Medicare Fee For Service (FFS) 5010 and 837I

Purpose of Today’s Call Highlight significant differences between the 4010A1 837I and the I Provide update on Medicare FFS activities Discuss the 837I Errata

What was adopted under HIPAA 5010 Version 5010 of the X12 standards General Changes Implementation Guides (IG) are now referred to as Technical Review Type 3 (TR3) Front matter was revised to be more consistent across transaction types (e.g. claim, eligibility, claim status) “Situational” rules further clarified and updated to specify when an element is required or not allowed. Ambiguities in 4010A1 rules were corrected; “should” was replaced with “must” in many cases. If not required…do not send.

Differences in 5010 Billing Provider (2010AA) prohibits use of PO Box Billing provider address (2010AA) and Service facility address (2310E) require a 9 digit zip code SBR loops allow for 8 additional iterations Removed Responsibility Party and Credit/Debit card loops (2010BC and 2010BD)

Differences in 5010 cont’d Modifications to DTP (Date) segments Modifications to AMT (Amount) segments Patient Status Code (CL103) usage required POA indicator moved from the K3 segment to the HI segment Added a ‘not otherwise classified’ (NOC) procedure code description The Unit Rate (SV206) is changed to ‘Not Used’

Medicare Implementation of 5010 Common Edits and Enhancement Module (CEM) Standardized Claim Editing One set of edits per line of business Consistent editing Consistent results for transaction exchange Standardized Error Handling TA1 Interchange Acknowledgement High level report of the ISA-IEA Complete file failure

Medicare Implementation of 5010 Common Edits and Enhancement Module (CEM) cont’d 999 Replaces the 997 transaction Communicates X12 and IG syntax violations Can result in all claims being returned (unless 999E) 277CA (claims acknowledgement) Used to communicate the status of individual claims (accepted or rejected) Replaces proprietary reports

Medicare Implementation of 5010 Common Edits and Enhancements Module (CEM) cont’d Receipt, Control, and Balancing System of internal checks and balances Flags out of balance situations Claim Number Assignment Immediate assignment of DCN to accepted claims DCN will be included in the acknowledgments Allows faster access to status inquiry/IVR

Medicare FFS Business Changes Increased adjudication capability of ‘other’ diagnosis codes from 8 to 24 Increased adjudication capability of ‘other’ procedure codes from 5 to 24 Updated the core processing system to accept 7 byte diagnosis codes Updated the NPI validation in the front end Implemented the PWK segment Added MSP balancing edits

837I Errata Proposed Errata Content Change of various N4 (City State Zip) segments from REQUIRED to SITUATIONAL Addition of a Property and Casualty Patient Identifier segment in the 2010CA loop (Patient Name) Change 2010BA NM108 & NM109 (Subscriber Primary Identifier) to SITUATIONAL – required when a “person”

837I Errata cont’d Change the Admission Type Code (CL101) from SITUATIONAL to REQUIRED Change to situational rule for the LIN segment (Drug Identification) and code values in LIN02 segment to capture product number/device identifier Medicare does not anticipate any impact to 5010 implementation or compliance dates.

Submitter Testing Procedures 25 claim minimum ISA15 must = T for testing 100% syntax 95% Medicare business rules Submitter is considered in test until approved by contractor

Timelines Target DateActivity 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 Medicare FFS will implement the Errata versions to meet HIPAA compliance requirements. Jan 1, /D.0 Compliance Date for all covered entities.

Are you preparing for 5010 Start now Ask your vendor and/or clearinghouse about their plans and timeframes implementing 5010 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 Compliance deadlines were set per public comments CMS expects compliance deadlines to be met – no extensions Success will depend on starting early!

Future EDI ACTs 2011 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 calls (all times 1-2:30pm cst): Date Dial In ID January 13, March 10, May 12, July 14, September 8, November 10,

EDI Addresses & Numbers Medicare Part A Legacy A Medicare J5 MAC Part A & B (multiple states)(Iowa, Kansas, Missouri, Nebraska)WPS Medicare EDI PO Box West Broadway Omaha, NE 68101Madison, WI Fax: (402) Fax: (608) Med A Hotline: (866) J5 Hotline: (866) Medicare Part B Legacy (Illinois, Michigan, Minnesota, Wisconsin)(EFT) WPS Medicare Electronic Data Services 912 N Pentecost Drive8120 Penn Ave. S., Suite 200 Marion, IL 62959Bloomington, MN Fax : (618) Fax: (952) Med B EDI Hotline:(877) Phone: (952) (952) (952)

Resources CMS 5010 and D.0 Webpage Educational Resources: Service_Systems.asp 5010 Technical Report Type 3 guides: X12: Washington Publishing WPS 5010: Readiness.shtml