Medicare Fee For Service (FFS)
5010
Troubleshooting with your
contractor.
Welcome and Purpose of
Today’s Call
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Request and Offers
Testing requirements and procedures
Trouble Shooting through “lessons
learned”
Top 10 suggestions
Going into production
Questions and Answers
Expectations: WPS will offer…
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Timely sending of 999 and 277CAs
Provide timely test files and feedback
(Phased approach: 1. Translator, 2.
CEM/business edits)
Update Frequently Asked Questions
(FAQ) with commonly identified issues
Expectations: WPS request…
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Address issues identified in testing in
a timely manner
Keep open lines of communication
with WPS
Ensure all testing issues are resolved
prior to going into production.
5010 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 999
accept or accept with errors)
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/ICN to accepted
claims
DCN will be included in the acknowledgments
Allows faster access to status inquiry/IVR
Timeline
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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 preparing for 5010?
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Start now
Ask your vendor and/or clearinghouse about their
plans and timeframes implementing 5010
Communicate and coordinate
Test: internally and externally
Know your vendor’s schedule
Know your trading partner’s schedule
Communicate within entire organization to insure all
impacts identified early
Checklist for Testing
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Is your vendor going to have a 5010 errata HIPAAcompliant billing program?
Does your billing system have all the required
information needed to create a 5010 errata compliant
claim?
When will your vendor be testing?
Will you have to bill through a clearinghouse?
When will your vendor roll out updates to you?
When will you be able to test?
When will you be ready to go into production?
Checklist Continued
HIPAA
Transaction
Transaction
Standard
Institutional
Claims
837I
Professional
Claims
837P
ERA
835
Eligibility
270/271
Claim Status
276/277
Claims
Acknowledgement
999
Functional
Acknowledgement
999/TA1
Currently
Supported?
Will Be
Supported?
Beta Test Date?
Production
Release Date?
Compliance Dates
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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
Not just a Medicare issue
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.
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
1000B/NM109 must = contract code
Testing Continued
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Know your Trading Partners plan
What is your Trading Partner doing to
prepare??
Get on their schedule
Review with your office what you need to do
to implement 5010
Test what is applicable to you
Know what needs to be changed
More testing information
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January 1, 2012 – Compliance Date
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CMS does not anticipate extensions to this deadline.
Dual submission of 4010A1 and 5010 transactions are
allowed until December 31, 2011.
Test under your current submitter ID
Consult with Software Vendor to confirm the 999 and
277CA will be returned in a readable format!
The timeline for testing the errata version begins now.
Make sure your updates are scheduled before the
compliance date.
WPS is ready to test NOW!
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Testing has begun!
We have already received and reviewed
tests
Test results returned within 3 business
days
Lessons Learned
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ISA14 must = 1 in order to get TA1 for rejection
ISA15 Test/Production Indicator T when testing
Test files incorrectly sent as production. Upload to
“Test” directory when transmitting
1000B/NM109 must = contract code
Update contact information in PER segment to
include email address and phone number
No PO Boxes in billing and/or facility loops
Valid 9 digit zip codes, no gap filling with 0000 or
9999
835 Testing
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WPS will provide a production parallel
of your current 835 v 4010A1
No end-to-end 835 testing
Medicare Remit Easy Print (MREP) is
5010 ready
PC-Print will be 5010 ready soon.
Contact your Medicare EDI Helpdesk to
request a parallel
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 software may be downloaded and tested
now
Additional instruction regarding set up to follow and will
be posted on above web site
New PC-Ace users must test and go into production with
5010 errata version after April 2011
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
Links to Edit Spreadsheets
Transaction
URL Link
Professional Claim 837P
http://www.cms.gov/MFFS5010D0/Downloads/ProfessionalClaim4010A1to5010.pdf
Institutional Claim 837I
http://www.cms.gov/MFFS5010D0/Downloads/InstitutionalClaim4010A1to5010.pdf
Remittance 835
http://www.cms.gov/MFFS5010D0/Downloads/Remittance4010A1to5010.pdf
Claim Status 276/277
http://www.cms.gov/MFFS5010D0/Downloads/ClaimStatus4010A1to5010.pdf
CMS National Provider Calls
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CMS will be hosting 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.asp
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 calls (all times 1-3:00pm cst):
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Date
October 5, 2011
November 10, 2011
Dial In
800-305-2862
800-305-2862
ID
23353260
23353261
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!
EDI Addresses & Numbers
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 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
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
Medicare Part B
(EFT Only)
WPS Medicare Electronic Data Services
8120 Penn Ave. S., Suite 200
Bloomington, MN 55431
Fax:
(952) 885-2899
Phone: (952) 885-2811
(952) 885-2881
(952) 885-2882
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: http://www.X12.org
Washington Publishing
http://www.WPC-EDI.com
WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml
CMS National Provider Calls:
http://www.eventsvc.com/palmettogba/