cms full encounter data by january, 2012 presentation: may 25, … · 2011-06-09 · 11 cms...
TRANSCRIPT
SCAN Health PlanProvider Partners Webinar
SCAN Health PlanSCAN Health PlanProvider Partners WebinarProvider Partners Webinar
CMS Full Encounter Data by January, 2012
Presentation: May 25, 2011
CMS Full Encounter CMS Full Encounter Data by January, 2012Data by January, 2012
Presentation: May 25, 2011Presentation: May 25, 2011
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Introduction
SCAN FED Project Status
Updates on CMS Requirements
Impacts on Providers
Resources
Q&A
Next Steps
CMS Full Encounter Data AgendaCMS Full Encounter Data Agenda
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IntroductionIntroduction
Oct 29th, 2010: CMS formally announced decision to transition to a new Encounter Data Processing System (EDPS) from the current Risk Adjustment Processing System (RAPS).
– Measuring healthcare utilization in MA organizations
– Calibrating MA specific Risk Adjustment models
– Calculating disproportionate share hospital payments
EDPS Target Production Date of January 2nd, 2012
RAPS data submission will continue side-by-side during transition
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Scope of encounter data collection
– We still want all the data…but now CMS wants it all too.
Accuracy of data
– Provider identification
– Codes and reference data
Timeliness and completeness
– supplemental data submissions
– encounter data rejects response
This mandates increased:
IntroductionIntroduction
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Complete Data Submission
MA must submit all data from all types of service, including:
Inpatient HospitalInpatient Rehab Inpatient Psychiatric Long Term CareSkilled Nursing Inpatient/Swing Bed Skilled Nursing OutpatientOutpatient HospitalCommunity Mental HealthHome Health (DME) End-Stage Renal Disease
Critical Access Hospital Inpatient/Swing BedCritical Access Hospital OutpatientRural health Clinic Federally Qualified Health Center Outpatient RehabPhysician/ProfessionalClinical LaboratoryDurable Medical EquipmentAmbulatory Surgical CentersAmbulanceRadiology
IntroductionIntroduction
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SCAN FED Project Status
SCAN FED Project Status
CMS Full Encounter DataCMS Full Encounter Data
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SCAN FED Project StatusSCAN FED Project StatusSCAN is:
Developing an assessment readiness tool (a
Provider Readiness Assessment )and consulting program to help you independently determine your current status and needs
Preparing a CMS Full Encounter Data-specific SCAN website and email address to allow dialogue with Provider Partners on specific questions
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SCAN FED Project StatusSCAN FED Project Status
Working with our clearinghouses to put together planning and tracking for all Provider Partner implementations of CMS Full Encounter Data
Office Ally and DDD are alerted and planning to be ready on their end
SCAN is:
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Q: What do you envision in terms of sharing the rejects with IPA/Medical Groups? Are you going to modify the existing provider portal to share the rejects there? Or are you going to produce reports? A: Existing portal and sharing rejects for providers – will be opened up to all providers for direct remediation of encounter rejection. We may produce other reports like the CMS rejection report so that they can send corrections back.
SCAN FED Project StatusSCAN FED Project Status
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Updates on CMS Full Encounter Data
Requirements
Updates on CMS Full Encounter Data
Requirements
CMS Full Encounter DataCMS Full Encounter Data
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CMS Requirements StatusCMS Requirements Status
Encounters will be required for all Medicare-covered and non-Medicare-covered services
DME encounters will not be included in the January 2012 start date, but instead will be implemented separately by June 2012
SCAN will require all encounters be sent in the 837v5010 format as of January 1, 2012 and will be operating under Full Encounter Data Processing Guidelines as of that date
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Timely Filing– Encounter must be to CMS (cleanly passing all EDI and Adjudication Edits) within 13
months of the date of service– Chart Review Data (ex – HCC Programs or RADV) can be submitted within the same
Sweep Date timeframes as today
Direct Submissions (Alternative Submission Format)– Format will remain the same or very similar (TBD)– Encounter must first be on file at SCAN or direct submission record will be rejected– Must be used to delete specific DX codes from an encounter
Replacing and Voiding Encounters– Resub/replace entire encounter
• Claim Frequency Code = ’7’• Must include SCAN’s DCN for encounter
– Void entire encounter• Claim Frequency Code = ’8’• Must include SCAN’s DCN for encounter
CMS Requirements StatusCMS Requirements Status
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CMS Requirements Status
Encounters/Claims to Submit– All Paid & Denied (for contractual/payment
reasons) must be submitted– Rejected (for bad/incomplete date) should not be
submitted– Pending (not yet paid) should not be submitted
Submission Frequency– SCAN recommends submitting encounter data on
a weekly or bi-weekly basis. – This helps with maintain a workable submission
and rejection process
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Provider Identification– NPI is required; CMS still too provide final guidance for those providers
without an NPI (NPPES will allow almost all provider specialties to enroll for an NPI)
– All addresses (Billing Provider, Servicing Facility, Ambulance Pick Up, etc) must have 9 digit zip code
– Billing address must be the physical address and cannot be a PO Box or lockbox.
