1. Transactions, Code Sets and Identifiers (NPI) Update
The Privacy Symposium
The Sixteenth National HIPAA Summit
Cambridge, MA
Transactions, Code Sets and Identifiers (NPI) Update
                                 
Jim Whicker, CPAM
Intermountain Healthcare
Director of EDI, A/R Management
Chair, WEDI
AAHAM EDI Liaison

2. NPI – Our Experiences Claims processing ok Unexpected rejections
Concern for some providers as not all segments fully NPI only
Unexpected rejections
Payer Crosswalks
Inability to handle provider who practices in multiple locations
835’s processing mostly without incident
Some payers have difficulty with paper and crossover claims
Clearinghouse/Payer creating loops and segments not on outbound claim then rejecting claim for non compliance!

3. National Provider ID - NPI
Additional Issues:
Provider required to submit NPI on bill even when referring doc has no NPI/Unable to obtain
Medicare Transmittal 235 made recommendations, but has since been rescinded without alternative
Provider NPPES and IRS name mismatch
Requirement to Update 855 documents with CMS and wait to update NPPES until AFTER CMS updates internal systems.
Interaction issue between NPPES and PECOS
CMS has processing issues for certain institutional bill types hitting the right area internally for payment.

4. "You really don't need my driver's license officer
"You really don't need my driver's license officer...I have an NPI, a 10-digit, intelligence-free, numeric identifier."
Cartoon by Dave Harbaugh

5. NPRM – 5010, D.0, and ICD-10
Information released for public view Friday, August 15
Publication in Federal Register August 22, 2008
Comments Due October 21, 2008
For 5010 and D.0
Industry internal review for changes – begin September 2008
Internal/External Testing by April 2009
CMS expects to have full compliance by April, 2010
Short process for review of comments and posting of final rule?
For ICD-10
Industry begin design and documentation June 2009
Industry build and internally test system changes December 2009
Test with trading partners July 2010 – October 2011
Full compliance October 2011
Still no Attachments final rule, nor plans for a National Payer ID
Recommendation to adopt Acknowledgements, Standard ID Card

6. 5010? Why? Current transactions are over 6 years old
More than 500 industry requested changes via DSMO
Many more industry requested changes via ASC X12
Addresses problems encountered with 4010A1
Improvements to implementation instructions
More consistent implementations by trading partners
Should reduce Companion Guide TP requirements

7. Upgrade not a HIPAA “Do-over”
Change analysis will require a thorough review of all transaction TR3s
Analysis is X12 to X12
Less complicated than with round 1
Changes are not a 100% change
Some transactions changed very little
Other transactions changed moderately
Others had significant changes (claims)

8. General changes to all transactions
More standardized front matter
Addressed industry needs missing from 4010
Clarified intent where previously ambiguous
Clarified, Added, or Deleted code values and qualifiers:
To address industry requests
To reduce confusion from similar or redundant values
TR#’s (Implementation Guides) “Free” for 4010, Must be purchased for 5010

9. 837 – Health Care Claims (I, P, D)
Fixed significant industry problems:
Improved front matter explanation of COB reporting and balancing logic
Added COB crosswalk – and examples
Section added to explain allowed and approved amounts
Subscriber/patient hierarchy modified
837I Provider types were redefined in conjunction with the NUBC code set

10. 837 – Health Care Claims (cont’d)
Improved rules and instructions for reporting provider roles and use of NPI
Added front matter sections to:
Explain Medicaid subrogation
Pay-to Plan information
Explain reporting of drug claims
POA Moved to a specific segment rather than “Kludged”
Capability to do ICD-10
837 Professional - Anesthesia minutes
Ambulance “Pick-up” information added
Dental – easier to coordinate benefits between dental and medical plans
Start/Stop dates for crowns/bridges
Allows for Tooth numbers with International systems

11. 835 – Claims Payment/Remittance
Many improvements are in the Front Matter
Tighter business rules to eliminate options and codes
Allows compatibility with claims sent under version 4010 for transition
Added Health Care Medical Policy – via payer URL
Claim status has clearer guidance to report how a claim was adjudicated
Better instructions for handling reversals and corrections; interest payments and prompt pay discounts
Limits use of denial claim status to specific business case
Advanced payments and reconciliation
Secondary payment reporting considerations section revised

12. 834 - Enrollment/Disenrollment
820 – Premium Payments
834:
Allow usage of ICD-10 for reporting pre-existing condittions
Privacy issues addressed
Added codes to explain coverage changes
Clarifies usage of coverage dates
820:
Ability to report additional deductions from payments
Method used to deliver remittance
Simplifies and clarifies when adjustments to previous payments are needed

13. 270/271 – Eligibility Clarified instructions for sending inquiries:
When subscriber is patient
When dependent is patient
Newly required response information
When a patient has active benefit coverage, the health plan must report:
Beginning effective eligibility date, Plan name, and the Benefit effective dates if different from the overall coverage.
All demographic information needed by the health plan on subsequent transactions must be reported, primary care provider if available, and other payers if known.

14. 270/271 – Eligibility Required alternate search options
When payers are unable to find member eligibility information using all the data elements of the primary search, health plans must support inquiries with:
Member ID, Last name only, and Date of Birth to help eliminate false negatives.
This was a controversial requirement, and was just modified during the June trimester meeting, changes to the TR3 (Implementation Guide) will be forthcoming to reflect this modification.

15. 270/271 – Eligibility (cont’d)
Nine categories that must be reported
Medical Care
Chiropractic Care
Dental Care
Hospital
Emergency Services
Pharmacy
Professional Visit – Office
Vision
Mental Health
Urgent Care

16. 270/271 – Eligibility (cont’d)
Clear requirements for reporting patient responsibility with a monetary amount or percentage
Added 38 new service type codes

17. 276/277 – Health Care Claim Status
Eliminated sensitive patient information that was unnecessary for business purpose
Added Pharmacy related data segments and the use of NCPDP Payment Reject Codes
Increased Claim Status segment repeat to > 1 for more detailed status information
Added more examples to clarify instructions

18. 278 – Referral Certification and Authorization
Little implementation due to constraints under 4010
Added segments for reporting key patient conditions
Added/expanded support for various business needs
Expanded usage for authorizations

19. Thank You!