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Medicare Fee For Service (FFS) EDI ACT (February 14, 2013)

Medicare Fee For Service (FFS) EDI ACT (February 14, 2013). Purpose of Power Point. Avoiding Errors (2000B/SBR03, Beneficiary name, 837I ambulance) Top 5010 errors 837I and 837P Current issues Monitor Your Business Go Green Contacting EDI. Subscriber’s Group or Policy Number Reminder.

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Medicare Fee For Service (FFS) EDI ACT (February 14, 2013)

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  1. Medicare Fee For Service (FFS) EDI ACT (February 14, 2013)

  2. Purpose of Power Point • Avoiding Errors (2000B/SBR03, Beneficiary name, 837I ambulance) • Top 5010 errors 837I and 837P • Current issues • Monitor Your Business • Go Green • Contacting EDI

  3. Subscriber’s Group or Policy Number Reminder • Effective 1/4/2013, the 2000B/SBR03 must be blank. • Electronic claims (837I and 837P) that include the Subscriber’s Insured Group or Policy Number (2000B/SBR03) will receive a 999E and will be rejected on the 277CA by the Common Edit Module (CEM). • The patient's red, white and blue Medicare card does not contain a group number, therefore, the 2000B/SBR03 data element must not be sent.

  4. Beneficiary Name • CR7260 requires name must match CWF • First 6 characters of last name • First character of first name • If mis-match, returned as unprocessable or RTP’d • Beneficiary name - 2010BA/NM1 • Name should appear exactly as is on Medicare card. • Special Characters in Name (NM103) - CEM can accept, most common: • Apostrophe (‘) • Hyphen (-) • Space ( ) • Suffix (2010BA/NM107): Jr, Sr, I, II, III, IV… • FISS issue regarding suffix identified and being worked.

  5. Top 5010 Errors – Med A 837I • Invalid Entities Additional/Secondary Identifier • Invalid Billing Providers NPI • Billing Provider’s TAXID Not Associated to Billing Providers NPI • Invalid Subscriber’s Contract/Member Number • Invalid Codes • HPCPS • HIPPS • Patient Discharge Status • Principal Diagnosis Code • Hospital Admission Type • Subscriber’s Postal/Zip Code • Other Insured’s Postal/Zip Code • Other Carrier Claim Filing Indicator • Invalid Billing Provider’s Specialty/Taxonomy Code • Duplicate ST-SE • Relational field in error for service(s) rendered • Invalid NUBC Occurrence Code(s) and Date(s)

  6. How to Avoid 837I Ambulance Rejections • Institutional ambulance claims with dates of service on or after April 1, 2012. • Only non-emergency trips (i.e., Healthcare Common Procedure Coding System (HCPCS) codes A0426, A0428 (when A0428 is billed without modifier QL)) require a National Provider Identifier (NPI) in the Attending Physician field. • The inappropriate use of the Attending Physician is not required for emergency trips and may cause claims to fail in EDI prepass editing (i.e., HCPCS codes A0427, A0429, A0430, A0431, A0432, A0433, A0434, and A0428 (when A0428 is billed with the modifier QL)). • For claims with dates of service on or after April 1, 2012, Medicare will assure that only non-emergency trips (i.e., HCPCS A0426, A0428 (when A0428 is billed without modifier QL)) require an NPI in the Attending Physician field. Emergency trips on Institutional claims • A non-scheduled transportation claim shall not include 2310A NM1 data. (277CA response A7:732:560:71) • Reference: http://www.cms.gov/Transmittals/downloads/R2383CP.pdf

  7. Current Med A Issues • Some IRF HIPPS codes rejecting at CEM incorrectly • PcPrint - the Claim Adjustment Reason Code (CARC) 45 is mapping to the NonCovered/Denied field instead of Contractual field. • PcPrint – The Outlier amount is not mapping to the Outlier field on the Single Claim (SC) tab.

  8. Top 5010 Errors – Med B 837P • Billing provider not authorized for this submitter (not linked to sub ID or rendering NPI sent in billing loop) • NPI Crosswalk Error - Billing provider NPI not related to TaxID • Invalid Provider NPI • Invalid Health Insurance Claim Number • Duplicate File (ST-SE) submitted • Invalid codes • Diagnosis Code (ICD-9) • Zip (can not be padded with 0s or 9s) • HCPCS • Modifiers • SV101-7 code description required for NOC/NOS codes • Other Insured's Adjustment Quantity; 2430.CAS must not be equal to zero • Missing or invalid Payer ID • Future Dates in DTP03.

  9. Current Med B Issues • Canadian Beneficiary Address • Sporadic delays in sending responses (999, 277CAs or 835s) • Incorrect Common Edit Module 277CA rejections for various reference files.

  10. PPTN - ELGB Removal (effective 4/1/2013) • Who does this affect? PPTN users in J5B and IN-B who access beneficiary eligibility via ELGB. • Suggested alternate means to obtain confirmation: • CSNAP eligibility • 270/271 to CMS data center

  11. 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. • Current version 2.42

  12. 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.

  13. 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?

  14. 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… EDIMedicareA@WPSIC.com, EDIMedicareB@WPSIC.com

  15. 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.

  16. 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! Medicare Remit Easy Print (MREP) and PcPrint Software

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  18. New and Improved: Revised EDI Forms • EDI Enrollment form guidelines have been updated per CMS requirements. • Change of Submitter form has been updated to include 3rd Party Information. • All forms will be updated to include a version number and will be only forms accepted after March 1st, 2013. • Not necessary to re-enroll • All forms can be located at: http://www.wpsic.com/edi/med_index.shtml

  19. Future EDI ACTs 2013 • 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. • 2013 calls (all times 1-2:30 pm cst): DateDial InID • April 11, 2013 800-305-2862 65137666 • June 13, 2013 800-305-2862 65137687 • August 8, 2013 800-305-2862 65137705 • October 10, 2013 800-305-2862 65137725 • December 12, 2013 800-305-2862 65137742

  20. 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

  21. EDI Addresses & Numbers EDIMedicareA@WPSIC.comEDIMedicareB@WPSIC.com Medicare J5, J8 MAC Part A & BMedicare Part B Legacy (Iowa, Kansas, Missouri, Nebraska and (Illinois, Minnesota, Wisconsin) J5 National) (Indiana, Michigan) WPS Medicare Electronic Data Services WPS Medicare EDI 912 N Pentecost Drive 1717 West Broadway Marion, IL 62959 Madison, WI. 53713 Fax : (618) 998-5170 Fax: (608) 223-3824 Med B EDI Hotline: (877) 567-7261 J5 J8 Hotline: (866) 503-9670 Reminder: Please use the appropriate call center numbers. Michigan J8B trading partners should dial 866-503-9670, option 2.

  22. Important Dates • Next EDI ACT April 11, 2013, 1 pm cst

  23. 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

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