Medicare Fee For Service (FFS)
EDI ACT
(February 14, 2013)
Purpose of Power Point
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Avoiding Errors (2000B/SBR03,
Beneficiary name, 837I ambulance)
Top 5010 errors 837I and 837P
Current issues
Monitor Your Business
Go Green
Contacting EDI
Subscriber’s Group or Policy
Number Reminder
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Effective 1/4/2013, the 2000B/SBR03 must be
blank.
Electronic claims (837I and 837P) that include
the Subscriber’s Insured Group or Policy
Number (2000B/SBR03) will receive a 999E and
will be rejected on the 277CA by the Common
Edit Module (CEM).
The patient's red, white and blue Medicare card
does not contain a group number, therefore, the
2000B/SBR03 data element must not be sent.
Beneficiary Name
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CR7260 requires name must match CWF
 First 6 characters of last name
 First character of first name
 If mis-match, returned as unprocessable or RTP’d
Beneficiary name - 2010BA/NM1
Name should appear exactly as is on Medicare card.
Special Characters in Name (NM103) - CEM can accept, most
common:
 Apostrophe (‘)
 Hyphen (-)
 Space ( )
Suffix (2010BA/NM107): Jr, Sr, I, II, III, IV…
FISS issue regarding suffix identified and being worked.
Top 5010 Errors – Med A 837I
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Invalid Entities Additional/Secondary Identifier
Invalid Billing Providers NPI
Billing Provider’s TAXID Not Associated to Billing Providers NPI
Invalid Subscriber’s Contract/Member Number
Invalid Codes
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HPCPS
HIPPS
Patient Discharge Status
Principal Diagnosis Code
Hospital Admission Type
Subscriber’s Postal/Zip Code
Other Insured’s Postal/Zip Code
Other Carrier Claim Filing Indicator
Invalid Billing Provider’s Specialty/Taxonomy Code
Duplicate ST-SE
Relational field in error for service(s) rendered
Invalid NUBC Occurrence Code(s) and Date(s)
How to Avoid 837I Ambulance
Rejections
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Institutional ambulance claims with dates of service on or after April 1,
2012.
Only non-emergency trips (i.e., Healthcare Common Procedure Coding System
(HCPCS) codes A0426, A0428 (when A0428 is billed without modifier QL))
require a National Provider Identifier (NPI) in the Attending Physician field.
The inappropriate use of the Attending Physician is not required for emergency
trips and may cause claims to fail in EDI prepass editing (i.e., HCPCS codes
A0427, A0429, A0430, A0431, A0432, A0433, A0434, and A0428 (when A0428 is
billed with the modifier QL)).
For claims with dates of service on or after April 1, 2012, Medicare will assure
that only non-emergency trips (i.e., HCPCS A0426, A0428 (when A0428 is billed
without modifier QL)) require an NPI in the Attending Physician field. Emergency
trips on Institutional claims
A non-scheduled transportation claim shall not include 2310A NM1 data. (277CA
response A7:732:560:71)
Reference:
http://www.cms.gov/Transmittals/downloads/R2383CP.pdf
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.
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 B Issues
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Canadian Beneficiary Address
Sporadic delays in sending responses
(999, 277CAs or 835s)
Incorrect Common Edit Module 277CA
rejections for various reference files.
PPTN - ELGB Removal
(effective 4/1/2013)
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Who does this affect? PPTN users in J5B
and IN-B who access beneficiary
eligibility via ELGB.
Suggested alternate means to obtain
confirmation:
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CSNAP eligibility
270/271 to CMS data center
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 2.42
Monitor Your Business!!!
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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
Clearinghouse options?
What are your contractual arrangements with vendor
and/or clearinghouse?
Paper claim submission is not a contingency option
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…
EDIMedicareA@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!
Sign Up for E-News
New and Improved: Revised
EDI Forms
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EDI Enrollment form guidelines have been updated
per CMS requirements.
Change of Submitter form has been updated to
include 3rd Party Information.
All forms will be updated to include a version number
and will be only forms accepted after March 1st,
2013.
Not necessary to re-enroll
All forms can be located at:
http://www.wpsic.com/edi/med_index.shtml
Future EDI ACTs 2013
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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.
2013 calls (all times 1-2:30 pm cst):
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Date
Dial In
April 11, 2013
June 13, 2013
August 8, 2013
October 10, 2013
December 12, 2013
800-305-2862
800-305-2862
800-305-2862
800-305-2862
800-305-2862
ID
65137666
65137687
65137705
65137725
65137742
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 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 J8 Hotline:
(866) 503-9670
EDIMedicareB@WPSIC.com
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
Reminder: Please use the appropriate call center numbers.
Michigan J8B trading partners should dial
866-503-9670, option 2.
Important Dates
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Next EDI ACT
April 11, 2013, 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
WPS 5010:
www.WPC-EDI.com
http://www.wpsic.com/edi/5010-Readiness.shtml