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©2011 General Electric Company – All rights reserved.
This does not constitute a representation or warranty or documentation regarding the product or service featured. All illustrations are provided as fictional examples only. Your product features and configuration may be different than those shown. Information contained herein is proprietary to GE. No part of this publication may be reproduced for any purpose without written permission of GE.
DESCRIPTIONS OF FUTURE FUNCTIONALITY REFLECT CURRENT PRODUCT DIRECTION, ARE FOR INFORMATIONAL PURPOSES ONLY AND DO NOT CONSTITUTE A COMMITMENT TO PROVIDE SPECIFIC FUNCTIONALITY. TIMING AND AVAILABILITY REMAIN AT GE’S DISCRETION AND ARE SUBJECT TO CHANGE AND APPLICABLE REGULATORY CLEARANCE.
* GE, the GE Monogram, Centricity and imagination at work are trademarks of General Electric Company.
General Electric Company, by and through its GE Healthcare division.
Today’s discussion
• Introduction to 5010
• Key Changes from 4010 to 5010
• Changes to CPS Application
• EDI Plug-in Changes
• New 5010 EDI Reports
• CPS 10 Non-5010 Changes Related to EDI
• Questions
Introduction to 5010
The Version 5010 final rule (CMS-0009-F) at 45 CFR Part 162, adopts new versions of the ASC X12 for HIPAA transactions.
This rule will replace the current 4010/4010A transaction formats.
The compliance date for this rule is January 1, 2012.
http://edocket.access.gpo.gov/2009/pdf/E9-740.pdf
Introduction to 5010
The updated ASC X12 Version 5010 of the HIPAA transaction standards represent substantial technical and operational improvements that respond to industry business needs and requests.
The 5010 Modifications are significant, encompassing more than 850 changes.
Key Changes from 4010 to 5010
• Full support of ICD-10 – Federal Deadline is October 1, 2013
• Full support for reporting National Provider Identifier (NPI)
• Unused content from 4010A1 has been removed
• More specific requirements as to what is and isn’t allowed
• Implementation Guides (IG) are now called
Technical Review Type 3 (TR3)
Key Changes from 4010 to 5010
• PO Boxes are prohibited for the Billing Provider (2010AA)
• Pay-To Address Required when different that the Billing
Provider Address (2010AB)
• Nine-digit Zip required for Billing and Service Provider
• Taxonomy Codes can be reported in any combination
• Tax ID and SSN can only be sent in the Billing Provider loop
• Subdivision field has been added to all Address fields – it is
required for all addresses outside of the USA
Key Changes from 4010 to 5010
• Field Lengths have increased for the majority of existing 4010
fields
• Up to 12 Diagnosis Codes are allowed on a claim
• Date of Service Range only required when an actual range of
dates are reported
• Implementation of ‘Accept Assignment’ (2300 CLM07) changed
to allow use by all payers
• Modifications to the AMT segments for reporting Coordination
of Benefits (COB)
Key Changes from 4010 to 5010
• Anesthesia time must now be reported in Minutes, rather than Units.
• Contact Information and Date is now required for Property & Casualty
claims
• Ambulance Pick-Up and Drop-Off Location loops added
• When POS is equal to Home (12), the facility address is now required
• ‘Present on Admission’ indicator added for reporting on Institutional
claims
• ‘Outpatient Visit’ segment added on Institutional claims
Administration Module Changes
Responsible Provider
Referring Provider
Company
Facility
Insurance Carrier
List Editor
Responsible Provider - Information Tab
An address Subdivision field has been added to the Responsible Provider and will accept a 3 characters
Field Lengths extended to support new 5010 guidelines
Administration Module
Not for Patient Use - Product Under Development
Referring Provider address subdivision has been added to the product and will accept 3 characters
Field Lengths extended to support new 5010 guidelines
Administration ModuleReferring Provider - Information Tab
Not for Patient Use - Product Under Development
A Company address subdivision field has been added to the product and will accept 3 characters
A company Specialty field has been added to the Information tab to support Taxonomy
Used to report the 2010AB Pay-To Address when different than the Billing Provider address
Administration Module Company - Information Tab
Not for Patient Use - Product Under Development
A Subdivision field for the Facility address was created and will accept 3 characters
Field Lengths extended to support new 5010 guidelines
Administration ModuleFacility - Information Tab
