Medicare Fee For Service (FFS)
5010
Late Push For Late
Implementers
Welcome and Purpose of
Today’s Call
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Transactions and errata
Testing requirements and procedures
Discuss readiness
Companion Guide
Going into production
Expectations: WPS will offer…
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Perform out-reach to common trading
partner vendors that have yet to
engage in testing
Dedicate resources to provide
technical support for testing
Provide timely test files and feedback
(Phased approach: 1. Translator, 2.
CEM/business edits)
Expectations: WPS request…
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Compile a representative set of business-relevant
test cases to use for testing
Ensure ability to receive and forward 999 and
277CA transactions from contractors prior to testing
Ensure timely correction of rejections identified by
999 or 277CA response
Ensure complete testing with your vendor prior to
testing with the contractor
Move into production in a timely manner following
production approval.
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)
5010 Errata
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
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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
Medicare Implementation of 5010
Common Edits and Enhancements Module (CEM) cont’d
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Receipt, Control, and Balancing
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System of internal checks and balances
Flags out of balance situations
Claim Number Assignment
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Immediate assignment of DCN to accepted claims
DCN will be included in the acknowledgments
Allows faster access to status inquiry/IVR
Timeline – 87 DAYS LEFT!!!
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Current contractor activities
January through March 2011 – translator level 1 and 2 testing (TA1 and
999s)
April 2011: Errata testing – including translator level 1 and 2, Common
Edit Module responses (277CA) including Medicare business rules, 835
testing
April 2011 through December 31, 2011 – Testing/Migration
Must be 5010 Errata ONLY by January 2012!!!
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?
Compliance Date
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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!
Ready, Set, Go…
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Don’t Wait to test or go into production!
Short migration period, only 87 days left!
Not just a Medicare issue – this affects all payers
vendors and clearinghouses
CMS does not anticipate any delays to compliance
date
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.
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
WPS is ready NOW!
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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.
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.
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.
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.
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/5010-Readiness.shtml
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PC-Ace Pro32
Paper claim submission is not a
contingency option
Other?
CMS National Provider Calls
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CMS will be 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 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 & 2012 calls (all times 1-3:00pm cst):
Date
Dial In
ID
 November 10, 2011
800-305-2862 23353261
 February 9, 2012
800-305-2862 11132712
 April 12, 2012
800-305-2862 11138600
 June 14, 2012
800-305-2862 11138601
 August 9, 2012
800-305-2862 11138602
 October 11, 2012
800-305-2862 11138603
 December 6, 2012
800-305-2862 11138604n
Our Message to you…
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Start preparing now!
Work with your vendor and/or clearinghouse
Know your vendor and clearinghouse schedule
It is your responsibility to be compliant
CMS expects compliance deadlines to be met – no
extensions
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/