MAC J5 and J8
EDI ACT
(August 14, 2014)
Participant Line: (800) 305-2862
Passcode: 84826989
Purpose of Power Point
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Current issues
ICD-10 Update
Reminder MSP Claims
ERA Myth Busting
Go Green
Operation Rules
Connectivity Misconceptions
PC-Ace
Monitor Your Business
Upcoming EDI ACT 2014
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Contacting EDI – Toll Free Numbers
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Current Med A Issues –
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PCPrint Update:
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Current version 4.3.3
Version 4.3.1 and above, are not compatible with Windows XP.
Part A providers using Windows XP should continue to use
version 4.2.6 of PC Print until they are able to upgrade to a
newer version of Windows.
The “Find” function in PCPrint is not working in version 4.3.1
and after. A fix for this is anticipated in October 2014.
Sporadic delays in sending responses (999, 277CA, 277
or 835s)
Current Med B Issues
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Foreign and military zip codes.
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Foreign zips can be alpha-numeric zips and not currently loaded to CEM.
Military zips code set not currently loaded to CEM.
CEM Edits Require:
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2010BA.N403 must be a valid postal/zip Code when N404 equals US or blank.
2010BA.N404 must be a valid 2 character Country Code.
Valid alpha-2 Country Code reference must be available for this edit. (from Part 1 of
ISO 3166)
Example:
N3*POSTFACH 88~
N4*MARLIX**7074*CH~
Sporadic delays in sending responses (999, 277CA, 277
or 835s)
MREP issues for Windows 7 or 8 users
ICD-10 Update
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ICD-10 is the biggest change in standard healthcare coding systems in
decades.
ICD-10 will impact every system, process and transaction that contains or
uses a diagnosis code.
This past March, the Centers for Medicare & Medicaid Services (CMS)
conducted a successful ICD-10 testing week.
This testing week allowed an opportunity for testers and CMS alike to learn
valuable lessons about ICD-10 claims processing.
CMS anticipates additional testing for trading partners.
ICD-10 Update
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SE1410 – alerts providers that on October 1, 2015, all Medicare
claims submissions of diagnosis codes will change from the
International Classification of Diseases, 9th Edition, Clinical
Modification (ICD-9-CM) to the 10th Edition (ICD-10-CM).
Factors affect how ICD-10-CM must be used:
 The claim “From” date (episode start date);
 The Outcome and Assessment Information Set (OASIS)
assessment completion date (OASIS item M0090 date); and
 The claim “Through” date.
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/Downloads/SE1410.pdf
Reminder MSP Claims - 5010
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MSP claims are not an ASCA (Administrative Simplification
Compliance Act) exception and must be sent electronically.
Avoid front end rejections, delays and Unprocessable
rejections:
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When determining the beneficiary’s insurance coverage, it is
important to determine the correct insurance type code.
Always give the MSP insurance type code.
Other Insured's Adjustment Quantity; 2430/CAS must not be
equal to zero.
Primary paid amount should not exceed the billed amount.
Primary paid amounts at the claim level should agree with the
amounts submitted at the line level.
Instructions: http://www.wpsic.com/edi/files/msp5010A1.pdf
ERA Myth Busting
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I was unaware of the ERA. Tell me more about EDI and ERA.
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I'm not really sure. If it is something you need to sign up for we may not have been
informed.
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Fact – ERA is optional, at this time, but provides several benefits to your business.
Because paper is more reliable than electronic remittance. It also allows me to track
internal errors. I am able to follow our patients better who have cross over claims, as
our cross over claims do not always get processed by the state and this way we
assure that happens on a weekly basis. I am in need of the paper EOB when I post
the primary EOB to send to the other plan and I make those copies at the time of
primary posting .
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Goal – We want to educate on the benefits of ERA.
Fact – Paper and ERA contain the same information. Per HIPAA, the data content of paper cannot be
greater then that of the electronic transaction (xref 162.925).
Cost of vendor retrieval of ERAs. I do not know how to receive ERA.
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Fact – You can download directly from WPS or through a clearinghouse (clearinghouse charges apply).
