Medicare Fee For Service (FFS)
(June 14, 2012)

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5010 Status
Cutting off 4010
Moving Into Production
J8 Implementation
Contacting EDI
Important Dates

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Testing began in January 2011
Processing 5010 claims since April 2011
Over 3.00 million claims accepted last week
Test results returned within 3 business days
835 Production Parallel files available upon request by contacting the EDI Hotline.
Results returned on a first come first served basis.

Contract
Legacy A
J5A
J5B
IL
MI
WI
MN
Over 99.4% of all claim accepted are 5010 (as of
5/25/2012).
Submitter
Sending
5010 Accepted
Claims %
730
400
1922
1051
529
555
277
99.1%
99.9%
99.7%
99.6%
98.0%
99.9%
99.8%
Provider %
Sending 5010
99.7%
98.5%
99.7%
99.3%
97.0%
99.8%
99.5%
5010-835s Sent
49.36%
48.00%
90.99%
91.96%
95.73%
87.53%
94.52%

Direct Submitters Testing Procedures
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CMS recommends 25 claim minimum
Testing in errata version only
100% syntax
95% Medicare business rules
ISA14 highly recommended to = 1
ISA15 must = T
Submitter is considered in test until approved by contractor

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Invalid information within the Payer Claim Filing Indicator
Invalid information within the Subscribers Contract/Member number
Relational field in error for service(s) rendered
Invalid information within the HCPCS
Billing Provider’s National Provider Identifier (NPI) and Billing Provider’s taxid
Duplicate ST-SE
Invalid information within the Subscribers Country code
Claim is out of balance within the Payers payment information
Invalid information within the Subscribers Postal/Zip code
Invalid information within the Attending Physicians Specialty/Taxonomy code

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Billing provider not authorized for this submitter (not linked, rendering
NPI…)
NPI Crosswalk Error - Billing provider NPI not related to TaxID
Missing or invalid Payer ID or Receiver ID
Invalid Health Insurance Claim Number
SV101-7 code description required for NOC/NOS codes
Invalid Billing NPI
Invalid codes
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Diagnosis Code (ICD-9)
Zip (can not be padded with 0s or 9s)
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HCPCS
Anesthesia services require MJ qualifier, all other services UN qualifier
Other Insured's Adjustment Quantity; 2430.CAS must not be equal to zero

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277 - Claim Status Response - the STC01-1
(Claim Status Category Code) from the the
5010 277 flat file.
835 - Electronic Remittance Advice – PLB0X-2 missing from FISS flat file which is failing compliance checking.
MSP on DDE System - FISS mapping issue where primary payer name is not mapping to
FISS.

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Canadian Beneficiary Address
Partial 835 (not a complete ISA-IEA)
Sporadic delays in sending responses
(999, 277CAs)

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835 Production Parallel files available upon request by contacting the EDI Hotline.
Production 835 is generated based on how the receiver/provider are set up
Not generated based on inbound claim format
When ready, we can “flip” the entire submitter from 4010 to
5010-835.
We can also “flip” on a provider by provider basis who gets
5010-835.
Request to switch from 4010 to 5010-835 should be done in writing.
If a user doesn’t request to be flipped, they will automatically be switched to 5010 effective July 1, 2012 .

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Testing is not required
“Testing” is done using production data
ISA05 must = ZZ
ISA06 must = ZZ
ISA14 highly recommended to = 1
Be sure to have ISA15 = P

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To assist trading partners and their business associates with exchanging transactions
Companion Guide provides technical and connectivity specification for the following:
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837 Health Care Claim Institutional
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837 Health Care Claim Professional
835 Health Care Claim Payment Advice
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276/277 Status Inquiry and Response
Companion guides posted to: http://www.wpsic.com/edi/pdf/med_a_837i_companion.pdf
http://www.wpsic.com/edi/pdf/med_b_837p_companion.pdf

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Last 4010 inbound transactions accepted must be received and processed by WPS, before 4 pm cst, June 29, 2012.
4010 transactions received after 4 pm will receive message that the format is no longer accepted.
835 receivers, who have not previously converted to 5010 will be switched.
NO ADDITIONAL DELAYS!

