preparing for 5010 claims filing -...

5010 Claims Filing

Aida Anderson – HealthSystemsChandra Ross – GE Healthcare

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Today’s discussion

• Introduction to 5010

• Key Changes from 4010 to 5010

• Changes to CPS Application

• EDI Plug-in Changes

• New 5010 EDI Reports

• CPS 10 Non-5010 Changes Related to EDI

• Questions

Introduction to 5010

The Version 5010 final rule (CMS-0009-F) at 45 CFR Part 162, adopts new versions of the ASC X12 for HIPAA transactions.

This rule will replace the current 4010/4010A transaction formats.

The compliance date for this rule is January 1, 2012.

http://edocket.access.gpo.gov/2009/pdf/E9-740.pdf

Introduction to 5010

The updated ASC X12 Version 5010 of the HIPAA transaction standards represent substantial technical and operational improvements that respond to industry business needs and requests.

The 5010 Modifications are significant, encompassing more than 850 changes.

Key Changes from 4010 to 5010

• Full support of ICD-10 – Federal Deadline is October 1, 2013

• Full support for reporting National Provider Identifier (NPI)

• Unused content from 4010A1 has been removed

• More specific requirements as to what is and isn’t allowed

• Implementation Guides (IG) are now called

Technical Review Type 3 (TR3)


• PO Boxes are prohibited for the Billing Provider (2010AA)

• Pay-To Address Required when different that the Billing

Provider Address (2010AB)

• Nine-digit Zip required for Billing and Service Provider

• Taxonomy Codes can be reported in any combination

• Tax ID and SSN can only be sent in the Billing Provider loop

• Subdivision field has been added to all Address fields – it is

required for all addresses outside of the USA


• Field Lengths have increased for the majority of existing 4010

fields

• Up to 12 Diagnosis Codes are allowed on a claim

• Date of Service Range only required when an actual range of

dates are reported

• Implementation of ‘Accept Assignment’ (2300 CLM07) changed

to allow use by all payers

• Modifications to the AMT segments for reporting Coordination

of Benefits (COB)


• Anesthesia time must now be reported in Minutes, rather than Units.

• Contact Information and Date is now required for Property & Casualty

claims

• Ambulance Pick-Up and Drop-Off Location loops added

• When POS is equal to Home (12), the facility address is now required

• ‘Present on Admission’ indicator added for reporting on Institutional

claims

• ‘Outpatient Visit’ segment added on Institutional claims

Administration Module Changes

Responsible Provider

Referring Provider

Company

Facility

Insurance Carrier

List Editor

Responsible Provider - Information Tab

An address Subdivision field has been added to the Responsible Provider and will accept a 3 characters

Field Lengths extended to support new 5010 guidelines

Administration Module

Not for Patient Use - Product Under Development

Referring Provider address subdivision has been added to the product and will accept 3 characters


Administration ModuleReferring Provider - Information Tab


A Company address subdivision field has been added to the product and will accept 3 characters

A company Specialty field has been added to the Information tab to support Taxonomy

Used to report the 2010AB Pay-To Address when different than the Billing Provider address

Administration Module Company - Information Tab


A Subdivision field for the Facility address was created and will accept 3 characters


Administration ModuleFacility - Information Tab


A Subdivision field for the Insurance carriers address has been added to the Information tab and will accept 3 characters


Administration ModuleInsurance Carrier - Information Tab


Administration ModuleList Editor – Code Lists

New 5010 Qualifiers added to all applicable Code Lists


Registration Module Changes

Patient

Case Management

Registration Module - Patient

Subdivision:

New field that supports 3

characters for non-US

Addresses

Field Lengths

increased to

support 5010

guidelines


Registration Module – Case Mgt

Subdivision:

New field that

supports 3 characters

for non-US Addresses

Field Lengths

increased to

support 5010

guidelines



Separate Fields for

storing Authorization

and Referral Number



Ability to set the

‘Present on Admission’

Indicator on a case

basis



Five Additional Condition Codes added for Case Mgt


Billing Module Changes

Visit Info

Visit Filing 1

Visit Filing 2

Visit Filing 3

Visit Filing 4

Visit Ambulance

Visit Charge Entry

Billing Module – Visit Info

Separate Fields for storing Authorization and Referral Number


Billing Module – Visit Filing 1



Generates the LQ

segment when populatedBy populating the Question #

with one or more Responses,

the FRM is generated in the

837P. Up to 17 FRM segments

can be created, based on the

Form in use.When the Certificate of

Medical Necessity is

populated, the 2440 LQ

& FRM segments

generate with the first

procedure on the visit.



Five Additional Condition

Codes have been added –

Used for Institutional

and Professional 5010

Claims Filing



Outpatient Visit:Check Box added –When selected, 2300 HI “Reason for Patient Visit” is generated with the primary Dx Code



All Ambulance-related fields have been migrated to the new Ambulance Tab.

