Medicare Fee For Service (FFS)5010

Moving Into Production - II(April 12, 2012)

Purpose of Power Point

Testing Requirements Most Recent OESS Announcement CMS Medicare FFS Announcements Calling EDI? Moving into production July 1, 2012

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)

Medicare is ready. Are you?

Testing began in January 2011 Processing 5010 claims since April 2011 Over 3.00 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

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 Billing provider not authorized for this submitter (not linked,

rendering NPI…) NPI Crosswalk Error - Billing provider NPI not related to TaxID Missing or invalid Payer ID or Receiver ID Invalid Health Insurance Claim Number SV101-7 code description required for NOC/NOS codes Invalid Billing NPI Invalid codes

Diagnosis Code (ICD-9) Zip (can not be padded with 0s or 9s) HCPCS

Anesthesia services require MJ qualifier, all other services UN qualifier

Other Insured's Adjustment Quantity; 2430.CAS must not be equal to zero

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.pdfhttp://www.wpsic.com/edi/pdf/med_b_837p_companion.pdf

Clarification of OESS Announcement CMS Office of E Standards (OESS) issued

guidance extending “it would not initiate enforcement action,.. until 90 days after ” e.g. July 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 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 to their Contractor showing how they will complete their transition by July 1, 2012.

All transactions received after 4 pm cdst on June 29th must be in version 5010 by MACs.

Some choose to wait…

Contacting WPS’s Medicare EDI Hotlines? 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? Average/Max wait times last week:

Avg MaxJ5A-EDI 1:09 10:54J5B-EDI 0:16 10:57Legacy A-EDI 1:33 24:54Legacy B-EDI 1:15 13.35

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 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… When you call have information available which

will help us identify your file and research your issue:

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… EDIMediareA@WPSIC.com, EDIMedicareB@WPSIC.com

Medicare Part A Statistics 98.6% of all claim accepted are 5010 (as of 3/30/2012)

Contract # of Submitters Approved

Submitter Sending 5010 Accepted Claims %

Legacy Part A

738 706 99.6%

J5A 423 386 98.7%

Medicare Part B Statistics 97.57% of all claim accepted are 5010. 2.65 million claims received (as of 3/30/2012).

Contract # of Submitters Approved

Submitter Sending

5010 Accepted Claims %

Provider % Sending 5010

IL 992 992 99.09% 97.9%

MI 561 504 92.60% 84.3%

WI 615 528 99.56% 98.2%

MN 261 261 99.35% 99.3%

J5B 2098 1780 99.25% 98.0%

Current Med A Issues 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

Canadian Beneficiary Address Delays in getting claims into

adjudication system Partial 835 (not a complete ISA-

IEA) Sporadic delays in sending

responses (999, 277CAs)

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. If a user doesn’t request to be flipped, they will

automatically be switched to 5010 effective July 1, 2012.

Medicare Part A 835 Statistics

Contract # of 5010 Receivers

Legacy Part A

57

J5A 61

Go Green!!! Even if you don’t post

electronically you can take advantage of 835.

PC Print is free and easy to use.

Medicare Part B 835 Statistics 87.47% of all ERAs are in 5010 format (as of 3/30/2012)

Contract

# of 5010 Receivers

5010 ERA%

ERA vs SPR %

IL 158 86.82% 59.77%

MI 93 91.68% 67.19%

WI 108 80.90% 58.57%

MN 92 93.77% 77.04%

J5B 197 84.8% 69.64%

Go Green!!! Even if you don’t

post electronically you can take advantage of 835.

Medicare Remit Easy Print (MREP) is free and easy to use.

Medicare Remit Easy Print (MREP) and PC Print Software MREP for Part B; PC Print for Part A Will enable physicians and suppliers to

view and locally print a Medicare Part B / DMERC HIPAA compliant 835 file in a format that mirrors the Medicare Standard Paper Remittance Advice (SPR).

Eliminates physical filing and storage space needs.

Print remit same day as 835 is available. Print and forward claims for other payers. Quick and easy access to claim

information. No waiting for mail. Several useful reports. Save time and money. It’s FREE!

Getting 5010 – 276/277 Claim Status Inquiry and Response

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 ACheck 14th digit of DCN = 7.Ex: 21200100627607

Part B Check your ICN

regions. RRYYJJJCCCCCCEx: 1012001123450

5010 EMC4010 EMC

IL/IA 09 10 02

MI/MO 18 19 11

WI/KS 28 29 22

MN/NE 38 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/5010-Readiness.shtml

PC-Ace Pro32 Paper claim submission is not a

contingency option Clearinghouse options? Step Up? Step

Down? What are your contractual

arrangements with vendor and/or clearinghouse? Other?

Cutting Off 4010 Last 4010 inbound transactions

accepted must be received and processed by WPS, before 4 pm cdst, June 29, 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.

PWK Initiative Delayed

Originally scheduled for April 2012 Change Requests (CRs):

7041, 7306, and 7330 Contractors continue to test.

Our Message to you… 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!

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 Dial In ID June 14, 2012 800-305-286211138601 August 9, 2012 800-305-286211138602 October 11, 2012 800-305-286211138603 December 6, 2012 800-305-286211138604

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 EDIMedicareA@WPSIC.com EDIMedicareB@WPSIC.com

Medicare Part A Legacy A Medicare J5 MAC Part A & B(multiple states) (Iowa, Kansas, Missouri, Nebraska)WPS Medicare EDI WPS Medicare EDIPO Box 1602 1717 West BroadwayOmaha, NE 68101 Madison, WI. 53713Fax: (402) 995-0606 Fax: (608) 223-3824Med A Hotline: (866) 734-6656 J5 Hotline: (866) 503-9670

Medicare Part B Legacy(Illinois, Michigan, Minnesota, Wisconsin)WPS Medicare Electronic Data Services 912 N Pentecost DriveMarion, IL 62959Fax : (618) 998-5170Med B EDI Hotline: (877) 567-7261

Resources CMS 5010 and D.0 Webpage

http://www.cms.gov/version5010andD0 Educational Resources:

http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys

5010 Technical Review Type 3 guides: 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/