– CMS/SCAN may require identifiers such as:• CLIA and Mammography Certification Number
Multi-Specialty Providers– CMS Specialty ’70’ is no longer allowed for rendering provider and will be
rejected by SCAN– Must have individual providers NPI/specialty
Taxonomy Codes– Not required for submission to SCAN; will be derived from NPPES database
CMS Requirements StatusCMS Requirements Status
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Diagnosis Codes– 837P = 12 fields– 837I = 23 Fields– If more than allotted then:
• Can send duplicate encounter with remaining DX codes• Can add DX codes in SCAN’s Encounter Data Portal• Can submit additional DX codes on Direct Submission format (after SCAN
confirms initial encounter processing)• Other ideas?
Amount Fields– Fields such as billed amount, paid amount, and patient responsibility should be
populated– If capitated and no dollar amount is available, then may populate with $0– The patient responsibility must be populated for Medicare Out of Pocket Max
calculations– 837 EDI encounter must “balance” to pass validation
• Claim amounts must equal the sum of the Claim line amounts
CMS Requirements StatusCMS Requirements Status
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CMS Requirements Status
CMS Implementation Schedule
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Outstanding Questions For CMS
Outstanding Questions For CMS
CMS Full Encounter DataCMS Full Encounter Data
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Outstanding Questions for CMSOutstanding Questions for CMS
What is the definition of an encounter? One claim form? One DOS? One service?
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• Q: How will provider data differentiate between a capitated claim versus a FFS claim in the 5010 file somehow? A: How is not yet completely clear. CMS may allow us to put zero dollars in an encounter indicating that it was for a capitated service. SCAN may make this differentiation on your data as part of the data scrubbing / preparation for transmission to CMS. More information will be provided when CMS provides the answers.
Outstanding Questions for CMSOutstanding Questions for CMS
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Q: Can you define the scope and types of validation edits (FFS edits) that are going to be used for this project? A: We don’t know for sure the scope and pricing of FFS edits.
Outstanding Questions for CMSOutstanding Questions for CMS
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Q: What is CMS’s logic for dups in the 5010? What will be SCAN’s dup logic when this is implemented? A: CMS has not published their dup logic yet but it will be similar to their FFS side dup logic, based on information regarding the visit / service. True duplicates will reject. However, we will still need to send multiple versions of the encounter in order to get more than 6 diag codes. CMS will accommodate these addendums.
Outstanding Questions for CMSOutstanding Questions for CMS
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Impacts on ProvidersImpacts on Providers
CMS Full Encounter DataCMS Full Encounter Data
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Identify a specific individual to maintain contact and coordination with SCAN for the duration of this transition – there will be more webinars and Q&As
Alert and prepare all of your downstream providers of the upcoming changes
Prepare to work with SCAN on assessment
– Assess your current technical (IT) status and transition capabilities
– Assess workflow and resources for Encounter Data rejections
Develop a plan to accomplish the transition
Impacts on SCAN Provider PartnersImpacts on SCAN Provider Partners
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Impacts on SCAN Provider PartnersImpacts on SCAN Provider Partners
Provider partners must submit valid Procedures and DX codes. Diagnosis Code V70.0 is routinely rejected in Medicare FFS claim adjudication.
Providers partners must submit claims on the correct forms (UB-04 vs. CMS-1500).
Providers partners must keep their physicians’NPPES NPI, Addresses(!), and Taxonomy information up to date.
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Impacts on SCAN Provider PartnersImpacts on SCAN Provider Partners
Providers will need to begin submitting 100% of all encounter data for all services by 1/1/2012
SCAN provider partners will need to ensure that ALLyour providers begin submitting claims or encounter data to you by 1/1/2012
Providers will need to change many files, formats, business operations and processes to comply with the CMS Full Encounter Data requirements
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2011 Second and Third Quarter Provider Tasks:
Providers will need to assess and adjust systems, data controls, file formats, workflows and down stream communications
Providers will need an encounter extraction process which has access to all required and situational-required ANSI 5010-data elements
Impacts on SCAN Provider PartnersImpacts on SCAN Provider Partners
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2011 Third and Fourth Quarter Provider Tasks
Test in the third and fourth quarter of 2011 your new formats and processes with SCAN and our clearinghouses
Impacts on SCAN Provider PartnersImpacts on SCAN Provider Partners
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Q&A SessionQ&A Session
CMS Full Encounter DataCMS Full Encounter Data
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SCAN Full Encounter Data ResourcesSCAN Full Encounter Data Resources
Publishing industry-wide CMS Full Encounter data updates and information to www.hccuniversity.com
Marc Carren ([email protected])
Stacey Hernandez ([email protected])