Medicare Fee For Service
(FFS)
5010 and 837I
Purpose of Today’s Call
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Highlight significant differences
between the 4010A1 837I and the 5010
837I
Provide update on Medicare FFS
activities
Discuss the 837I Errata
What was adopted under HIPAA
5010
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Version 5010 of the X12 standards
General Changes
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Implementation Guides (IG) are now referred to
as Technical Review Type 3 (TR3)
Front matter was revised to be more consistent
across transaction types (e.g. claim, eligibility,
claim status)
“Situational” rules further clarified and updated to
specify when an element is required or not
allowed.
Ambiguities in 4010A1 rules were corrected;
“should” was replaced with “must” in many cases.
If not required…do not send.
Differences in 5010
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Billing Provider (2010AA) prohibits use
of PO Box
Billing provider address (2010AA) and
Service facility address (2310E) require
a 9 digit zip code
SBR loops allow for 8 additional
iterations
Removed Responsibility Party and
Credit/Debit card loops (2010BC and
2010BD)
Differences in 5010 cont’d
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Modifications to DTP (Date) segments
Modifications to AMT (Amount) segments
Patient Status Code (CL103) usage required
POA indicator moved from the K3 segment to
the HI segment
Added a ‘not otherwise classified’ (NOC)
procedure code description
The Unit Rate (SV206) is changed to ‘Not
Used’
Medicare Implementation of 5010
Common Edits and Enhancement Module (CEM)
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Standardized Claim Editing
One set of edits per line of business
 Consistent editing
 Consistent results for transaction exchange
Standardized Error Handling
 TA1 Interchange Acknowledgement
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High level report of the ISA-IEA
Complete file failure
Medicare Implementation of 5010
Common Edits and Enhancement Module (CEM) cont’d
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999
Replaces the 997 transaction
 Communicates X12 and IG syntax
violations
 Can result in all claims being returned
(unless 999E)
277CA (claims acknowledgement)
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Used to communicate the status of
individual claims (accepted or rejected)
 Replaces proprietary reports
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Medicare Implementation of 5010
Common Edits and Enhancements Module (CEM) cont’d
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Receipt, Control, and Balancing
System of internal checks and balances
 Flags out of balance situations
Claim Number Assignment
 Immediate assignment of DCN to accepted
claims
 DCN will be included in the
acknowledgments
 Allows faster access to status inquiry/IVR
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Medicare FFS Business Changes
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Increased adjudication capability of ‘other’
diagnosis codes from 8 to 24
Increased adjudication capability of ‘other’
procedure codes from 5 to 24
Updated the core processing system to
accept 7 byte diagnosis codes
Updated the NPI validation in the front end
Implemented the PWK segment
Added MSP balancing edits
837I Errata
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Proposed Errata Content
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Change of various N4 (City State Zip)
segments from REQUIRED to
SITUATIONAL
Addition of a Property and Casualty Patient
Identifier segment in the 2010CA loop
(Patient Name)
Change 2010BA NM108 & NM109
(Subscriber Primary Identifier) to
SITUATIONAL – required when a “person”
837I Errata cont’d
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Change the Admission Type Code (CL101)
from SITUATIONAL to REQUIRED
Change to situational rule for the LIN
segment (Drug Identification) and code
values in LIN02 segment to capture product
number/device identifier
Medicare does not anticipate any impact to
5010 implementation or compliance dates.
Submitter Testing Procedures
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25 claim minimum
ISA15 must = T for testing
100% syntax
95% Medicare business rules
Submitter is considered in test until
approved by contractor
Timelines
Activity
Target Date
Dec 2010
Jan 2011
Achieve Level 1 compliance (Covered entities have completed
internal testing and can send and receive compliant
transactions)
Begin Level 2 testing period activities (external testing with
Trading Partners and move into production; dual 4010A/5010
processing mode)
Begin initial ICD-10 compliance activities (Gap analysis,
design, development, internal testing)
April 2011
Jan 1, 2012
Medicare FFS will implement the Errata versions to meet
HIPAA compliance requirements.
5010/D.0 Compliance Date for all covered entities.
Are you preparing for 5010
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Start now
Ask your vendor and/or clearinghouse about
their plans and timeframes implementing
5010
Communicate and coordinate
Test: internally and externally
Know your vendor’s schedule
Know your trading partner’s schedule
Communicate within entire organization to
insure all impacts identified early
Compliance Dates
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Compliance deadlines were set per
public comments
CMS expects compliance deadlines to
be met – no extensions
Success will depend on starting
early!
Future EDI ACTs 2011
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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.
2011 calls (all times 1-2:30pm cst):
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Date
January 13, 2011
March 10, 2011
May 12, 2011
July 14, 2011
September 8, 2011
November 10, 2011
Dial In
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
ID
23338581
23353257
23353258
23353259
23353260
23353261
EDI Addresses & Numbers
EDIMedicareA@WPSIC.com
EDIMedicareB@WPSIC.com
Medicare Part A Legacy A
(multiple states)
WPS Medicare EDI
PO Box 1602
Omaha, NE 68101
Fax:
(402) 351-6188
Med A Hotline: (866) 734-6656
Medicare J5 MAC Part A & B
(Iowa, Kansas, Missouri, Nebraska)
WPS Medicare EDI
1717 West Broadway
Madison, WI. 53713
Fax:
(608) 223-3824
J5 Hotline:
(866) 503-9670
Medicare Part B Legacy
(Illinois, Michigan, Minnesota, Wisconsin)
WPS Medicare Electronic Data Services
912 N Pentecost Drive
Marion, IL 62959
Fax :
(618) 998-5170
Med B EDI Hotline: (877) 567-7261
Medicare Part B Legacy
(EFT)
WPS Medicare Electronic Data Services
8120 Penn Ave. S., Suite 200
Bloomington, MN 55431
Fax:
(952) 885-2899
Phone: (952) 885-2811
(952) 885-2881
(952) 885-2882
Resources
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CMS 5010 and D.0 Webpage
http://www.cms.gov/version5010andD0
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Educational Resources:
http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-ForService_Systems.asp
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5010 Technical Report Type 3 guides:
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X12: www.X12.org
Washington Publishing
WPS 5010:
Readiness.shtml
www.WPC-EDI.com
http://www.wpsic.com/edi/5010-