Property/Casualty Date of First Contact:Field added to support new DTP segment


Billing Module – Visit Ambulance

Migrated from

Filing 4 Tab

New Pick-up and Drop-off

Fields added to support

Ambulance Billing for

5010


Billing Module – Visit Ambulance

Ability to set User

Preferences for the

tab display


Billing Module – Visit Charge 1

Separate Fields for

storing Authorization

and Referral Number


Billing Module – Visit Charge 2

Ability to assign a

Provider at the

procedure level


Billing Module – Visit Anesthesia

OB Anesthesia

Additional Units: New

field to accommodate

5010 Requirements


Billing Module – Visit Anesthesia

When Anesthesia

is not checked in

the Procedure

setup, all

Anesthesia fields

are grayed out.


Billing Module – Visit Test/Drug/Vision

Link Sequence Number:New Field to support 5010 guidelinesPrescription Date:

New Field to support 5010 guidelines

Four additional Replacement Reason Vision fields added

Four additional Test Results fields added


Billing Module – Visit Other Specialty

Ambulance Patient

Count:

New Field to support

5010 guidelines


Billing Module – Visit Charge Entry

Charge Entry Columns: All new fields added to Charge Entry have been included as column selections. They default to a Hidden Column.


Billing Module –Charge Entry

New field to support

837 Institutional

reporting of ‘Present

on Admission’


Transaction ModuleTransaction Distribution

Transaction Module – Trans. Dist.

Remaining Patient Liability: Replaces Patient Responsibility

Non-Covered Amount: Replaces COB Total Non-Covered


Transaction Module – Trans. Dist.

Medicare Remark Codes: Additional fields added and grouped together; Field length increased to 50 characters


EDI Plug-in Changes

Overall Changes

File Creators

File Processor

Behind-the-scenes Changes

EDI Plug-in Changes

Coding changed from Visual Basic to C#

Transmission Mode is still based in Visual Basic

Qualifiers updated for all plug-ins

4010 Builds will be included with 5010 Builds

No changes to the Clearinghouse level settings

EDI Plug-in Changes

User is able to select the either

the 4010 or 5010 File Creator

based upon the Insurance

Carrier


EDI Plug-in Changes

All the Insurance Carrier settings have been moved to one screen, instead of having multiple tabs for the user to select

Two settings removed from the Clearinghouse section:•Use Envoy Intermediary•Requires PIN

Professional File Creator


EDI Plug-in Changes

All the Insurance Carrier settings have been moved to one screen, instead of having multiple tabs for the user to select

Loop 2010 Settings Removed:•Send Insured ID in 2010BA NM1•Send Qualifier “23”in 2010BA REF•Send Provider Telephone in 2010AA PER

Loop 2300 Settings Removed:•Send Payer Estimated Amount Due in 2300 AMT•Do Not Send Patient Paid Amount in 2300 AMT

Other Settings Removed:•Paper EOB is Not Requested•Send Submitter Address in 1000A N3 & N4•Send Attending Physician Address 2310 N3, N4•Send Line Item Control in 2400•Suppress All Legacy Ids in REF Segments•Send Qualifier “SY” in Loop 2330A REF

Institutional File Creator


EDI Plug-in Changes

Eligibility Status Criteria has been removed; additionally, the schedule follows specific rules for creating a 5010 transaction

Eligibility File Creator


EDI Plug-in Changes

Loop 2100B NM109 Settings Removed:•Send Additional ID2 w/Qualifier “SV”•Send PIN with Qualifier “SV”•Send EMC with Qualifier “SV”



EDI Plug-in Changes

Qualifiers have been updated to reflect the 5010 transaction standards



EDI Plug-in Changes

Additional Service Type Codes have been added to both the Insurance Carrier dialog and the Clearinghouse dialog for Service Type Codes



EDI Plug-in Changes

Non-Payment Codes have been moved to a button display rather than a full tab; the screen look is the same

Remittance File Processor


EDI Plug-in Changes

Service Type Codes have been updated for processing as well

Eligibility File Processor


EDI Plug-in ChangesBehind-the-scenes Changes

When all 12 diagnosis codes are input on the visit, they will

pull to the electronic file with the proper qualifiers.

HI*BK:600*BF:2501*BF:2503*BF:2504*BF:2505*BF:2506*BF:2

507*BF:2508*BF:2509*BF:25091*BF:25092*BF:25093~



For all Provider fields, only valid 5010 Qualifiers will be

pulled to the electronic file during the batching process

NM1*85*1*DOCTORLAST*DRFIRST*R**MD~

N3*3790 W. MAIN ST~

N4*CITYNAME*TX*75024~

REF*SY*123456~

REF*1G*4444~

REF*0B*B29453~

REF*G2*4187111475~

REF*LU*4H23T7~


When the Place of Service is 12 on the visit, the Patient’s

Address pulls to Loop 2310C to report the facility

information

NM1*77*2*HOME~

N3*2505 PLUMDALE DRIVE~

N4*CARROLLTON*IL*60206~

The Facility Name is based upon the Facility selected on the visit



When the Insurance Carrier is setup to send Property &

Casualty claims and a Property & Casualty number is listed

on the claim, the PER segment is created automatically in

all required loops

…Subscriber Information

PER*IC**TE*9725551234*EX*123~

…Patient Information

PER*IC*SUBSCRIBERLAST, SUBFIRST*TE*9725551234~

….Facility Information

PER*IC*FACILITY MULTISPECIALTY GROUP*TE*8185551234~


To support the changes for CLM07, the plug-ins are now

designed to pull for the element all insurance carriers. In

addition, there is logic to support the new qualifiers

accepted for 5010 in CLM07 (Assignment Participation) and

CLM08 (Benefit Assignment Indicator).

