MAC J5 and J8

EDI ACT(August 14, 2014)

Participant Line: (800) 305-2862Passcode: 84826989

Purpose of Power Point Current issues ICD-10 Update Reminder MSP Claims ERA Myth Busting Go Green Operation Rules Connectivity Misconceptions PC-Ace Monitor Your Business Upcoming EDI ACT 2014 Contacting EDI – Toll Free Numbers

Current Med A Issues –

PCPrint  Update: Current version 4.3.3 Version 4.3.1 and above, are not compatible with

Windows XP. Part A providers using Windows XP should continue to

use version 4.2.6 of PC Print until they are able to upgrade to a newer version of Windows.

The “Find” function in PCPrint is not working in version 4.3.1 and after. A fix for this is anticipated in October 2014.

Sporadic delays in sending responses (999, 277CA, 277 or 835s)

Current Med B Issues Foreign and military zip codes.

Foreign zips can be alpha-numeric zips and not currently loaded to CEM.  Military zips code set not currently loaded to CEM. CEM Edits Require:

2010BA.N403 must be a valid postal/zip Code when N404 equals US or blank. 2010BA.N404 must be a valid 2 character Country Code.  Valid alpha-2 Country Code reference must be available for this edit. (from

Part 1 of ISO 3166) Example:   N3*POSTFACH 88~

N4*MARLIX**7074*CH~

Sporadic delays in sending responses (999, 277CA, 277 or 835s)

MREP issues for Windows 7 or 8 users

ICD-10 Update 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. This past March, the Centers for Medicare & Medicaid Services

(CMS) conducted a successful ICD-10 testing week. This testing week allowed an opportunity for testers and CMS

alike to learn valuable lessons about ICD-10 claims processing.   CMS anticipates additional testing for trading partners.

ICD-10 Update SE1410 – alerts providers that on October 1, 2015, all

Medicare claims submissions of diagnosis codes will change from the International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM) to the 10th Edition (ICD-10-CM).

Factors affect how ICD-10-CM must be used: The claim “From” date (episode start date); The Outcome and Assessment Information Set (OASIS)

assessment completion date (OASIS item M0090 date); and The claim “Through” date.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1410.pdf

Reminder 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

ERA Myth Busting I was unaware of the ERA. Tell me more about EDI and ERA.

Goal – We want to educate on the benefits of ERA.

I'm not really sure. If it is something you need to sign up for we may not have been informed.

Fact – ERA is optional, at this time, but provides several benefits to your business.

Because paper is more reliable than electronic remittance. It also allows me to track internal errors. I am able to follow our patients better who have cross over claims, as our cross over claims do not always get processed by the state and this way we assure that happens on a weekly basis. I am in need of the paper EOB when I post the primary EOB to send to the other plan and I make those copies at the time of primary posting .

Fact – Paper and ERA contain the same information. Per HIPAA, the data content of paper cannot be greater then that of the electronic transaction (xref 162.925).

Cost of vendor retrieval of ERAs. I do not know how to receive ERA. Fact – You can download directly from WPS or through a clearinghouse (clearinghouse

charges apply). You can also use free products such as PCPrint or MREP for your ERA. Fact – Products like PCPrint and MREP as well as vendor product, have many useful reports.

ERA Myth Busting It is difficult enough with depositing directly to the account. I get an email

stating a deposit has been made to our account then, I have to hunt and review all of my Medicare clients to see where the money should go.

Fact – Operating Rules (370) reassociation requires the EIN and Check # be on both ERA and EFT.

ERA did not come faster, harder to read without printing and did not import into PCAce the reimbursements, so not streamlining or improving efficiency of office staff.

Fact – ERA is avaliable next business day after a claim finalizes. Fact – PCPrint and MREP provide many beneficial reports, some of which are formatted the

same as the paper remit.

We use PC-Ace to submit our electronic claims. Using ERA with that system has never been explained to us.

Fact – EDI Helpdesk staff are available to help.

Not sure, do not know how to set up. Fact – PCPrint and MREP user guides provide clear, concise intructions.

Facts. You too can Go Green!!!

Go Green!!! Even if you don’t post electronically you can take

advantage of 835. ERA has same content as SPR. Over 78% of all remittances are sent electronically in

5010-835 format. Download directly from WPS. Operating Rule 370 ensures EFT and ERA reassociation. 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!

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 must be listed in Assigning Authority 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.

Connectivity Misconceptions

WPS took over some years ago and submitting electronic claims went from pulling them up through the internet back to a bulletin board system (BBS). I asked WPS why they did this and they claimed it couldn't change until CMS OK'd it.

Fact - CMS Internet policy (ref IOM Chapter 24 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c24.pdf) prohibits the transmission of protected health data between providers and other parties who are not Medicare contractors over the Internet unless it is authenticated and encrypted…Unless otherwise approved, A/B MACs, DME MACs and CEDI are only permitted to accept EDI transactions via the Internet when explicitly directed by CMS.

We still have to transfer electronic claims through a dial up connection. Every other electronic submission I use is through the internet. I asked WPS about it and they said dial up is safe.

Fact: Dial up technology is proven secure. WPS also offers secure FTP (sFTP) via Networl Service Vendor (NSV) in addition to BBS.

WPS Connectivity Options Dial Up Bulletin Board System (BBS). Network Service Vendor (NSV) into Medicare EDI

Gateway (MEG) http://www.wpsic.com/edi/files/medicare_connection.pdf.

Ability Network ClaimShuttle Cortex EDI, Inc ECC Technologies' RAPID Network Episode Alert LLC eSolutions, Inc. McKesson Carebridge MedXpress Nebo Systems, Inc. Optimum Management

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 2.54

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… Before you call, have information available which

will help us authenticate you 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

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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

October 9, 2014 (800) 305-2862 84826999 December 11, 2014 (800) 305-2862 84827004 More in 2015!!!

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

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