Medicare Fee For Service (FFS)
5010 and 837P
Purpose of Today’s Call
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Highlight differences
Provide update on Medicare FFS
activities
Discuss Errata as it relates to 837
transactions and Medicare FFS
Emphasis on preparation
What was adopted under
HIPAA 5010?
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Version 5010 of the X12 standards
General Changes
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Implementation Guides (IG) are now referred to
as Technical Review Type 3 (TR3)
Front matter in guides more consistent across
transactions
“Situational” rules further clarified
Ambiguities in 4010A1 rolls corrected (ex “should”
replaced with “must”)
“If not required, do not send.”
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)
Differences in 5010
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Billing Provider (2010AA) prohibits use of PO
Box
Zip codes (N403) requires 9 digit zip
Added Pay to Plan loop (2010AC)
SBR loops allow for 8 additional iterations
Removed Responsible Party and Credit/Debit
card loops (2010BC and 2010BD)
Modification to DTP (Date) segments
Modifications to AMT (Amount) segments
Differences in 5010 cont’d
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Expansion of number of diagnosis codes to 12
HI segment allows for ICD-10
Added Ambulance Drop off and Pick Up loops
Added Anesthesia Related Procedure HI
segment
Added Condition Code HI segment
Added freeform narrative note at line level
Removed Purchased Service loop (2310C),
loop sequence restructured and reused
Differences in 5010 cont’d
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Added PWK segment in 2400 loop
Deleted Home Oxygen Therapy
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CR5
REF Oxygen Flow Rate
Addition of two new QTY segments for
Ambulance Patient Count and Obstetric Unit
Anesthesia Count
837P Errata
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The Standards Development Organizations have made
corrections to the 5010 and D.0 versions of certain transactions.
The Errata versions replace the Base versions for HIPAA
compliance. Per the Federal Register (Vol. 75, No. 197, October
13, 2010, 62684–62686 [2010–25684] found at
http://www.access.gpo.gov/su_docs/aces/fr-cont.html)
HIPAA compliance will require the implementation of the Errata
versions and the Base versions for those transactions not
affected by the Errata.
Compliance with the Errata must be achieved by the original
regulation compliance date of January, 2012.
Medicare FFS will implement the Errata versions to meet HIPAA
compliance requirements.
837P Errata
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Changed various N4 (City, State Zip) from required to
situational
Added Property and Casualty Patient Identifier
segment (2010CA)
Changed 2010BA/NM108 & NM109 to situational
Changed situational rule for LIN and added values in
LIN02 to capture product number/device identifier
Medicare does not anticipate any impact to
5010 implementation or compliance dates.
837P Errata Comparison
Loop
2010BA
2010BA
2010BA
2010BB
2010CA
Segment
ISA
GS
GS
ST
NM1
NM1
N4
N4
REF
2330A
2330B
2410
2410
N4
N4
LIN
LIN
2420E
N4
GE
IEA
Element
08
03
08
09
02
03
(example)
Description of change
Removed Segment Repeat (had '1')
Removed Segment Repeat (had '1')
Version number changed to '005010X222A1'
Version number changed to '005010X222A1'
Changed from required to 'Situational'
Changed from required to 'Situational'
Segment changed from required to 'Situational'
Segment changed from required to 'Situational'
New segment added for 'Property and Casualty
Patient Identifier'
Segment changed from required to 'Situational'
Segment changed from required to 'Situational'
Additional qualifiers added (EN,EO,HI,ON,UK,UP)
Element name changed to 'National Drug Code or
‘Universal Product Number’
Segment changed from required to 'Situational'
Removed Segment Repeat (had '1')
Removed Segment Repeat (had '1')
Medicare Implementation of 5010 –
Common Edits and Enhancement Module (CEM)
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Standardized Claim Editing
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Standardized Error Handling
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One set of edits per line of business
Consistent editing
Consistent results
TA1
999
277CA
Receipt, Control and Balancing
Claim Number Assignment
Medicare Implementation 5010
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Up to 12 diagnosis codes
Changes to core processing system
Increase quantity from 999.9 to 9999.9
NPI validation
PWK implementation (CR 7041)
Medicare Secondary Payer (MSP)
balancing edits
Timelines
Target Date
Activity
Dec 2010
Achieve Level 1 compliance (Covered entities have completed
internal testing and can send and receive compliant
transactions)
Jan 2011
Begin Level 2 testing period activities (external testing with
Trading Partners and move into production; dual 4010A/5010
processing mode)
Begin initial ICD-10 compliance activities (Gap analysis,
design, development, internal testing)
April 2011
Jan 1, 2012
Medicare FFS will implement the Errata versions to meet
HIPAA compliance requirements.
5010/D.0 Compliance Date for all covered entities.
Are you preparing for 5010?
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Start now
Ask your vendor and/or clearinghouse about their plans and
timeframes implementing 5010
4010A1 to 5010 gap analysis – identify:
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New content
Deleted content
Modified content
Impact to business needs
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.
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!
Our Message to you…
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Start preparing now!
Work with your vendor and/or clearinghouse.
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!
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 1-2:30pm cst):
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Date
January 13, 2011
March 10, 2011
May 12, 2011
July 14, 2011
September 8, 2011
November 10, 2011
Dial In
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
ID
23338581
23353257
23353258
23353259
23353260
23353261
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) 351-6188
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 Legacy
(EFT)
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 Report Type 3 guides:
http://www.cms.gov/version5010andD0
http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-ForService_Systems.asp
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X12: www.X12.org
Washington Publishing
WPS 5010:
www.WPC-EDI.com
http://www.wpsic.com/edi/5010-Readiness.shtml
HIPAA Version 5010: Fourteenth National Provider
Call January 19, 2011 1:00 – 2:30 cst. Go and
register at http://www.eventsvc.com/palmettogba/