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Don’t Get with 5010
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Don’t Get with 5010 Presented by Gretchen Beicher UW Medical Foundation April 3, 2009
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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 - PowerPoint PPT Presentation
Transcript of Don’t Get with 5010
Don’t Get with 5010
Presented by Gretchen Beicher
UW Medical FoundationApril 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
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 changedCodes removed from listNotes added for clarifications.
835 Remittance Advice
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.
835 Remittance AdviceClaims Status Codes
Payer Payer should know
whether or not they are primary. Multiple coverages may make this difficult to determine.
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
835 Remittance AdviceTechnical 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
Allows for Remit delivery data to be provided when both the EFT and 835 are sent to a financial institution. Not Required
835 Remittance Advice
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.
Additional Clarity for Balancing Balancing does not change
835 Remittance Advice
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.
Claim Overpayment Recovery is Clarified
Providers may still elect to negotiate specific methods in their contracts.
835 Remittance Advice
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.
835 Remittance AdviceOverpayment
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.
Remark Code Usage Situational Required when reason code is insufficient to
explain denial
835 Remittance Advice
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.
835 Remittance AdviceRARC Usage
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 scenario-based examples. www.wedi.org
5010 extends the definition of the subscriber identifier to all downstream transactions.
278, 837, 276/277, 835
270/271 Eligibility
Provider Simplifies software rules
needed for data capture, storage and exchange
Standardizes subscriber programming across transaction sets
Payer Some payers already
assign unique IDs to each family member
May require software changes where payer uses separate systems for enrollment and claims
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.
270/271 Eligibility
Payer This could be the most
difficult to achieve requiring significant programming effort
5010 requires eligibility response to include all subscriber/dependant patient identifiers that a payer requires on subsequent transactions
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
270/271 EligibilityPatient Identifiers Con’t.
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.
New required alternate search options using member ID and DOB or member ID and name
270/271 Eligibility
Provider Some payers now require an
exact match to patient name. Example: Mary E. Smith claims will deny if Mary Smith is submitted. The alternative search 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
Payer Compliance with the
Privacy Rule would restrict response where an exact match cannot be found.
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.
270/271 EligibilityAlternate Search Con’t.
Payer Significant software
modifications would be required.
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
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.
270/271 EligibilityAdditional Service Codes Con’t
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.
Provider Ambiguity remains for
financial responsibility. 5010 does not mandate content on response to patient responsibility. Benefits remaining or used are still unknown
270/271 EligibilityAdditional Service Codes Con’t
Payer It means a lot more
digging into benefits to determine the various types of coverage and report them at a very high level.
Requires the return of PCP where applicable
270/271 Eligibility
Provider Excellent change – Provides us
with the contact needed to obtain a referral prior to the visit
Payer Same as with the
requirements for additional service type reporting. Payers that in 4010 reported the minimum (active/inactive) will need software programming effort to report the additional data.
COB Information
270/271 Eligibility
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
