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HIPAA Batch EDI Tips and Trouble Shooting for Successful Testing

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    1. HIPAA Batch EDI Tips and Trouble Shooting for Successful Testing Webinar Readiness Series September 29, 2009 October 29, 2009

    2. October 2009 2

    3. Agenda ProviderOne Overview and Schedule Overview of EDI Testing Tips for Successful EDI Testing Support and Resource links Questions and Answers October 2009 3

    4. Overview of ProviderOne October 2009 4

    5. What is ProviderOne? ProviderOne is the new DSHS provider payment system ProviderOne will replace the current Medicaid Management Information System (MMIS) and the Social Service Payment System (SSPS) ProviderOne is a large undertaking that will be implemented in phases Overall goal is to support continuous services for clients and uninterrupted payments to providers October 2009 5

    6. Phased Implementation Schedule Phase 1: Replaces Current MMIS Pharmacy Claims Front-end Point of Sale (POS) system implemented October 20, 2008 with current MMIS on the backend Medical and Nursing Home Claims The next possible go-live date is January 10, 2010. This will include pharmacy claims Phase 2: Replaces Current SSPS and some manual payments Implemented over 2.5 years after Phase 1 October 2009 6

    7. Significant Activities To Date User Acceptance Testing (UAT) by state staff from July 2008 March 2009 Executed 5,000+ test cases with multiple iterations or nearly 20,000 total tests Pre-production (pilot) test with providers June August 2009 6,000+ claims processed with senior state staff comparing results with legacy MMIS Demonstrated that claims adjudication works well biggest challenge was completing EDI testing Announced final go live date this summer Experienced spike in provider contacts resulting in a backlog of calls October 2009 7

    8. Lessons Learned Need improved provider communication and instructions to ensure continuity of payments Readiness webinars one of several strategies to augment communications Five (5) webinar topics to help transition to ProviderOne 30 different webinar sessions to choose from 9/29 to10/29 see list serv announcement (http://hrsa.dshs.wa.gov/providerone/ScheduledWebinars.htm) System training webinars geared to using ProviderOne after go live Addresses how to bill, how to verify client eligibility, how to download remittance advice (RA), etc. (http://hrsa.dshs.wa.gov/providerone/SystemTraining.htm) October 2009 8

    9. Readiness Webinars - Summary October 2009 9

    10. 6 Steps to Provider Readiness

    11. Overview of EDI Testing October 2009 11

    12. 12 Two Types of EDI Claim Testing Format Compliance (837 Claim File) Required Ensures format complies with federal Implementation Guides and DSHS Companion Guides at the EDI gateway Uses the Edifecs EDI gateway tool (level 1, 2 and 7 edits) Level 7 edits are specific to DSHS Companion Guides Claims that pass EDI gateway edits generate a positive 997 acknowledgement and automatically proceed to ProviderOne for content compliance testing Content Compliance (837 Claim File) Optional Ensures content compliance with ProviderOne claims edits, including new identifier requirements such as NPI, taxonomy and new client ID Generates an electronic Remittance Advice (835) October 2009

    13. Why is EDI testing important? Completion of EDI format compliance testing and receipt of a positive 997 for each transaction type is required You will not be able to submit production transactions in ProviderOne until a positive response is successfully received for each transaction type you plan to use (270, 276, 278, 837I, 837P, and 837D) Content compliance testing is strongly recommended to ensure continuous payments October 2009 13

    14. How to complete EDI testing Complete pre-requisites Determine File Submission Method Set up Security if uploading files (overall readiness step #1) Complete Registration (overall readiness step #2) Submit Trading Partner Agreement (TPA) (overall readiness step #5) Obtain Submitter Number Modify Systems per the state specific Companion Guides Submit test files to the EDI environment per instructions in the Companion Guides Access the EDI environment at: https://www.waproviderone.org/edi October 2009 14

    15. Pre-Requisites File Submission Method Determine which of 2 methods you will use to submit electronic batch files Secure File Transfer Protocol (SFTP) reserved for large organizations with files greater than 50 MB Upload files within ProviderOne If SFTP, need to request an SFTP account Call 1-800-562-3022, option 2, 4 and 3 If upload within ProviderOne, need to set up users Staff responsible for uploading/downloading files will need a user name, password and appropriate security profile (overall readiness Step 1) October 2009 15

    16. Pre-Requisite - Registration Complete Registration (Readiness Step #2) Selections during steps 11 14 of the Business Process Wizard will affect EDI experience Select your submission method in Step 11 Designate authority for receiving the 835 (electronic RA) in Step 14 835 can only be received by one (1) organization (billing agent/clearinghouse or provider) Step 14 designation takes precedence over selections in Step 16 October 2009 16

    17. Pre-Requisite Trading Partner Agreement Print, sign and mail the Trading Partner Agreement (TPA) to DSHS (http://hrsa.dshs.wa.gov/providerenroll/) A new TPA is required before registration can be approved Current TPA is with the current vendor, not DSHS DSHS cannot exchange files containing Personal Health Information (PHI) until new TPA is received DSHS will send you a letter with your submitter number once your registration is approved Submitter number is a 9-digit number to be used on EDI transactions The current letter shows 9 digits, but if you have an older letter with a 7-digit number, please add 00 to the end October 2009 17

