mac j5 and j8 edi act (june 12, 2014) participant line: (800) 305-2862 passcode: 84826906
TRANSCRIPT
MAC J5 and J8
EDI ACT(June 12, 2014)
Participant Line: (800) 305-2862Passcode: 84826906
Purpose of Power Point Current issues Operating Rules HIPAA Security and Windows XP ICD-10 Update Monitor Your Business Go Green Upcoming EDI ACT 2014 Contacting EDI – Toll Free Numbers
Current Med A Issues –
PCPrint - PC Print version 4.3.1 and above, are not compatible with Windows XP. Part A providers using Windows XP should continue to use version 4.2.6 of PC Print until they are able to upgrade to a newer version of Windows
999 and 277CA not received
Current Med B Issues Canadian and military zip codes. Sporadic delays in sending responses
(999, 277CAs or 835s) MREP issues for Windows 7 or 8 users
MSP Claims - 5010 MSP claims are not an ASCA (Administrative
Simplification Compliance Act) exception and must be sent electronically.
Avoid front end rejections, delays and Unprocessable rejections:
When determining the beneficiary’s insurance coverage, it is important to determine the correct insurance type code.
Always give the MSP insurance type code. Other Insured's Adjustment Quantity; 2430/CAS must not
be equal to zero. Primary paid amount should not exceed the billed amount. Primary paid amounts at the claim level should agree with
the amounts submitted at the line level. Instructions:
http://www.wpsic.com/edi/files/msp5010A1.pdf
Operating Rules Affordable Care Act (ACA) defines operating rules as
“the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”
Operating rules address gaps in standards, help refine the infrastructure that supports electronic data exchange and recognize interdependencies among transactions.
Goal: Create as much uniformity in the Goal: Create as much uniformity in the implementation of electronic standard as possible.implementation of electronic standard as possible.
Operating Rule Named for Eligibility and Claim Status (effective 1/1/2013)
Phase 1 CORE 152 Eligibility and Benefit Real Time Companion Guide
Phase 1 CORE 153 Eligibility and Benefit Connectivity Rule
Phase 1 CORE 154 Eligibility and Benefit 270/271 Data Content Rule
Phase 1 CORE 155 Eligibility and Benefit Batch Response Time Rule
Phase 1 CORE 156 Eligibility and Benefit Real Time Response Time Rule
Phase 1 CORE 157 Eligibility and Benefit System Availability Rule
Phase 2 CORE 250 Claim Status Rule
Phase 2 CORE 258 Eligibility and Benefit Normalizing Patient Last Name Rule
Phase 2 CORE 259 Eligibility and Benefit 270/271 AAA Error Code Reporting Rule
Phase 2 CORE 260 Eligibility and Benefit Data Content (270/271) Rule
Phase 2 CORE 270 Connectivity Rule
EFT and ERA Operating Rule Impacts
835 Infrastructure CARC/RARC combinations EFT ERA Reassociation Electronic Enrollments for EFT and
ERA
EFT and ERA Operating Rules Named (effective 1/1/2014)
Phase 3 CORE 360 Health Care Claim Payment/Advice (835) Infrastructure Rule
Phase 3 CORE 350 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule
Phase 3 CORE 360 CORE-required Code Combinations for CORE-defined Business Scenarios
Phase 3 CORE 370 EFT & ERA Reassociation (CCD+/835) Rule
Phase 3 CORE 380 EFT Enrollment Data Rule
Phase 3 CORE 382 ERA Enrollment Data Rule
CARC/RARC Operating Rules4 Business Scenarios Defined (Rule 360)
Specific combinations of CARC and RARC are allowed for each business scenario.Scenario #1: Additional Information Required - Missing/Invalid/Incomplete Documentation Scenario #2: Additional Information Required – Missing/Invalid/Incomplete Data from Submitted Claim Scenario #3: Billed Service Not Covered by Health
Plan Scenario #4: Benefit for Billed Service Not
Separately Payable
EFT ERA Reassociation (Rule 370)
Reassociation is the process of matching an Electronic Remittance Advice (ERA) in the ASC X12 835 format to the associated Electronic Funds Transfer (EFT).