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Approved vendor, billing services and clearinghouse lists: http://www.wpsic.com/edi/5010-Readiness.shtml
PC-Ace Pro32
Paper claim submission is not a contingency option
Clearinghouse options? Step Up? Step
Down?
What are your contractual arrangements with vendor and/or clearinghouse? Other?

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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.

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Move into 5010 production now!
Continue to work with your vendor and/or clearinghouse
Monitor your business
It is your responsibility to be compliant
If you fail to prepare, it will be your business and cash flow that will be affected!

Providers will not need to re-enroll for
EDI claims submission or Electronic
Remittance Advice (ERA) provide you are:
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Currently an NGS EDI customer using one of the Network Service Vendors
(NSVs), or;
Currently a WPS submitter.

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Submitters will need to change their current contract number (receiver ID) on the weekend of the specified cutover:
Workload
IN-A
IN-B
MI-A
MI-B
Current Code
00130
00630
00452
00953
New J8 Code
08101
08102
08201
08202
Cutover Date
July 23, 2012
August 20, 2012
July 23, 2012
July 16, 2012

The new contract codes (receiver ID) will need to be placed in the following data elements within your
MAC J8 X12 837 claim files:
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ISA-08
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GS-03
1000B/NM1-09 (40 qualifier)

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CMS expects trading partners to transition to
5010 transactions;
WPS can assist with any 5010 transition issues;
Visit the WPS EDI 5010 readiness website at: http://www.wpsic.com/edi/5010-
Readiness.shtml
1500-5010 Crosswalk: https://www.wpsic.com/edi/pdf/npi_1500_crosswalk.
pdf

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WPS is working with the NSV to ensure there is no disruption in service to electronic providers;
Your current connectivity through an
NSV will remain in place, therefore, connectivity via bulletin board system is not required;
You can use your current submitter IDs for J8.

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WPS also utilizes PC-Ace Pro32 as the free,
Medicare supplied billing software;
Different versions of PC-Ace Pro32 are used by other payers;
WPS is working with the PC-Ace Pro32 vendor, SDI, to provide a patch which will allow retention of history, beneficiary and provider data.

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Current Michigan Medicare B submitters will not need to change their current connectivity to WPS;
Current Michigan B submitters will continue to use their existing WPS submitter ID.

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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.

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When you call have information available which will help us identify your file and research your issue:
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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…
EDIMediareA@WPSIC.com
,
EDIMedicareB@WPSIC.com

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Go Green!!!
Even if you don’t post electronically you can take advantage of 835.
PC Print and MREP are free and easy to use.

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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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Originally scheduled for April 2012
Change Requests (CRs):
7041, 7306, and 7330
Contractors continue to test.

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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.
2012 calls (all times 1-2:30 pm cst):
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Date
August 9, 2012
October 11, 2012
December 6, 2012
Dial In ID
800-305-2862 11138602
800-305-2862 11138603
800-305-2862 11138604

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We want to hear from you…
Also visit our 5010 readiness site for additional FAQs: http://www.wpsic.com/edi/5010-Readiness.shtml
J8 EDI Site: http://www.wpsic.com/edi/med-macj8.shtml

EDIMedicareA@WPSIC.com
EDIMedicareB@WPSIC.com
Medicare Part A Legacy A
(multiple states)
WPS Medicare EDI
PO Box 1602
Omaha, NE 68101
Fax: (402) 995-0606
Med A Hotline: (866) 734-6656
Medicare J5 J8 MAC Part A & B
(Iowa, Kansas, Missouri, Nebraska)
(Indiana, Michigan)
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

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4010 Cutoff June 29, 2012, 4 pm cst
J8 Implementations
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MI-B July 16,2012
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IN-A, MI-A
IN-B
July 23, 2012
August 20, 2012
Next EDI ACT August 9, 2012, 1 pm cst

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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:
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X12: www.X12.org
Washington Publishing www.WPC-EDI.com
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WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml
CMS National Provider Calls: http://www.eventsvc.com/palmettogba/