1 Implementation and Training Provider Taxonomy Changes for HIPAA 837 Claims Processing Audience for Training Database Administrators Clinical users The following slides will be discussed during the training session: mapping of CHCS specialties to HIPAA Provider Taxonomy- p. 8 multiple taxonomy codes per provider- p.8 screen shot of provider specialty field- p. 10 example of HIPAA Taxonomy Code table- p. 11 Please print presentation with notes pages. Go to Print→Print What→Notes Pages

2 Implementation and Training Provider Taxonomy Changes for HIPAA 837 Claims Processing Electronic Billing of Third Party Insurance Claims 27 October 2003 ACS Federal Healthcare, Inc.

3 Purpose The Purpose of the HIPAA 837 Claims Processing training is to ensure that all the required data for the X Professional and Institutional Claims are provided to TPOCS. This will provide compliant 837 transaction for claims processing. TPOCS is the MHS standard system for the processing of third-party claims for outpatient services, and supports billing processes. TPOCS sends the data captured to the clearinghouse to allow electronic billing for claims. HIPAA Compliance of 837 Claims

4 Benefits of Electronic Billing HIPAA Compliance of 837 Claims  Standardizes Data Requirements & Format  Increases Patient, Insurance, Coding and Billing Data Accuracy  Increases security of Patient Health Information  Eliminates costs and delays associated with paper documents  Reduces initial claims rejections and increase collections  Shortens waiting periods for reimbursement to MTF

A. Scheduling B. Verification D. Disposition E. Coding F. Verification 1. Insurance Confirmation 2. Insurance Verification 3. Pre-Cert Requirements Patient Access 1. Appointment Scheduling 2. Pre-Registration 3. Walk-in C. Patient Care EOB Billing/Collections 1. Claims Submission 2. Follow-up 3. Claims Status Health Information Mgmt. 1. Documentation 2. Diagnosis/Procedure Coding MTF Revenue Cycle CHCS /ADMTPOCS Billing/Collections MTF Paper EOB/Payment Clearinghouse Third Party Payer TPOCS Electronic file transmission HIPAA 837 Transaction

6 Overview Business Process Issues & Concerns  CHCS Data Quality Requirements  Provider Files-Provider Taxonomy HIPAA Compliance of 837 Claims Processing

7 Overview Data Requirements from CHCS Users  CHCS Data Quality Requirements  Provider Files-Provider Taxonomy HIPAA Compliance of 837 Claims Processing  Information Required to Allow Electronic Billing on TPOCS with 837 HIPAA Compliant Claims Processing

8 HIPAA II Taxonomy Phase II Project Overview HIPAA Compliance of 837 Claims Processing  The CHCS System has been enhanced to store multiple HIPAA Provider Taxonomy values in the HIPAA Provider Taxonomy Code field of the Provider file.  The CHCS Data Administration Provider Enter/Edit screen has been modified to permit users to designate a Primary HIPAA Provider Taxonomy value for a provider.  The Provider ASCII file download to TPOCS (Third Party Outpatient Collection System) has been modified to reflect multiple HIPAA Provider Taxonomy values for a provider and to designate the Primary HIPAA Provider Taxonomy value and allow for appropriate billing.

9 ADM Priority I Phase II Overview (use of HIPAA Provider Taxonomy III table)- summer 04 HIPAA Compliance of 837 Claims Processing  Residents have been mapped to their respective specialties on the taxonomy table, thus associating GME with a CMAC Provider class and CHCS Specialty Code (billable.)  Residents will continue to occupy Appointment Provider field in ADM and Supervising Provider will occupy second field (residents require supervising provider since GME is mapped to a non privileged provider status)  ADM Priority I Phase II, upon conversion, will trigger all billable events involving residents (for prior x months) to be pushed to TPOCS and be billed. Billers will see a one time higher volume of resident billable events upon conversion.)

10 Ambulatory Data Module Overview of Changes - Provider HIPAA Compliance of 837 Claims Processing CA-DAA-CFT-CFM-PRO *If the information applies, it needs to be completed to allow electronic billing*

11 PROVIDER: QUARLES,GARY DA PROVIDER EDIT Name: QUARLES,GARY Provider Flag: PROVIDER Provider ID: Provider Class: PHYSICIAN SSN: Select PROVIDER SPECIALITY: + CARDIOLOGIST Primary Provider Taxonomy: CMAC Provider Class: Select PROVIDER TAXONOMY: Location: CLARK CENTER HCP SIDR-ID: Branch of Service: Rank: CIVILIAN Help = HELP Exit = F10 File/exit = DO INSERT OFF Entering a Specialty will auto-populate the Primary Provider Taxonomy, CMAC, and Select PROVIDER TAXONOMY fields

12 PROVIDER: QUARLES,GARY DA PROVIDER EDIT Primary Provider Taxonomy: ?? CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY Select PROVIDER TAXONOMY: + 207RC0000X Location: CLARK CENTER HCP SIDR-ID: Branch of Service: Rank: CIVILIAN Help = HELP Exit = F10 File/exit = DO INSERT OFF 204C0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/NEUROMUSCULOSKELETAL MEDICINE/ 204D0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/NEUROMUSCULOSKELETAL MEDICINE & OMM 204E00000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/ORAL & MAXILLOFACIAL SURGERY 204F00000X PHYSCIIANS/ALLOPATHIC/OSTEOPATHIC/SURGERY/TRANSPLANT SURGERY + + Make choice = SELECT Exit = F10

13 PROVIDER: QUARLES,GARY DA PROVIDER EDIT Name: QUARLES,GARY Provider Flag: PROVIDER Provider ID: Provider Class: PHYSICIAN SSN: Select PROVIDER SPECIALITY: + CARDIOLOGIST Primary Provider Taxonomy: 207RC0000X CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY Select PROVIDER TAXONOMY: + 207RC0000X Location: CLARK CENTER HCP SIDR-ID: Branch of Service: Rank: CIVILIAN Help = HELP Exit = F10 File/exit = DO INSERT OFF Hitting in front of code will give a description including taxonomy code and CMAC.

