Transactions, Code Sets and Identifiers (NPI)

Update

Jim Whicker, CPAMIntermountain Healthcare Director of EDI, A/R Management

Chair, WEDI

AAHAM EDI Liaison

                                 

The Privacy Symposium

The Sixteenth National HIPAA Summit

Cambridge, MA

NPI – Our Experiences Claims processing ok

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!

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since been rescinded without alternative Provider NPPES and IRS name mismatch Requirement to Update 855 documents with CMS and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.

"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

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

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

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)

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

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

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

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

834 - Enrollment/Disenrollment820 – 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

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.

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.

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

270/271 – Eligibility (cont’d)

Clear requirements for reporting patient responsibility with a monetary amount or percentage

Added 38 new service type codes

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

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

Thank You!