission of 4010A1 and 5010 errata claim transactions can be allowed. Submitters are generally expected to move into production within 30 days of approval.
Top 5010 Errors – Med A 837I
Invalid codes
DRG HCPCS Diagnosis
Primary COB information missing COB out of balance Duplicate file Invalid NPI
Top 5010 Errors – Med B 837P
COB data missing Billing provider physical address not used Billing provider not authorized for this submitter 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.
Medicare Part A Statistics as of 10/22/11 thru 10/28/11 Contract
# of Approved Submitters
Percentage of 5010 Approved Submitters
# Submitters Sending 5010
% of 5010 Claims Received
J5 A
217/1,163
18.6%
98
8.8%
Legacy A
301/2,612
11.5%
160
11.0%
Medicare Part B Statistics 10/21/11 thru 10/28/11
Contract
# of Submitters Approved
Percentage of 5010 Approved Submitters
Submitter Sending 5010
% of 5010 Claims Received
IL
654/2,430
26.9%
223
7.3%
MI
396/1,146
34.6%
100
6.1%
WI
454/1,157
39.2%
139
10.3%
MN
153/855
17.9%
64
4.8%
J5B
864/4,909
17.6%
258
10.3%
Getting 5010 – 835 Electronic Remittance Advice
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.
Getting 5010 – 276/277 Claim Status Inquiry and Response
Testing is not required “Testing” is done using production data ISA14 highly recommended to = 1 Be sure to have ISA15 = P
Checklist for Moving Into Production
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.
How can I tell if I am 5010? Check your remittance advice.
Part A
Part B
Check 14th digit of DCN = 7. Ex: 21200100627607
Check your ICN regions. RRYYJJJCCCCCC Ex: 1012001123450 5010 EMC
IL/IA 09 MI/MO 18 WI/KS 28 MN/NE 38
4010 EMC
10
02
19
11
29
22
39
32
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.
Contingency Plans
Approved vendor, billing services and clearinghouse lists: http://www.wpsic.com/edi/5010Readiness.shtml
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?
Lessons Learned
Entities are slow to test Slow to move into production New EDI frontend was a good decision Early is never early enough
Was 2.5 years enough time?
Need to track submitters using an automated method Make no assumptions Improve Collaboration, Coordination & Communication Dual processing is a necessity Errata did not have any significant impact
Lessons Learned Continued…
Make no assumptions Improve interpretations Standardize acknowledgments Develop a transition plan Improve Collaboration, Coordination & Communication Ability to change Allow dual processing Test early & often is necessary Move to production as early as possible Education Accountability Review X12 guides during comment period!
CMS National Provider Calls
CMS will host a variety of national education calls that will inform the provider community of the steps that they need to take in order to be ready for implementation. These calls will also give participants an opportunity to ask questions of CMS subject matter experts Delivery of a series of National Provider Calls – presentations, transcripts and audio files available at http://www.cms.gov/Versions5010andD0/V50/list.as Registration for upcoming events: http://www.eventsvc.com/palmettogba/
Future EDI ACTs 2012
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):
Date February 9, 2012 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 800-305-2862
ID 11132712 11138600 11138601 11138602 11138603 11138604
Cutting Off 4010
Last 4010 inbound transactions accepted must be received and processed by WPS, before 4 pm cdst, December 30, 2011. 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…
Move into production now! Work with your vendor and/or clearinghouse Know your vendor and clearinghouse schedule Office of HIPAA Standards announced compliance deadlines to be met – no extensions 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
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
CMS 5010 and D.0 Webpage
Educational Resources:
5010 Technical Review Type 3 guides:
http://www.cms.gov/version5010andD0
http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
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/