14 PROVIDER: QUARLES,GARY DA PROVIDER EDIT #2A HIPAA Provider Taxonomy Code: 207RC0000X HIPAA Provider Taxonomy Description: PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY This is the Provider’s Primary Taxonomy. It cannot be edited or deleted.

15 Provider Personnel File HIPAA Compliance of 837 Claims Processing CA-CLN-Facility Quality Assurance-PRO-PER

16 PROVIDER PERSONNEL FILE Page 1 Provider: QUARLES,GARY SSN: Class: PHYSICIAN ============================================================ Branch:Corps: Rank: CIVILIAN Date of Rank: Primary Hospital Location: CLARK CENTER Department/Service: ORTHO CARE DEPT FE MEPRS:: BGAA Military Occupation Code: Flying Status: NO Provider Specialty(s): CARDIOLOGIST RESIDENT SURGEON SURGERY CONSULTANT Primary Division: NH PORTSMOUTH, VA Allowable Divisions: User File Reference: QUARLES, GARY Help = HELP Exit = F10 File/Exit = DO Personal Data - Privacy Act of 1974 (PL ) INSERT OFF Selecting a SPECIALTY and pressing will take you to a background screen and display additional information, including a description of the Provider Specialty and Taxonomy Code.

17 PROVIDER PERSONNEL PROFILE Provider: QUARLES,GARY =============================================================== Provider Specialty Code: 014 Provider Specialty Description: CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X HIPAA Provider Taxonomy Description: PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY Press to continue Help = HELP Exit = F10 File/Exit = DO Personal Data - Privacy Act of 1974 (PL ) INSERT OFF

18 Provider Specialty Type HIPAA Compliance of 837 Claims Processing CA-PAS-Managed Care-FMCP-PTAB-SPEC

19 PROVIDER SPECIALTY TYPE Enter/Edit Provider Specialty Type: CARDIOLOGIST Code Description 012 ALLERGIST HIPAA Provider Taxonomy Code: 207KA0200X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/ALLERGY & IMMUNOLOGY/ALLERGY 014CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE <- Enter Provider Specialty Enter Provider Specialty to add to Provider Specialty Type. Use the SELECT key to delete any Provider Specialties entered in error.

20 PROVIDER SPECIALTY TYPE Enter/Edit Provider Specialty Type: CARDIOLOGIST Code Description 012 ALLERGIST HIPAA Provider Taxonomy Code: 207KA0200X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/ALLERGY & IMMUNOLOGY/ALLERGY 014CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE DERMATOLOGIST<- Enter Provider Specialty 080 DERMATOLOGIST Are you adding ‘080’ as a new PROVIDER SPECIALTIES (the 3rd for this MCP PROVIDER SPECIALTY TYPE)? Y

21 PROVIDER SPECIALTY TYPE Enter/Edit Provider Specialty Type: CARDIOLOGIST Code Description 014CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE 080DERMATOLOGIST HIPAA Provider Taxonomy Code: 207N00000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/DERMATOLOGY <- Enter Provider Specialty Enter Provider Specialty to add to Provider Specialty Type. Use the SELECT key to delete any Provider Specialties entered in error.

22 Individual Provider - Place of Care Within Group HIPAA Compliance of 837 Claims Processing CA-PAS-Managed Care-FMCP-PTAB-PROV

23 INDIVIDUAL PROVIDER - PLACE OF CARE PROFILE WITHIN GROUP Provider: QUARLES,GARY Group: CLARK GROUP Place of Care: CLARK CENTER Select Specialty CARDIOLOGIST RESIDENT SURGEON SURGERY CONSULTANT Help = HELP Exit = F10 File/Exit = DO ============================================================= INSERT OFF Selecting one will give a description including taxonomy code and CMAC.

24 INDIVIDUAL PROVIDER - PLACE OF CARE PROFILE WITHIN GROUP Provider: QUARLES,GARY Group: CLARK GROUP Place of Care: CLARK CENTER Specialty Code: CARDIOLOGIST Accepts Specialty Referrals Accepts PCM Assignments Associated with Specialty associated with Specialty at this Place of Care at this Place of Card YES NO HIPAA Provider Taxonomy Code: 207RC0000X HIPAA Provider Taxonomy Description: PHYSICIANS/ALLOPATHIC/OSTEPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE CMAC Provider Class: 01 MEDICAL DOCTOR/DOCTOR OSTEOPATHY Help = HELP Exit = F10 File/Exit = DO ======================================================================= INSERT OFF

25 Summary HIPAA Compliance of 837 Claims Processing *If the information applies It needs to be completed To allow electronic billing*  Data Requirements  Provider Files-Provider Taxonomy

26 MILITARY HEALTH SYSTEM (MHS) HELP DESK HIPAA Compliance of 837 Claims The MHS Helpdesk provides support for U.S. Military Health Information systems, worldwide, 24 hours a day, 7 days a week. They are the single Point of Contact for your MHS Application needs. CONUS: Direct: OCONUS: Belgium: Germany: Greece: Guam: Italy: Japan: Korea: Netherlands: Panama: Portugal: Turkey: United Kingdom: Spain: Trouble tickets can be entered directly by authorized users on the internet at and use the HELPNOW tool. To open a trouble ticket through , send to You can also submit a ticket using Customer Service Fax number at