CLM*000409-01*211***12:B:1*Y*A*Y*Y~

CLM*000409-01*211***12:B:1*Y*C*W*Y~


New EDI ReportsAll existing clearinghouse reports will continue to

be supported for 5010.

Two new reports will be added:

999 - Implementation Acknowledgement for Health

Care Insurance

277-CA – Health Care Claim Acknowledgement

New EDI Reports999 Acknowledgement

• Similar to current 997 Functional Acknowledgement

• Will update the Visit Status

• Will process report details into the Claims tab of the Visit


New EDI Reports277-CA Claim Acknowledgement

• Similar to the current Unsolicited 277

• Will update the Visit Status

• Will process report details into the Claims tab of the Visit

• Will generate a human-readable report in EDI Response Management


CPS 10 Non-5010 EDI ChangesIn addition to the 5010 changes made in CPS 10,

there were also EDI content changes made to

improve product functionality.

Request: Check for all edits before reporting a batching edit. Currently,

during the batching process, it fails on the first edit, and has to be batched

again to check for further edits.

Resolution: During the Batching Process, all the process will cycle through

the whole visit and report all batching edits at one time and log in the Notes

tab.

CPS 10 Non-5010 EDI Changes


Request: Remittance processor does not post the whole

payment when some of the procedures in the remit file do not

match the visit.

Resolution: Each procedure is checked individually and if one

procedure fails, the remaining procedures continue to post.

The procedure that fails is documented in the Remit_ report.


Request: Remit_ Report is capturing to much erroneous

information

Resolution: Remit_ report has been revamped to remove

extraneous information.



Request: Remittance processing continues to post when code is set to

Reject and/or Ignore

Resolution: New functionality implemented when Reject and/or Ignore are

used:

When a remit is posted with Non-Payment Code configured with Action

Ignore and Reject Visit, the procedure amount will remain as Insurance

Balance and no Residual column is created.

When a remit is posted with Non-Payment Code configured with Action

None and Reject Visit, the procedure amount will remain as Insurance

Balance and the Residual column is created.


Request: Setting to include fees with 0 dollar procedures

prevents zero dollar claim creation

Resolution: Zero Fee claims can now be created when the

setting is checked to include zero dollar claims. The BHT06

segment will create with a qualifier of CH.


Request: Actual Allowed amounts from the transaction

distribution of the payer should be pulled into Loop 2400 CN102

Resolution: Enhancement to existing functionality to support

Medicare. When a secondary claim is batched with the

Contract Type selected, the CN102 pulls from Actual Allowed in

Transaction Distribution, rather than the Allowed.



Request: Remove Purchased Service Facility ID edit from the plug-ins

Resolution: Batching edit has been removed, but if the field is populated

and is using a valid qualifier, the REF segment containing the Facility ID is

output.



Request: Attachment Control # on the Visit needs to be able to

accommodate 80 alpha-numeric characters for TX Medicaid

COB Requirements

Resolution: Attachment Control # has been updated to

support up to 80 numbers, letters, or special characters.



Request: MIBCBS - Need to look at the potential of processing

the U277 Reports

Resolution: The MIBCBS plug-in has been coded to process the

277 electronic file format. This report is not currently received

by MIBCBS, but will need to be activated for all users once CPS

is in general release. The 277 is the electronic version of the

human readable U277 that customers currently receive.

The reports processor determines whether the file is 4010 or

5010 and processes appropriately, so users can receive either

4010 or 5010 compliant 277 files from the payer without an

issue processing against the visit.


Request: Appointment Date criteria is pulling patients that are already

checked

Resolution: The whole functionality of Verifying Eligibility from Schedule is

changed in the new design.

- If the Eligibility status is Pending/Not Verified, the 270 file is always

created for a Patient appointment from the schedule.

- If the Eligibility Status is Active/Inactive and Ins Carrier settings "Inquiry

per Patient", the 270 file is created once for a Patient appointment

- If the Eligibility Status is Active/Inactive and Ins Carrier settings "Inquiry

per Patient per Doctor", then 270 file is created once for a Patient

appointment for each different Provider's Schedule.


Request: Date of Service on Details screen does not update to current date

Resolution: Added a button that updates the DOS to today’s date and sends

the date electronically in the file when selected.



Request: Must select an All row in the Response Processors for

the Service Type Code Scrubber to work properly for Eligibility

Resolution: Service Type Code Scrubber now works when a

specific company is selected in the Insurance Carrier setup.



Request: Availity Eligibility does not allow new payer IDs to be used for

eligibility requests, only the four original payers for THIN will allow a request

to generate

Resolution: The 270 transaction will now create regardless of the payer ID

entered into the Insurance Carrier setup.



Are there any questions?

Thank you for joining us today!

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