The Privacy Symposium
The Sixteenth National
HIPAA Summit
Cambridge, MA
Transactions,
Code Sets and
Identifiers (NPI)
Update
Jim Whicker, CPAM
Intermountain Healthcare
Director of EDI, A/R Management
Chair, WEDI
AAHAM EDI Liaison
NPI – Our Experiences
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Claims processing ok
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Unexpected rejections
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Payer Crosswalks
Inability to handle provider who practices in
multiple locations
835’s processing mostly without incident
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Concern for some providers as not all
segments fully NPI only
Some payers have difficulty with paper and
crossover claims
Clearinghouse/Payer creating loops and
segments not on outbound claim then
rejecting claim for non compliance!
National Provider ID 
NPI
Additional Issues:
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Provider required to submit NPI on bill even when
referring doc has no NPI/Unable to obtain
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Medicare Transmittal 235 made recommendations, but has
since been rescinded without alternative
Provider NPPES and IRS name mismatch
Requirement to Update 855 documents with CMS and
wait to update NPPES until AFTER CMS updates internal
systems.
Interaction issue between NPPES and PECOS
CMS has processing issues for certain institutional bill
types hitting the right area internally for payment.
"You really don't need my driver's license officer...I have an NPI, a 10-digit,
intelligence-free, numeric identifier."
Cartoon by Dave Harbaugh
NPRM – 5010, D.0, and ICD-10
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Information released for public view Friday, August 15
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Publication in Federal Register August 22, 2008
Comments Due October 21, 2008
For 5010 and D.0
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Industry internal review for changes – begin September 2008
Internal/External Testing by April 2009
CMS expects to have full compliance by April, 2010
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Short process for review of comments and posting of final rule?
For ICD-10
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Industry begin design and documentation June 2009
Industry build and internally test system changes December 2009
Test with trading partners July 2010 – October 2011
Full compliance October 2011
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Still no Attachments final rule, nor plans for a National Payer ID
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Recommendation to adopt Acknowledgements, Standard ID Card
5010? Why?
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Current transactions are over 6 years old
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More than 500 industry requested changes via DSMO
Many more industry requested changes via ASC X12
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Addresses problems encountered with 4010A1
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Improvements to implementation instructions
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More consistent implementations by trading partners
Should reduce Companion Guide TP requirements
Upgrade not a HIPAA “Do-over”
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Change analysis will require a thorough
review of all transaction TR3s
Analysis is X12 to X12
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Less complicated than with round 1
Changes are not a 100% change
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Some transactions changed very little
Other transactions changed moderately
Others had significant changes (claims)
General changes to all transactions
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More standardized front matter
Addressed industry needs missing from
4010
Clarified intent where previously
ambiguous
Clarified, Added, or Deleted code values
and qualifiers:
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To address industry requests
To reduce confusion from similar or redundant
values
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TR#’s (Implementation Guides) “Free” for
4010, Must be purchased for 5010
837 – Health Care Claims (I, P, D)
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Fixed significant industry problems:
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Improved front matter explanation of COB
reporting and balancing logic
Added COB crosswalk – and examples
Section added to explain allowed and
approved amounts
Subscriber/patient hierarchy modified
837I Provider types were redefined in
conjunction with the NUBC code set
837 – Health Care Claims (cont’d)
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Improved rules and instructions for reporting
provider roles and use of NPI
Added front matter sections to:
Explain Medicaid subrogation
 Pay-to Plan information
 Explain reporting of drug claims
 POA Moved to a specific segment rather than “Kludged”
 Capability to do ICD-10
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837 Professional - Anesthesia minutes
Ambulance “Pick-up” information added
Dental – easier to coordinate benefits between dental
and medical plans
Start/Stop dates for crowns/bridges
Allows for Tooth numbers with International systems
835 – Claims Payment/Remittance
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Many improvements are in the Front Matter
Tighter business rules to eliminate options and codes
Allows compatibility with claims sent under version 4010 for
transition
Added Health Care Medical Policy – via payer URL
Claim status has clearer guidance to report how a claim was
adjudicated
 Better instructions for handling reversals and corrections;
interest payments and prompt pay discounts
 Limits use of denial claim status to specific business case
 Advanced payments and reconciliation
Secondary payment reporting considerations section revised
834 - Enrollment/Disenrollment
820 – Premium Payments
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834:
 Allow usage of ICD-10 for reporting pre-existing condittions
 Privacy issues addressed
 Added codes to explain coverage changes
 Clarifies usage of coverage dates
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820:
 Ability to report additional deductions from payments
 Method used to deliver remittance
 Simplifies and clarifies when adjustments to previous
payments are needed
270/271 – Eligibility
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Clarified instructions for sending
inquiries:
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When subscriber is patient
When dependent is patient
Newly required response information
– When a patient has active benefit
coverage, the health plan must report:
• Beginning effective eligibility date, Plan name, and
the Benefit effective dates if different from the overall
coverage.
• All demographic information needed by the health
plan on subsequent transactions must be reported,
primary care provider if available, and other payers if
known.
270/271 – Eligibility
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Required alternate search options
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When payers are unable to find member eligibility
information using all the data elements of the
primary search, health plans must support
inquiries with:
Member ID, Last name only, and Date of Birth to
help eliminate false negatives.
This was a controversial requirement, and was just
modified during the June trimester meeting,
changes to the TR3 (Implementation Guide) will
be forthcoming to reflect this modification.
270/271 – Eligibility (cont’d)
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Nine categories that must be reported
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Medical Care
Chiropractic Care
Dental Care
Hospital
Emergency Services
Pharmacy
Professional Visit – Office
Vision
Mental Health
Urgent Care
270/271 – Eligibility (cont’d)
Clear requirements for reporting
patient responsibility with a
monetary amount or percentage
 Added 38 new service type codes
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276/277 – Health Care Claim Status
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Eliminated sensitive patient information that
was unnecessary for business purpose
Added Pharmacy related data segments and
the use of NCPDP Payment Reject Codes
Increased Claim Status segment repeat to > 1
for more detailed status information
Added more examples to clarify instructions
278 – Referral Certification and
Authorization
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Little implementation due to constraints under
4010
Added segments for reporting key patient
conditions
Added/expanded support for various business
needs
Expanded usage for authorizations
Thank You!