Not for Patient Use - Product Under Development
A Subdivision field for the Insurance carriers address has been added to the Information tab and will accept 3 characters
Field Lengths extended to support new 5010 guidelines
Administration ModuleInsurance Carrier - Information Tab
Not for Patient Use - Product Under Development
Administration ModuleList Editor – Code Lists
New 5010 Qualifiers added to all applicable Code Lists
Not for Patient Use - Product Under Development
Registration Module - Patient
Subdivision:
New field that supports 3
characters for non-US
Addresses
Field Lengths
increased to
support 5010
guidelines
Not for Patient Use - Product Under Development
Registration Module – Case Mgt
Subdivision:
New field that
supports 3 characters
for non-US Addresses
Field Lengths
increased to
support 5010
guidelines
Not for Patient Use - Product Under Development
Registration Module – Case Mgt
Separate Fields for
storing Authorization
and Referral Number
Not for Patient Use - Product Under Development
Registration Module – Case Mgt
Ability to set the
‘Present on Admission’
Indicator on a case
basis
Not for Patient Use - Product Under Development
Registration Module – Case Mgt
Five Additional Condition Codes added for Case Mgt
Not for Patient Use - Product Under Development
Billing Module Changes
Visit Info
Visit Filing 1
Visit Filing 2
Visit Filing 3
Visit Filing 4
Visit Ambulance
Visit Charge Entry
Billing Module – Visit Info
Separate Fields for storing Authorization and Referral Number
Not for Patient Use - Product Under Development
Billing Module – Visit Filing 1
Generates the LQ
segment when populatedBy populating the Question #
with one or more Responses,
the FRM is generated in the
837P. Up to 17 FRM segments
can be created, based on the
Form in use.When the Certificate of
Medical Necessity is
populated, the 2440 LQ
& FRM segments
generate with the first
procedure on the visit.
Not for Patient Use - Product Under Development
Billing Module – Visit Filing 2
Five Additional Condition
Codes have been added –
Used for Institutional
and Professional 5010
Claims Filing
Not for Patient Use - Product Under Development
Billing Module – Visit Filing 3
Outpatient Visit:Check Box added –When selected, 2300 HI “Reason for Patient Visit” is generated with the primary Dx Code
Not for Patient Use - Product Under Development
Billing Module – Visit Filing 4
All Ambulance-related fields have been migrated to the new Ambulance Tab.
Property/Casualty Date of First Contact:Field added to support new DTP segment
Not for Patient Use - Product Under Development
Billing Module – Visit Ambulance
Migrated from
Filing 4 Tab
New Pick-up and Drop-off
Fields added to support
Ambulance Billing for
5010
Not for Patient Use - Product Under Development
Billing Module – Visit Ambulance
Ability to set User
Preferences for the
tab display
Not for Patient Use - Product Under Development
Billing Module – Visit Charge 1
Separate Fields for
storing Authorization
and Referral Number
Not for Patient Use - Product Under Development
Billing Module – Visit Charge 2
Ability to assign a
Provider at the
procedure level
Not for Patient Use - Product Under Development
Billing Module – Visit Anesthesia
OB Anesthesia
Additional Units: New
field to accommodate
5010 Requirements
Not for Patient Use - Product Under Development
Billing Module – Visit Anesthesia
When Anesthesia
is not checked in
the Procedure
setup, all
Anesthesia fields
are grayed out.
Not for Patient Use - Product Under Development
Billing Module – Visit Test/Drug/Vision
Link Sequence Number:New Field to support 5010 guidelinesPrescription Date:
New Field to support 5010 guidelines
Four additional Replacement Reason Vision fields added
Four additional Test Results fields added
Not for Patient Use - Product Under Development
Billing Module – Visit Other Specialty
Ambulance Patient
Count:
New Field to support
5010 guidelines
Not for Patient Use - Product Under Development
Billing Module – Visit Charge Entry
Charge Entry Columns: All new fields added to Charge Entry have been included as column selections. They default to a Hidden Column.
Not for Patient Use - Product Under Development
Billing Module –Charge Entry
New field to support
837 Institutional
reporting of ‘Present
on Admission’
Not for Patient Use - Product Under Development
Transaction Module – Trans. Dist.
Remaining Patient Liability: Replaces Patient Responsibility
Non-Covered Amount: Replaces COB Total Non-Covered
Not for Patient Use - Product Under Development
Transaction Module – Trans. Dist.