You can also use free products such as PCPrint or MREP for your ERA.
Fact – Products like PCPrint and MREP as well as vendor product, have many useful reports.
ERA Myth Busting
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It is difficult enough with depositing directly to the account. I get an email stating a
deposit has been made to our account then, I have to hunt and review all of my
Medicare clients to see where the money should go.
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ERA did not come faster, harder to read without printing and did not import into
PCAce the reimbursements, so not streamlining or improving efficiency of office
staff.
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Fact – ERA is avaliable next business day after a claim finalizes.
Fact – PCPrint and MREP provide many beneficial reports, some of which are formatted the same as the
paper remit.
We use PC-Ace to submit our electronic claims. Using ERA with that system has
never been explained to us.
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Fact – Operating Rules (370) reassociation requires the EIN and Check # be on both ERA and EFT.
Fact – EDI Helpdesk staff are available to help.
Not sure, do not know how to set up.
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Fact – PCPrint and MREP user guides provide clear, concise intructions.
Facts. You too can Go
Green!!!
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Go Green!!!
Even if you don’t post electronically you can take advantage of
835.
ERA has same content as SPR.
Over 78% of all remittances are sent electronically in 5010-835
format.
Download directly from WPS.
Operating Rule 370 ensures EFT and ERA reassociation.
PcPrint and MREP are free and easy to use.
You can download MREP and PcPrint from:
http://www.wpsic.com/edi/tools.shtml
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!
Operating Rules
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Affordable Care Act (ACA) defines operating rules as “the
necessary business rules and guidelines for the electronic
exchange of information that are not defined by a
standard or its implementation specifications.”
Operating rules address gaps in standards, help refine
the infrastructure that supports electronic data exchange
and recognize interdependencies among transactions.
Goal: Create as much uniformity in the implementation
of electronic standard as possible.
Operating Rule Named for Eligibility
and Claim Status (effective 1/1/2013)
Phase 1 CORE 152
Eligibility and Benefit Real Time Companion Guide
Phase 1 CORE 153
Eligibility and Benefit Connectivity Rule
Phase 1 CORE 154
Eligibility and Benefit 270/271 Data Content Rule
Phase 1 CORE 155
Eligibility and Benefit Batch Response Time Rule
Phase 1 CORE 156
Eligibility and Benefit Real Time Response Time Rule
Phase 1 CORE 157
Eligibility and Benefit System Availability Rule
Phase 2 CORE 250
Claim Status Rule
Phase 2 CORE 258
Eligibility and Benefit Normalizing Patient Last Name
Rule
Phase 2 CORE 259
Eligibility and Benefit 270/271 AAA Error Code
Reporting Rule
Phase 2 CORE 260
Eligibility and Benefit Data Content (270/271) Rule
Phase 2 CORE 270
Connectivity Rule
EFT and ERA Operating Rule
Impacts
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835 Infrastructure
CARC/RARC combinations
EFT ERA Reassociation
Electronic Enrollments for EFT and ERA
EFT and ERA Operating Rules
Named (effective 1/1/2014)
Phase 3 CORE 360
Health Care Claim Payment/Advice (835) Infrastructure Rule
Phase 3 CORE 350
Uniform Use of Claim Adjustment Reason Codes and Remittance
Advice Remark Codes (835) Rule
Phase 3 CORE 360
CORE-required Code Combinations for CORE-defined Business
Scenarios
Phase 3 CORE 370
EFT & ERA Reassociation (CCD+/835) Rule
Phase 3 CORE 380
EFT Enrollment Data Rule
Phase 3 CORE 382
ERA Enrollment Data Rule
CARC/RARC Operating Rules
4 Business Scenarios Defined (Rule 360)
Specific combinations of CARC and RARC are allowed for
each business scenario.
