Medicare Fee For Service (FFS)
EDI ACT
(August 9, 2012)
Purpose of Power Point
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5010 Status
Cutting off 4010
J8 Implementation
Monitor Your Business
Go Green
Contacting EDI
Medicare is ready. Are you?
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Testing began in January 2011
Processing 5010 claims since April 2011
Over 3.00 million claims accepted last week
Test results returned within 3 business days
835 Production Parallel files available upon
request by contacting the EDI Hotline.
Results returned on a first come first served
basis.
WPS Medicare 5010 Statistics
100% of all claim accepted are 5010 (as of 7/27/2012).
Contract
Submitter
Sending
5010 Accepted
Claims %
Provider %
Sending 5010
5010-835s Sent
J5A
412
100%
100%
73.88%
J8A
109
100%
100%
100%
Legacy A
715
100%
100%
95.80%
J5B
2013
100%
100%
94.23%
J8B
574
100%
100%
97.84%
IL
1115
100%
100%
94.89%
WI
583
100%
100%
93.32%
MN
285
100%
100%
96.76%
Top 5010 Errors – Med A 837I
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Invalid information within the Payer Claim Filing Indicator
Invalid information within the Subscribers Contract/Member number
Relational field in error for service(s) rendered
Invalid information within the HCPCS
Billing Provider’s National Provider Identifier (NPI) and Billing Provider’s
taxid
Duplicate ST-SE
Invalid information within the Subscribers Country code
Claim is out of balance within the Payers payment information
Invalid information within the Subscribers Postal/Zip code
Invalid information within the Attending Physicians Specialty/Taxonomy
code
Top 5010 Errors – Med B 837P
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Billing provider not authorized for this submitter (not linked, rendering
NPI…)
NPI Crosswalk Error - Billing provider NPI not related to TaxID
Missing or invalid Payer ID or Receiver ID
Invalid Health Insurance Claim Number
SV101-7 code description required for NOC/NOS codes
Invalid Billing NPI
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
Anesthesia services require MJ qualifier, all other services UN qualifier
Other Insured's Adjustment Quantity; 2430.CAS must not be equal to
zero
Current Med A Issues
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277 - Claim Status Response - the STC01-1
(Claim Status Category Code) from the the
5010 277 flat file.
835 - Electronic Remittance Advice – PLB0X-2
missing from FISS flat file which is failing
compliance checking.
MSP on DDE System - FISS mapping issue
where primary payer name is not mapping to
FISS.
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)
Getting 5010 – 835 Electronic
Remittance Advice
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Production 835 is generated based on
how the receiver/provider are set up
Not generated based on inbound claim
format
If a user did not request to be flipped,
they were automatically switched to
5010 effective August 1, 2012.
Getting 5010 – 276/277 Claim
Status Inquiry and Response
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Testing is not required
“Testing” is done using production data
ISA05 must = ZZ
ISA06 must = ZZ
ISA14 highly recommended to = 1
Be sure to have ISA15 = P
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
4010 - Cut Off
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Last 4010 inbound transactions
accepted must be received and
processed by WPS, before 4 pm cst,
June 29, 2012.
4010 transactions received after 4 pm
receive message that the format is no
longer accepted.
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
Clearinghouse options? Step Up? Step
Down?
What are your contractual arrangements with
vendor and/or clearinghouse? Other?
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.
EDI Information For J8
Implementation
J8 Implementation
Providers will not need to re-enroll for
EDI claims submission or Electronic
Remittance Advice (ERA) provide you are:
 Currently an NGS EDI customer using
one of the Network Service Vendors
(NSVs), or;
 Currently a WPS submitter.
J8 Submitter IDs
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Your submitter ID will NOT change.
You should have received confirmation
of WPS registration and temporary
password.
If you have not received confirmation of
sub ID and temporary password,
contact EDI immediately.
J8 Contract Numbers
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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 J8 Code
Cutover Date
IN-A
00130
08101
July 23, 2012
IN-B
00630
08102
August 20, 2012
MI-A
00452
08201
July 23, 2012
MI-B
00953
08202
July 16, 2012
J8 - 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 J8 X12 837 claim files:
 ISA-08
 GS-03
 1000B/NM1-09 (40 qualifier)
 2010BB/NM1-09 (Part B Only)
J8 - Important X12 835 Data
Element Change
The new contract codes (receiver ID) will
be reported in the following data
elements within your MAC J8 X12 835
Electronic Remittance Advice:
 ISA-06
 GS-02
 1000A/REF02 (2U qualifier)
J8 and 5010
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CMS expects trading partners to transition to
5010 transactions;
WPS can assist with any 5010 transition
issues;
Visit the WPS EDI 5010 readiness website at:
http://www.wpsic.com/edi/5010Readiness.shtml
1500-5010 Crosswalk
https://www.wpsic.com/edi/pdf/npi_1500_crosswalk.
pdf
J8 and Network Service Vendors
(NSV)
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WPS is working with the NSV to ensure
there is no disruption in service to
electronic providers;
Your current connectivity through an
NSV will remain in place, therefore,
connectivity via bulletin board system is
not required;
You can use your current submitter IDs
for J8.
J8 and PC-Ace Pro32
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WPS also utilizes PC-Ace Pro32 as the free, Medicare
supplied billing software;
Different versions of PC-Ace Pro32 are used by other
payers;
WPS has an upgrade which will allow retention of history,
beneficiary and provider data. J8 providers will need to
run the upgrade on or after your respective cutover
date in order to transition to the new Part B J8
MAC contractor codes.
J8 and MI Medicare B
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MI-B transition date was July 16, 2012.
Michigan Medicare B submitters did not need
to change their current connectivity to WPS;
Michigan B submitters will continue to use
their existing WPS submitter ID.
Monitor Your Business!
Checklist for Moving Into
Production (5010 and J8)
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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.
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.
PC Print and MREP are free and easy to
use.
Medicare Remit Easy Print (MREP)
and PC Print 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!
PWK Initiative Delayed
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Originally scheduled for April 2012
Change Requests (CRs):
7041, 7306, and 7330
Contractors continue to test.
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
October 11, 2012
800-305-2862
December 6, 2012
800-305-2862
2012 Schedule to be announced.
ID
11138603
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
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J8 EDI Site:
http://www.wpsic.com/edi/med-macj8.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, 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)
(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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4010 Cutoff
June 29, 2012, 4 pm cst
J8 Implementations
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MI-B
IN-A, MI-A
IN-B
Next EDI ACT
July 16,2012
July 23, 2012
August 20, 2012
August 9, 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/