Medicare Remark Codes: Additional fields added and grouped together; Field length increased to 50 characters
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Coding changed from Visual Basic to C#
Transmission Mode is still based in Visual Basic
Qualifiers updated for all plug-ins
4010 Builds will be included with 5010 Builds
No changes to the Clearinghouse level settings
EDI Plug-in Changes
User is able to select the either
the 4010 or 5010 File Creator
based upon the Insurance
Carrier
Not for Patient Use - Product Under Development
EDI Plug-in Changes
All the Insurance Carrier settings have been moved to one screen, instead of having multiple tabs for the user to select
Two settings removed from the Clearinghouse section:•Use Envoy Intermediary•Requires PIN
Professional File Creator
Not for Patient Use - Product Under Development
EDI Plug-in Changes
All the Insurance Carrier settings have been moved to one screen, instead of having multiple tabs for the user to select
Loop 2010 Settings Removed:•Send Insured ID in 2010BA NM1•Send Qualifier “23”in 2010BA REF•Send Provider Telephone in 2010AA PER
Loop 2300 Settings Removed:•Send Payer Estimated Amount Due in 2300 AMT•Do Not Send Patient Paid Amount in 2300 AMT
Other Settings Removed:•Paper EOB is Not Requested•Send Submitter Address in 1000A N3 & N4•Send Attending Physician Address 2310 N3, N4•Send Line Item Control in 2400•Suppress All Legacy Ids in REF Segments•Send Qualifier “SY” in Loop 2330A REF
Institutional File Creator
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Eligibility Status Criteria has been removed; additionally, the schedule follows specific rules for creating a 5010 transaction
Eligibility File Creator
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Loop 2100B NM109 Settings Removed:•Send Additional ID2 w/Qualifier “SV”•Send PIN with Qualifier “SV”•Send EMC with Qualifier “SV”
Eligibility File Creator
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Qualifiers have been updated to reflect the 5010 transaction standards
Eligibility File Creator
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Additional Service Type Codes have been added to both the Insurance Carrier dialog and the Clearinghouse dialog for Service Type Codes
Eligibility File Creator
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Non-Payment Codes have been moved to a button display rather than a full tab; the screen look is the same
Remittance File Processor
Not for Patient Use - Product Under Development
EDI Plug-in Changes
Service Type Codes have been updated for processing as well
Eligibility File Processor
Not for Patient Use - Product Under Development
EDI Plug-in ChangesBehind-the-scenes Changes
When all 12 diagnosis codes are input on the visit, they will
pull to the electronic file with the proper qualifiers.
HI*BK:600*BF:2501*BF:2503*BF:2504*BF:2505*BF:2506*BF:2
507*BF:2508*BF:2509*BF:25091*BF:25092*BF:25093~
Not for Patient Use - Product Under Development
EDI Plug-in ChangesBehind-the-scenes Changes
For all Provider fields, only valid 5010 Qualifiers will be
pulled to the electronic file during the batching process
NM1*85*1*DOCTORLAST*DRFIRST*R**MD~
N3*3790 W. MAIN ST~
N4*CITYNAME*TX*75024~
REF*SY*123456~
REF*1G*4444~
REF*0B*B29453~
REF*G2*4187111475~
REF*LU*4H23T7~
EDI Plug-in ChangesBehind-the-scenes Changes
When the Place of Service is 12 on the visit, the Patient’s
Address pulls to Loop 2310C to report the facility
information
NM1*77*2*HOME~
N3*2505 PLUMDALE DRIVE~
N4*CARROLLTON*IL*60206~
The Facility Name is based upon the Facility selected on the visit
Not for Patient Use - Product Under Development
EDI Plug-in ChangesBehind-the-scenes Changes
When the Insurance Carrier is setup to send Property &
Casualty claims and a Property & Casualty number is listed
on the claim, the PER segment is created automatically in
all required loops
…Subscriber Information
PER*IC**TE*9725551234*EX*123~
…Patient Information
PER*IC*SUBSCRIBERLAST, SUBFIRST*TE*9725551234~
….Facility Information
PER*IC*FACILITY MULTISPECIALTY GROUP*TE*8185551234~
EDI Plug-in ChangesBehind-the-scenes Changes
To support the changes for CLM07, the plug-ins are now
designed to pull for the element all insurance carriers. In
addition, there is logic to support the new qualifiers
accepted for 5010 in CLM07 (Assignment Participation) and
CLM08 (Benefit Assignment Indicator).
CLM*000409-01*211***12:B:1*Y*A*Y*Y~
CLM*000409-01*211***12:B:1*Y*C*W*Y~
Not for Patient Use - Product Under Development
New EDI ReportsAll existing clearinghouse reports will continue to
be supported for 5010.