    18. Pre-Requisite Modify Systems Download Companion Guides (one for each transaction type) available at: http://hrsa.dshs.wa.gov/dshshipaa/ Modify your system according to the Companion Guides Tip: carefully read the Companion Guide this was the biggest lesson learned during the pilot test with providers this summer October 2009 18

    19. When to test Begin testing as soon as you complete the pre-requisites. (Recommend completing by Oct 30.) On December 24, 2009, testing will be suspended while we transition to ProviderOne Testing will not be available again until after ProviderOne is implemented. The next possible go-live date is January 10 2010. Payments could be delayed if you dont pass format testing before December 24 How long your testing takes depends on how carefully you follow the DSHS HIPAA Companion Guides Providers are averaging 4 weeks of trial and error to receive successful EDI responses October 2009 19

    20. Limits of EDI Environment EDI environment is a test environment for the purpose of testing EDI files only Data current as of 6/29/09 Except for updates due to security (readiness step 1) and registration (readiness step 2), which are updated real-time EDI environment does not have converted claims history No correspondence component No .pdf version of RA Batch files only no Direct Data Entry October 2009 20

    21. Tips for Successful Testing Carefully read and follow DSHS HIPAA Companion Guides when modifying system Allow ample time for testing through trial and error it is taking up to 4 weeks to complete EDI testing Submit small files initially until format testing passes Increase file size and complexity to test your business scenarios during content testing Include any third parties you may use, like software vendors, in your preparations Clearinghouses/billing agents should work closely with providers to ensure transactions process correctly October 2009 21

    22. Tips for Successful Testing, cont. Use 9 digit submitter ID in the appropriate field If your submitter letter shows a 7 digit submitter ID add 00 as a suffix to make it a 9 digit submitter ID Use ProviderOne Client ID rather than PICs Use National Provider Identifiers rather than current Medicaid provider IDs Use taxonomy on claims for billing and servicing providers Remove legacy identifiers from Secondary Identification Loops Remove invalid insertions of Line Feeds and Carriage Returns October 2009 22

    23. Important Testing Terms & Tips TA1 Envelope Acknowledgment All submitted files receive a TA1. If an error occurs in the envelope, the file is not processed further. The submitter must correct the error and resubmit the file for further processing 997 Functional Acknowledgement All submitted files having a positive TA1 receive either a positive or negative 997 Positive 997: A positive 997 and Custom Report are generated for each file that passes the header and trailer check and the HIPAA Level 1, 2 and 7 editing Negative 997: A negative 997 and Custom Report is generated when HIPAA Level 1, 2 and 7 errors occur in the file Custom Report All submitted files having a +TA1 and a +/- 997 receive a Custom Report 23 October 2009

    24. Important Testing Terms & Tips, cont. Only the submitting organization receives the TA-1 and 997 Providers who use a Billing Agent/Clearinghouse (BA/CH) will not receive these acknowledgment files Providers who use a BA/CH will only receive an 835 (electronic RA) from DSHS if they designate authority for receiving an 835 during Step #14 of registration (again, step #14 takes precedence over step #16) October 2009 24

    25. Important Testing Terms & Tips, cont. SFTP folder structure (if applicable reserved for large organizations with large files): Use TEST Root Directory and folders within the SFTP account assigned to you Drop files submitted to DSHS to: TEST_HIPAA_Inbound folder Retrieve acknowledgements from: TEST_HIPAA_Ack folder Retrieve 835 from: TEST_HIPAA_Outbound folder Assumes the appropriate designations were made during registration step #14 October 2009 25

    26. Interpreting 837 Responses 26 October 2009

    27. Important Links

    28. Getting Support Telephone and e-mail support system to address questions Use email where possible include key information in the subject line 1-800-562-3022, option 2, 4, then press 1 for security questions and login issues, or provideronesecurity@dshs.wa.gov 2 changes to NPI or Tax ID number or registration questions if you do not submit electronic batches, providerenrollment@dshs.wa.gov 3 for HIPAA set-up questions (SFTP site, missing/bad 997 file, etc.) 4 for HIPAA testing questions or hipaa-help@dshs.wa.gov For registration questions (only if youre an electronic batch submitter), providerrelations@dshs.wa.gov Stay on the line for general questions or providerone@dshs.wa.gov 28 October 2009

    29. More Information Sources Visit ProviderOne internet: http://hrsa.dshs.wa.gov/providerone/providers.htm Newsletters Fact Sheets Q&A Training Resources Security and Registration instructions and resources Join the e-mail distribution list for ProviderOne Countdown Newsletter & updates http://listserv.wa.gov/archives/providerone_provider_readiness.html E-mail questions directly to: providerone@dshs.wa.gov Call toll-free telephone line (1-800-562-3022) Select 2, then option 4 (see previous slide for prompt options) 29 October 2009

    30. Questions? October 2009 30