MAC J5 and J8

EDI ACT(April 10, 2014)

Participant Line: (800) 305-2862Passcode: 84826714

Purpose of Power Point Current issues Operating Rules HIPAA Security and Windows XP ICD-10 Preparedness, Nat’l Test Days, HR 4302 Monitor Your Business Go Green Upcoming EDI ACT 2014 Contacting EDI – New Toll Free Number

Current Med A Issues –

PCPrint  - DLL error for Windows 8 users Has been reported to Shared System Maintainer. As a work around, users may run the program in “compatibility mode.”

999 and 277CA not received.

Current Med B Issues Canadian and military zip codes. Sporadic delays in sending responses

(999, 277CAs or 835s) MREP issues for Windows 7 or 8 users

MSP Claims - 5010 MSP claims are not an ASCA (Administrative

Simplification Compliance Act) exception and must be sent electronically.

Avoid front end rejections, delays and Unprocessable rejections:

When determining the beneficiary’s insurance coverage, it is important to determine the correct insurance type code.

Always give the MSP insurance type code. Other Insured's Adjustment Quantity; 2430/CAS must not

be equal to zero. Primary paid amount should not exceed the billed amount. Primary paid amounts at the claim level should agree with

the amounts submitted at the line level. Instructions:

http://www.wpsic.com/edi/files/msp5010A1.pdf

Operating Rules Affordable Care Act (ACA) defines operating rules as

“the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”

Operating rules address gaps in standards, help refine the infrastructure that supports electronic data exchange and recognize interdependencies among transactions.

Goal: Create as much uniformity in the Goal: Create as much uniformity in the implementation of electronic standard as possible.implementation of electronic standard as possible.

Operating Rule Named for Eligibility and Claim Status (effective 1/1/2013)

Phase 1 CORE 152 Eligibility and Benefit Real Time Companion Guide

Phase 1 CORE 153 Eligibility and Benefit Connectivity Rule

Phase 1 CORE 154 Eligibility and Benefit 270/271 Data Content Rule

Phase 1 CORE 155 Eligibility and Benefit Batch Response Time Rule

Phase 1 CORE 156 Eligibility and Benefit Real Time Response Time Rule

Phase 1 CORE 157 Eligibility and Benefit System Availability Rule

Phase 2 CORE 250 Claim Status Rule

Phase 2 CORE 258 Eligibility and Benefit Normalizing Patient Last Name Rule

Phase 2 CORE 259 Eligibility and Benefit 270/271 AAA Error Code Reporting Rule

Phase 2 CORE 260 Eligibility and Benefit Data Content (270/271) Rule

Phase 2 CORE 270 Connectivity Rule

EFT and ERA Operating Rule Impacts

835 Infrastructure CARC/RARC combinations EFT ERA Reassociation Electronic Enrollments for EFT and

ERA

EFT and ERA Operating Rules Named (effective 1/1/2014)

Phase 3 CORE 360 Health Care Claim Payment/Advice (835) Infrastructure Rule

Phase 3 CORE 350 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule

Phase 3 CORE 360 CORE-required Code Combinations for CORE-defined Business Scenarios

Phase 3 CORE 370 EFT & ERA Reassociation (CCD+/835) Rule

Phase 3 CORE 380 EFT Enrollment Data Rule

Phase 3 CORE 382 ERA Enrollment Data Rule

CARC/RARC Operating Rules4 Business Scenarios Defined (Rule 360)

Specific combinations of CARC and RARC are allowed for each business scenario.Scenario #1: Additional Information Required - Missing/Invalid/Incomplete Documentation Scenario #2: Additional Information Required – Missing/Invalid/Incomplete Data from Submitted Claim Scenario #3: Billed Service Not Covered by Health

Plan Scenario #4: Benefit for Billed Service Not

Separately Payable

EFT ERA Reassociation (Rule 370)

Reassociation is the process of matching an Electronic Remittance Advice (ERA) in the ASC X12 835 format to the associated Electronic Funds Transfer (EFT).

EFT must match 835 transaction. Reconcile actual cash received to check amounts in

the 835 PRIOR to posting to patient accounting system.

Bank need to ensure the “7 record” is sent to provider (typically sent upon request only).

Example EFT: 705TRN*1*8834567890*1391268299~ Example 835: TRN*1*8834567890*1391268299~

Ensure Proper Completion of ERA Form (Rule 382):

DEG1 the address must match what is on file with Provider Enrollment.

DEG2 Medicare PTAN must be listed in other identifier. DEG2 Valid WPS submitter id/trading partner ID DEG3 Provider contact information must be someone from

the provider’s office (not a biller, billing service or clearinghouse).

DEG7 NPI is required DEG8 is required if using a clearinghouse. DEG10 Mark the submission information -

ex: New Enrollment, Change Enrollment, Cancel Enrollment.

ICD-10 Impact ICD-10 is the biggest change in

standard healthcare coding systems in decades.

ICD-10 will impact every system, process and transaction that contains or uses a diagnosis code.

ICD-10 ICD-10-CM will be used in all

healthcare settings. ICD-10-PCS will be used for facility

reporting of hospital inpatient services.

Are you prepared for ICD-10?

Start now Ask your vendor and/or clearinghouse about their plans and timeframes

implementing ICD-10 ICD-9 to ICD-10 analysis – identify:

New, deleted and modified content Impact to business needs

Training -Staff training 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. Identify contingencies It is your responsibility to be compliant. If you fail to prepare, it will be your business and cash flow that will be

affected!

