Medicare Fee For Service (FFS)
5010
Are you ready???
Welcome and Purpose of
Today’s Call
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Transactions and errata
Testing requirements and procedures
Know your readiness status
Going into production
5010 Transactions and
Affected Business Processes
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Claims (837 Institutional, Professional, COB, Dental, NCPDP)
Claim Status (276/277)
Claim Payment (835)
Enrollment (834)
Premium Payment (820)
Eligibility (270/271)
Referrals and Prior Authorizations (278)
Claims Acknowledgements (277CA)
Acknowledgement for Health Care Insurance (999)
Companion Guide
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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:
 837 Health Care Claim Institutional
 837 Health Care Claim Professional
 835 Health Care Claim Payment Advice
 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
Timeline – 50 DAYS LEFT!!!
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Current contractor activities
April 2011 through December 31, 2011 – Testing/Migration
Must be 5010 Errata ONLY by January 2012!!!
Last Day for 4010, December 30, 2011 before 4 pm cdst.
Are you ready?
Compliance Date
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Compliance deadlines were set per
federal rule
CMS expects compliance deadlines to
be met – no extensions
Success will depend on starting
early!
WPS is ready NOW! Are you?
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Testing began in January 2011
Submitters are in production NOW
Test results returned within 3 business days
when able
835 Production Parallel files available upon
request by contacting the EDI Hotline.
Results returned on a first come first served
basis.
Are you prepared for 5010?
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Do you know your vendor’s schedule?
Do you know your trading partner’s
schedule?
Has you vendor or clearinghouse tested
and been approved?
Have you tested and been approved?
Have you moved into production?
Ready, Set, Go…
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Don’t Wait to test or go into production!
Migration period ending soon, only 50 days left!
Not just a Medicare issue – this affects all payers
vendors and clearinghouses
CMS fee for service does not anticipate any delays to
compliance date
CMS regulatory agency does no
In order to receive the customer service and
support you are accustomed to from your
payers, vendors and clearinghouses it is
important that you test early and go into
production early.
If you choose to wait…
Direct Submitters Testing Procedures
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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
Testing FAQs
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Testing under your current sub ID
Advanced registration is not required
Know what needs to be changed
Test what is applicable to you
5010 Top 10 Submission Errors
http://www.wpsic.com/edi/5010-Readiness.shtml
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Valid 9 digit zip codes in billing and facility
loops.
More testing information
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January 1, 2012 – Compliance Date
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CMS does not anticipate extensions to this deadline.
Test under your current submitter ID.
Submitters are considered in test until approved by WPS.
Consult with Software Vendor to confirm the 999 and 277CA will
be returned in a human readable format!
The timeline for testing the errata version begins now. Make sure
your updates are scheduled before the compliance date.
Dual submission of 4010A1 and 5010 errata claim transactions
can be allowed.
Submitters are generally expected to move into production within
30 days of approval.
Top 5010 Errors – Med A 837I
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Invalid codes
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DRG
HCPCS
Diagnosis
Primary COB information missing
COB out of balance
Duplicate file
Invalid NPI
Top 5010 Errors – Med B 837P
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COB data missing
Billing provider physical address not used
Billing provider not authorized for this submitter
Invalid codes
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Zip (can not be padded with 0s or 9s)
HCPCS
NDC
Rendering provider NPI same as Billing
SV101-7 code description required for NOC/NOS
codes.
Medicare Part A Statistics
as of 10/22/11 thru 10/28/11
Contract
# of Approved
Submitters
Percentage of
5010 Approved
Submitters
#
Submitters
Sending
5010
% of 5010
Claims Received
J5 A
217/1,163
18.6%
98
8.8%
Legacy A
301/2,612
11.5%
160
11.0%
Medicare Part B Statistics
10/21/11 thru 10/28/11
Contract
# of
Submitters
Approved
Percentage of 5010
Approved
Submitters
Submitter
Sending 5010
% of 5010
Claims Received
IL
654/2,430
26.9%
223
7.3%
MI
396/1,146
34.6%
100
6.1%
WI
454/1,157
39.2%
139
10.3%
MN
153/855
17.9%
64
4.8%
J5B
864/4,909
17.6%
258
10.3%
Getting 5010 – 835 Electronic
Remittance Advice
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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.
Getting 5010 – 276/277 Claim
Status Inquiry and Response
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Testing is not required
“Testing” is done using production data
ISA14 highly recommended to = 1
Be sure to have ISA15 = P
Checklist for Moving Into
Production
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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.
How can I tell if I am 5010?
Check your remittance advice.
Part A
Part B
Check 14th digit of DCN =
7.
Ex: 21200100627607
Check your ICN regions.
RRYYJJJCCCCCC
Ex: 1012001123450
5010 EMC
IL/IA 09
MI/MO 18
WI/KS 28
MN/NE 38
4010 EMC
10
02
19
11
29
22
39
32
PC-Ace Pro32
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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.
Contingency Plans
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Approved vendor, billing services and
clearinghouse lists: http://www.wpsic.com/edi/5010Readiness.shtml
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PC-Ace Pro32
Paper claim submission is not a contingency
option
Clearinghouse options? Set Up? Set Down?
What are your contractual arrangements with
vendor and/or clearinghouse?
Other?
Lessons Learned
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Entities are slow to test
Slow to move into production
New EDI frontend was a good decision
Early is never early enough
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Was 2.5 years enough time?
Need to track submitters using an automated method
Make no assumptions
Improve Collaboration, Coordination &
Communication
Dual processing is a necessity
Errata did not have any significant impact
Lessons Learned Continued…
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Make no assumptions
Improve interpretations
Standardize acknowledgments
Develop a transition plan
Improve Collaboration, Coordination & Communication
Ability to change
Allow dual processing
Test early & often is necessary
Move to production as early as possible
Education
Accountability
Review X12 guides during comment period!
CMS National Provider Calls
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CMS will host a variety of national education calls
that will inform the provider community of the steps
that they need to take in order to be ready for
implementation. These calls will also give participants
an opportunity to ask questions of CMS subject
matter experts
Delivery of a series of National Provider Calls –
presentations, transcripts and audio files available at
http://www.cms.gov/Versions5010andD0/V50/list.as
Registration for upcoming events:
http://www.eventsvc.com/palmettogba/
Future EDI ACTs 2012
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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
February 9, 2012
April 12, 2012
June 14, 2012
August 9, 2012
October 11, 2012
December 6, 2012
Dial In
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
ID
11132712
11138600
11138601
11138602
11138603
11138604
Cutting Off 4010
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Last 4010 inbound transactions accepted
must be received and processed by WPS,
before 4 pm cdst, December 30, 2011.
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.
Our Message to you…
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Move into production now!
Work with your vendor and/or clearinghouse
Know your vendor and clearinghouse schedule
Office of HIPAA Standards announced compliance
deadlines to be met – no extensions
It is your responsibility to be compliant
If you fail to prepare, it will be your
business and cash flow that will be
affected!
Questions and Answers
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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
EDI Addresses & Numbers
EDIMedicareA@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 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
EDIMedicareB@WPSIC.com
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
Resources
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CMS 5010 and D.0 Webpage
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Educational Resources:
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5010 Technical Review Type 3 guides:
http://www.cms.gov/version5010andD0
http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
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X12: www.X12.org
Washington Publishing
www.WPC-EDI.com
WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml
CMS National Provider Calls:
http://www.eventsvc.com/palmettogba/