EFT must match 835 transaction. Reconcile actual cash received to check amounts in
the 835 PRIOR to posting to patient accounting system.
Bank need to ensure the “7 record” is sent to provider (typically sent upon request only).
Example EFT: 705TRN*1*8834567890*1391268299~ Example 835: TRN*1*8834567890*1391268299~
Ensure Proper Completion of ERA Form (Rule 382):
DEG1 the address must match what is on file with Provider Enrollment.
DEG2 Medicare must be listed in Assigning Authority DEG2 Medicare PTAN must be listed in other identifier DEG2 Valid WPS submitter id/trading partner ID DEG3 Provider contact information must be someone from
the provider’s office (not a biller, billing service or clearinghouse).
DEG7 NPI is required DEG8 is required if using a clearinghouse. DEG10 Mark the submission information -
ex: New Enrollment, Change Enrollment, Cancel Enrollment.
ICD-10 Update ICD-10 is the biggest change in standard healthcare coding
systems in decades. ICD-10 will impact every system, process and transaction that
contains or uses a diagnosis code. This past March, the Centers for Medicare & Medicaid Services
(CMS) conducted a successful ICD-10 testing week. This testing week allowed an opportunity for testers and CMS
alike to learn valuable lessons about ICD-10 claims processing. HHS expects to release an interim final rule in the near future that
will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015
Contingency Plans Approved vendor, billing services, clearinghouse
and Network Service Vendor (NSV) lists: http://www.wpsic.com/edi/files/medicare_connection.pdf
PC-Ace Pro32 Clearinghouse options? What are your contractual arrangements with
vendor and/or clearinghouse? Paper claim submission is not a contingency
option Other?
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. Import 277CA or 835 into readable reports. A common piece of providers’ contingency plans! Current version 2.52
New 1500 (02/12) Paper billing – NOT A CONTINGENCY! ASCA
Rules still apply. Does your billing software need updating in order to
accommodate the new form (02/12)? Do your printer settings need to be modified? Item - 14 multiple date field, requires date qualifier. Item – 21 ICD-9 or ICD-10 indicator, up to 12
diagnosis. Item 24E must use the appropriate alpha (A-L)
diagnosis code pointers.
Monitor Your Business!!! 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… [email protected], [email protected]
WPS Connectivity Options
Dial Up Bulletin Board System (BBS). Network Service Vendor (NSV) into
Medicare EDI Gateway (MEG).
Go Green!!! Go Green!!! Even if you don’t post electronically you can take
advantage of 835. Over 78% of all remittances are sent
electronically in 5010-835 format. PcPrint and MREP are free and easy to use. You can download MREP and PcPrint from:
http://www.wpsic.com/edi/tools.shtml
Medicare Remit Easy Print (MREP) and PcPrint 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!
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Future EDI ACTs 2014 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.
2014 calls (all times 1-2:30 pm cst):Date
August 14, 2014 (800) 305-2862 84826989 October 9, 2014 (800) 305-2862 84826999 December 11, 2014 (800) 305-2862 84827004
Questions and Answers
We want to hear from you… If you have additional questions, you
can also send an email to: [email protected] [email protected]
Also visit our EDI site for additional information: http://www.wpsic.com/edi/
EDI Addresses & Numbers [email protected] [email protected]
MAC J5, J8 Part A & B(Iowa, Kansas, Missouri, Nebraska and J5 National) (Indiana,
Michigan)WPS Medicare EDI1717 West Broadway Madison, WI. 53713Fax: (608) 223-3824
New Single Point of Contact Numbers!!!J5 Single Point Of Contact (SPOC): (866) 518-3285 opt 1J8 Single Point Of Contact (SPOC): (866) 234-7331 opt 1
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 Medicare EDI: www.wpsic.com/edi/med_index.shtml
NACHA: www.nacha.org, www.electronicpayments.org
CAQH CORE: www.caqh.org