Two new reports will be added:
999 - Implementation Acknowledgement for Health
Care Insurance
277-CA – Health Care Claim Acknowledgement
New EDI Reports999 Acknowledgement
• Similar to current 997 Functional Acknowledgement
• Will update the Visit Status
• Will process report details into the Claims tab of the Visit
Not for Patient Use - Product Under Development
New EDI Reports277-CA Claim Acknowledgement
• Similar to the current Unsolicited 277
• Will update the Visit Status
• Will process report details into the Claims tab of the Visit
• Will generate a human-readable report in EDI Response Management
Not for Patient Use - Product Under Development
CPS 10 Non-5010 EDI ChangesIn addition to the 5010 changes made in CPS 10,
there were also EDI content changes made to
improve product functionality.
Request: Check for all edits before reporting a batching edit. Currently,
during the batching process, it fails on the first edit, and has to be batched
again to check for further edits.
Resolution: During the Batching Process, all the process will cycle through
the whole visit and report all batching edits at one time and log in the Notes
tab.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: Remittance processor does not post the whole
payment when some of the procedures in the remit file do not
match the visit.
Resolution: Each procedure is checked individually and if one
procedure fails, the remaining procedures continue to post.
The procedure that fails is documented in the Remit_ report.
CPS 10 Non-5010 EDI Changes
Request: Remit_ Report is capturing to much erroneous
information
Resolution: Remit_ report has been revamped to remove
extraneous information.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: Remittance processing continues to post when code is set to
Reject and/or Ignore
Resolution: New functionality implemented when Reject and/or Ignore are
used:
When a remit is posted with Non-Payment Code configured with Action
Ignore and Reject Visit, the procedure amount will remain as Insurance
Balance and no Residual column is created.
When a remit is posted with Non-Payment Code configured with Action
None and Reject Visit, the procedure amount will remain as Insurance
Balance and the Residual column is created.
CPS 10 Non-5010 EDI Changes
Request: Setting to include fees with 0 dollar procedures
prevents zero dollar claim creation
Resolution: Zero Fee claims can now be created when the
setting is checked to include zero dollar claims. The BHT06
segment will create with a qualifier of CH.
CPS 10 Non-5010 EDI Changes
Request: Actual Allowed amounts from the transaction
distribution of the payer should be pulled into Loop 2400 CN102
Resolution: Enhancement to existing functionality to support
Medicare. When a secondary claim is batched with the
Contract Type selected, the CN102 pulls from Actual Allowed in
Transaction Distribution, rather than the Allowed.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: Remove Purchased Service Facility ID edit from the plug-ins
Resolution: Batching edit has been removed, but if the field is populated
and is using a valid qualifier, the REF segment containing the Facility ID is
output.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: Attachment Control # on the Visit needs to be able to
accommodate 80 alpha-numeric characters for TX Medicaid
COB Requirements
Resolution: Attachment Control # has been updated to
support up to 80 numbers, letters, or special characters.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: MIBCBS - Need to look at the potential of processing
the U277 Reports
Resolution: The MIBCBS plug-in has been coded to process the
277 electronic file format. This report is not currently received
by MIBCBS, but will need to be activated for all users once CPS
is in general release. The 277 is the electronic version of the
human readable U277 that customers currently receive.
The reports processor determines whether the file is 4010 or
5010 and processes appropriately, so users can receive either
4010 or 5010 compliant 277 files from the payer without an
issue processing against the visit.
CPS 10 Non-5010 EDI Changes
Request: Appointment Date criteria is pulling patients that are already
checked
Resolution: The whole functionality of Verifying Eligibility from Schedule is
changed in the new design.
- If the Eligibility status is Pending/Not Verified, the 270 file is always
created for a Patient appointment from the schedule.
- If the Eligibility Status is Active/Inactive and Ins Carrier settings "Inquiry
per Patient", the 270 file is created once for a Patient appointment
- If the Eligibility Status is Active/Inactive and Ins Carrier settings "Inquiry
per Patient per Doctor", then 270 file is created once for a Patient
appointment for each different Provider's Schedule.
CPS 10 Non-5010 EDI Changes
Request: Date of Service on Details screen does not update to current date
Resolution: Added a button that updates the DOS to today’s date and sends
the date electronically in the file when selected.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: Must select an All row in the Response Processors for
the Service Type Code Scrubber to work properly for Eligibility
Resolution: Service Type Code Scrubber now works when a
specific company is selected in the Insurance Carrier setup.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development
Request: Availity Eligibility does not allow new payer IDs to be used for
eligibility requests, only the four original payers for THIN will allow a request
to generate
Resolution: The 270 transaction will now create regardless of the payer ID
entered into the Insurance Carrier setup.
CPS 10 Non-5010 EDI Changes
Not for Patient Use - Product Under Development