Why ICD-10? Improve accuracy and efficiency of coding Reduce training effort Improve communication with physicians Completeness - All substantially different procedures have

a unique code Expandability - The structure of the system allows

incorporation of new procedures as unique codes Standardize terminology - Includes definitions of the

terminology used. While the meaning of specific words can vary in common usage,

ICD-10-PCS defines a single meaning for each term used in the system.

ICD-10 Timeframes NPRM

Published August 22, 2008 with comments by October 21, 2008

Final rule Published January 16, 2009

Compliance date OCTOBER 1, 2014 837I - ICD-10 on institutional claims with a discharge date, of

October 1, 2014 or later 837P - ICD-10 codes on professional claims with a date of service

October 1, 2014 or later

HR 4302 May not adopt prior to October 1, 2015

House Resolution (HR) 4302

SEC. 212. DELAY IN TRANSITION FROM ICD–9 TO ICD–10 CODE SETS.The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002 of title 45, Code of Federal Regulations.CMS is assessing the impact of HR 4302, and we’ll communicate more information as we receive it.

ICD-10 FAQs http://www.wpsmedicare.com/j5macparta/claims/icd-10/

index.shtml

http://www.wpsmedicare.com/j5macpartb/claims/icd-10/index.shtml

http://www.wpsmedicare.com/j8macparta/claims/icd-10/index.shtml

http://www.wpsmedicare.com/j8macpartb/claims/icd-10/index.shtml

Are you ready for ICD-10? ICD-10 codes are 3-7 characters long. Have you contacted your

vendor to ensure that your billing software will accommodate ICD-10 codes?

When will you be ready to send a ICD-10 test to your payer or clearinghouse?

Have your staff been trained on ICD-10? Do you know when your payer will be ready to test ICD-10? Do you know when your payer will be ready to receive production

ICD-10 claims?

CMS Announces Testing Days

CR8465 Allow trading partners access to MACs for

testing with real-time help desk support. Front End (999/277CA) testing only. Submit ICD-10 codes on claims. Register in advance via site or email. March 3-7, 2014 More expected…

Results Nat’l Test Days

Limited End-to-End Testing As a result of the industry interest

and demand… Medicare is able to provide some

limited end-to-end testing, which includes 835 generation. 

CR 8602

Volunteering for End-to-End

Limited # of testers (16 - J5 and 16 - J8 each).

Cross-section of large/small providers, geographic area, provider type, bill type…

WPS participating with other MACs to “share” national clearinghouses.

Contingency Plans Approved vendor, billing services, clearinghouse

and Network Service Vendor (NSV) lists: http://www.wpsic.com/edi/files/medicare_connection.pdf

PC-Ace Pro32 Clearinghouse options? What are your contractual arrangements with

vendor and/or clearinghouse? Paper claim submission is not a contingency

option Other?

PC-Ace Pro32 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. Import 277CA or 835 into readable reports. A common piece of providers’ contingency plans! Current version 2.52

New 1500 (02/12) Paper billing – NOT A CONTINGENCY! ASCA

Rules still apply. Does your billing software need updating in order to

accommodate the new form (02/12)? Do your printer settings need to be modified? Item - 14 multiple date field, requires date qualifier. Item – 21 ICD-9 or ICD-10 indicator, up to 12

diagnosis. Item 24E must use the appropriate alpha (A-L)

diagnosis code pointers.

Monitor Your Business!!! 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.

Help Us Help You… When you call, have information available which

will help us identify your file and research your issue:

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… EDIMedicareA@WPSIC.com, EDIMedicareB@WPSIC.com

WPS Connectivity Options

Dial Up Bulletin Board System (BBS). Network Service Vendor (NSV) into

Medicare EDI Gateway (MEG).

Go Green!!! 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. You can download MREP and PcPrint from:

http://www.wpsic.com/edi/tools.shtml

Medicare Remit Easy Print (MREP) and PcPrint Software

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!

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Future EDI ACTs 2014 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.

2014 calls (all times 1-2:30 pm cst):Date

June 12, 2014 (800) 305-2862 84826906 August 14, 2014 (800) 305-2862 84826989 October 9, 2014 (800) 305-2862 84826999 December 11, 2014 (800) 305-2862 84827004

Questions and Answers

We want to hear from you… If you have additional questions, you

can also send an email to: EDIMedicareA@WPSIC.com EDIMedicareB@WPSIC.com

Also visit our EDI site for additional information: http://www.wpsic.com/edi/

EDI Addresses & Numbers EDIMedicareA@WPSIC.com EDIMedicareB@WPSIC.com

MAC J5, J8 Part A & B(Iowa, Kansas, Missouri, Nebraska and J5 National) (Indiana,

Michigan)WPS Medicare EDI1717 West Broadway Madison, WI. 53713Fax: (608) 223-3824

New Single Point of Contact Numbers!!!J5 Single Point Of Contact (SPOC): (866) 518-3285 opt 1J8 Single Point Of Contact (SPOC): (866) 234-7331 opt 1

Important Dates

June 12, 2014 EDI ACT

Resources CMS 5010 and D.0 Webpage

http://www.cms.gov/version5010andD0 Educational Resources:

http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys

5010 Technical Review Type 3 guides: X12: www.X12.org Washington Publishing www.WPC-EDI.com

WPS Medicare EDI: www.wpsic.com/edi/med_index.shtml

NACHA: www.nacha.org, www.electronicpayments.org

CAQH CORE: www.caqh.org