Medicare Fee For Service (FFS)
EDI ACT
(October 11, 2012)
Purpose of Power Point
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J8 Status
Top 5010 errors and issues
Legacy A (52280) transition to J5A
Monitor Your Business
Go Green
Contacting EDI
J8 Status
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J8A claims processed – Sept 632,459
J8B claims processed – Sept 4.08 million
WPS was able to help Indiana B providers
in obtaining their Electronic Remittance
Advice (ERA)
MSP claims are not an ASCA exception
and are expected to be filed electronically.
WPS Medicare Statistics
All claims, all 835, all 276/277 are 5010.
Contract
Submitter
Sending
5010
5010
Accepted
Claims
Submitters
Receiving
5010-835
5010 835s
EDI%
of Remittance
Sent
Legacy A
766
208,053
763
10,285
95.03%
J5A
420
102,200
568
6,509
95.34%
J5B
2,071
3,209,284
1,267
127,375
73.37%
J8A
222
632,459
272
4,483
91.83%
J8B
964
4,080,216
632
159,809
66.55%
IL
1,149
3,029,317
449
101,610
63.37%
WI
600
1,098,390
222
33,250
63.19%
MN
291
726,782
168
31,264
79.37%
Top 5010 Errors – Med A 837I
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Invalid Payer Claim Filing Indicator
Claim is out of balance within the Payers payment information
Invalid Subscribers Contract/Member number
Relational field in error for service(s) rendered
Invalid Codes
 HPCPS
 Other carrier Claim Filing Indicator
 Subscribers State/Province
 Other Payer’s EOB Postal/Zip Code
 Other Insured’s Postal/Zip Code
Billing Provider’s TAXID Not Associated to Billing Providers NPI
Duplicate ST-SE
Units must be > than Zero
Invalid Billing Providers NPI
Invalid Attending Physicians NPI
Top 5010 Errors – Med B 837P
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Billing provider not authorized for this submitter (not linked to sub ID or
rendering NPI sent in billing loop)
NPI Crosswalk Error - Billing provider NPI not related to TaxID
Invalid Provider NPI
Invalid Health Insurance Claim Number
Duplicate File (ST-SE) submitted
Invalid codes
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Diagnosis Code (ICD-9)
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Zip (can not be padded with 0s or 9s)
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HCPCS
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Modifiers
SV101-7 code description required for NOC/NOS codes
Other Insured's Adjustment Quantity; 2430.CAS must not be equal to zero
Missing or invalid Payer ID
Future Dates in DTP03.
Current Med A Issues
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Some IRF HIPPS codes rejecting at CEM
incorrectly
PcPrint - the Claim Adjustment Reason Code
(CARC) 45 is mapping to the
NonCovered/Denied field instead of
Contractual field.
PcPrint – The Outlier amount is not mapping
to the Outlier field on the Single Claim (SC)
tab.
Current Med B Issues
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Canadian Beneficiary Address
Partial 835 (not a complete ISA-IEA)
Sporadic delays in sending responses
(999, 277CAs or 835s)
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.
Current version 2.40
EDI Information For Legacy A
Transition to J5 National
Legacy A Transition to
J5A National
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Legacy A transition date is October 22, 2012.
Legacy A submitters do not need to change their current
connectivity to WPS;
Legacy A submitters will continue to use their existing WPS
submitter ID.
Providers will not need to re-enroll for EDI claim submission or
Electronic Remittance Advice (ERA)
The new toll free number will change to 1-866-503-9670 on
October 22, 2012.
The Hours of Operation will change to 8:00 AM – 4:00 PM CST
on October 22, 2012.
J5 National - Contract Number
Change
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Submitters will need to change their current
contract number (receiver ID) on the
weekend of the specified cutover:
Workload
Current Code
New J5A Code
Cutover Date
Legacy A
52280
05901
October 22, 2012
J5 National - Important X12
837 Data Element Change
The new contract codes (receiver ID) will
need to be placed in the following data
elements within your
MAC J5 X12 837I claim files:
 ISA08
 GS03
 1000B/NM109 (40 qualifier)
J5 National - Important X12 835
Data Element Change
The new contract code (receiver ID) will
be reported in the following data
elements within your MAC J5 X12 835
Electronic Remittance Advice:
 ISA06
 GS02
 1000A/REF02 (2U qualifier)
Legacy A Transition to J5
National and PC-Ace Pro32
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WPS utilizes PC-Ace Pro32 as the free, Medicare supplied billing
software;
WPS has an upgrade which will allow retention of history,
beneficiary and provider data. If you currently use PC-Ace
software to submit your Medicare claims, you will need to
download the most current PC-Ace software version on or after
10/22/2012 which will automatically change your current 52280
contract code to the new 05901 contract code. The new
contractor name will be Medicare J5A National.
Monitor Your Business!
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.
Use these tools to monitor your business so when
you call, you’ll already have an idea what the issue
may be.
Contingency Plans
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Approved vendor, billing services, clearinghouse and
Network Service Vendor (NSV) lists:
http://www.wpsic.com/edi/files/medicare_connection.pdf
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PC-Ace Pro32
Paper claim submission is not a contingency option
Clearinghouse options? What are your contractual
arrangements with vendor and/or clearinghouse?
Other?
Help Us Help You…
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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
Go Green!!!
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Go Green!!!
Even if you don’t post electronically you
can take advantage of 835.
Over 78% of all remittances are sent
electronically in 5010-835 format.
PcPrint and MREP are free and easy to
use.
Medicare Remit Easy Print (MREP)
and PcPrint Software
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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!
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
Dial In
December 6, 2012
800-305-2862
2013 Schedule to be announced.
ID
11138604
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
1717 West Broadway
Madison, WI 53713
Fax: (608) 223-3824
Med A Hotline: (866) 734-6656
Medicare Part B Legacy
(Illinois, 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, J8 MAC Part A & B
(Iowa, Kansas, Missouri, Nebraska and
J5 National) (Indiana, Michigan)
WPS Medicare EDI
1717 West Broadway
Madison, WI. 53713
Fax:
(608) 223-3824
J5 Hotline:
(866) 503-9670
Important Dates
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J5A Legacy A Implementations
 Legacy A
October 22, 2012
Next EDI ACT
December 6, 2012, 1 pm cst
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/