Medicare Fee For Service (FFS)
EDI ACT
(December 6, 2012)
Purpose of Power Point
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SUBSCRIBER’S GROUP OR POLICY
NUMBER
Top 5010 errors and current issues
CR7260 Beneficiary Name
Monitor Your Business
Go Green
Contacting EDI
Subscriber’s Group or Policy
Number
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Effective for claims received on 01-04-13 after 4:00
pm CST: Electronic claims 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.
This is CMS's logic for creating this new edit that will
reject the claim if information is present in this field.
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)
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 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.
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 or 835s)
Beneficiary Name
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CR7260 requires name must match CWF
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Beneficiary name - 2010BA/NM1
Name should appear exactly as is on Medicare card.
Special Characters in Name (NM103) CEM can accept, most
common:
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First 6 characters of last name
First character of first name
If mis-match, returned as unprocessable or RTP’d
Apostrophe (‘)
Hyphen (-)
Space ( )
Suffix (NM107): Jr, Sr, I, II, III, IV…
FISS issue regarding suffix identified and being worked.
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 2.40
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…
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.
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
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
ID
February 14, 2013
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
800-305-2862
65132395
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 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
Important Dates
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Next EDI ACT
February 14, 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
www.WPC-EDI.com
WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml
CMS National Provider Calls:
http://www.eventsvc.com/palmettogba/