 Scenario #1: Additional Information Required Missing/Invalid/Incomplete Documentation
 Scenario #2: Additional Information Required –
Missing/Invalid/Incomplete Data from Submitted Claim
 Scenario #3: Billed Service Not Covered by Health Plan
 Scenario #4: Benefit for Billed Service Not Separately
Payable
EFT ERA Reassociation
(Rule 370)
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Reassociation is the process of matching an Electronic
Remittance Advice (ERA) in the ASC X12 835 format to
the associated Electronic Funds Transfer (EFT).
EFT must match 835 transaction.
Reconcile actual cash received to check amounts in the
835 PRIOR to posting to patient accounting system.
Bank need to ensure the “7 record” is sent to provider
(typically sent upon request only).
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Example EFT: 705TRN*1*8834567890*1391268299~
Example 835: TRN*1*8834567890*1391268299~
Ensure Proper Completion of
ERA Form (Rule 382):
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DEG1 the address must match what is on file with Provider
Enrollment.
DEG2 Medicare must be listed in Assigning Authority
DEG2 Medicare PTAN must be listed in other identifier
DEG2 Valid WPS submitter id/trading partner ID
DEG3 Provider contact information must be someone from the
provider’s office (not a biller, billing service or clearinghouse).
DEG7 NPI is required
DEG8 is required if using a clearinghouse.
DEG10 Mark the submission information ex: New Enrollment, Change Enrollment, Cancel Enrollment.
Connectivity Misconceptions
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WPS took over some years ago and submitting electronic claims
went from pulling them up through the internet back to a bulletin
board system (BBS). I asked WPS why they did this and they
claimed it couldn't change until CMS OK'd it.
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Fact - CMS Internet policy (ref IOM Chapter 24 http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c24.pdf) prohibits the transmission of
protected health data between providers and other parties who are not Medicare
contractors over the Internet unless it is authenticated and encrypted…Unless otherwise
approved, A/B MACs, DME MACs and CEDI are only permitted to accept EDI transactions via
the Internet when explicitly directed by CMS.
We still have to transfer electronic claims through a dial up
connection. Every other electronic submission I use is through the
internet. I asked WPS about it and they said dial up is safe.
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Fact: Dial up technology is proven secure. WPS also offers secure FTP (sFTP) via Networl
Service Vendor (NSV) in addition to BBS.
WPS Connectivity Options
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Dial Up Bulletin Board System (BBS).
Network Service Vendor (NSV) into Medicare EDI Gateway
(MEG) http://www.wpsic.com/edi/files/medicare_connection.pdf.
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Ability Network
ClaimShuttle
Cortex EDI, Inc
ECC Technologies' RAPID Network
Episode Alert LLC
eSolutions, Inc.
McKesson Carebridge
MedXpress
Nebo Systems, Inc.
Optimum Management
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?
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.
Import 277CA or 835 into readable reports.
A common piece of providers’ contingency plans!
Current version 2.54
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.
Help Us Help You…
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Before you call, have information available which will
help us authenticate you 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
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Future EDI ACTs 2014
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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.
2014 calls (all times 1-2:30 pm cst):
Date
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October 9, 2014
December 11, 2014
More in 2015!!!
(800) 305-2862
(800) 305-2862
84826999
84827004
Questions and Answers
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We want to hear from you…
If you have additional questions, you can
also send an email to:
EDIMedicareA@WPSIC.com
EDIMedicareB@WPSIC.com
Also visit our EDI site for additional
information: http://www.wpsic.com/edi/
EDI Addresses & Numbers
EDIMedicareA@WPSIC.com
EDIMedicareB@WPSIC.com
MAC J5, J8 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
New Single Point of Contact Numbers!!!
J5 Single Point Of Contact (SPOC):
(866) 518-3285 opt 1
J8 Single Point Of Contact (SPOC):
(866) 234-7331 opt 1
Resources
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CMS 5010 and D.0 Webpage
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Educational Resources:
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http://www.cms.gov/version5010andD0
http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
5010 Technical Review Type 3 guides:
 X12: www.X12.org
 Washington Publishing www.WPC-EDI.com
WPS Medicare EDI: www.wpsic.com/edi/med_index.shtml
NACHA: www.nacha.org, www.electronicpayments.org
CAQH CORE: www.caqh.org