What's New in 5010 - Version III

What’s New in 5010?

5010 HIPAA Implementation for

January 1, 2012

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Agenda

I. New Federal Standards for Electronic Health Care Transactions

II. 5010 Testing Readiness

III. MassHealth 5010 Web Site

IV. 5010 Transactions and Software Modifications

V. 837I Institutional Claims

VI. 837P Professional Claims

VII. New 999 Acknowledgement Transaction

VIII. 270/271 Eligibility Verification

IX. 276/277 Claim Status

X. EVSpc Highlights

New Federal Standards for ElectronicHealth Care Transactions

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The Centers for Medicare & Medicaid Services (CMS) have introduced new standards for electronic health care transactions as of January 1, 2012.

All electronic health care transactions must change from version 4010/4010A to version 5010 on January 1, 2012.

MassHealth will no longer process any 4010 claims after this date.

Providers must submit all claims in 5010 electronic format.

5010 Testing Readiness

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■ On November, 17, 2011 the Centers for Medicare & Medicaid Services’ Office of E-Health Standards and Services (OESS) Announced a 90-Day Period of Enforcement Discretion for Compliance with New HIPAA Transaction Standards.

■ MassHealth has relaxed testing requirements to allow trading partners to send in a file thru December 16, 2011.

■ MassHealth will continue to work towards a January 1, 2012 implementation date in order to comply with the federal mandate.

■ Providers can use DDE if they are not ready to test for 5010 after 1/01/12.

MassHealth 5010 Web Site

■ If you are submitting paper claims after 1/1/2012:– Use the CMS-1500 claim form when submitting

Professional paper claims to MassHealth. Refer to the MassHealth CMS-1500 Billing Guide for applicable 5010 instructions.

– Use the UB-04 claim form when submitting Institutional paper claims to MassHealth. Refer to the MassHealth UB-04 Billing Guide for applicable 5010 instructions.

■ Revised MassHealth billing and companion guides for HIPAA – Version 5010 appear on the MassHealth 5010 website:

http://www.mass.gov/eohhs/gov/newsroom/masshealth/providers/mmis-posc/hipaa-version-5010.html

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5010 Transactions and Software Modifications

POSC – Provider Online Service CenterGeneral 837 Changes

837P – Professional Claims837I – Institutional Claims837 – COB (Coordination of Benefits)

270/271 – Eligibility Verification 276/277 – Claim Status999 – New transaction replaces 997

EVSpc – Eligibility Verification System Software

(270/271 & 276/277)

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5010 Transactions and Software Modifications

General 837 Claim Changes

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837 HIPAA Electronic Claim Transaction A nine-digit zip code must be submitted. No PO Box address should be sent on a claim – street

addresses only. Electronic billers may place P.O. box information in the

pay-to address loop. Paper providers must provide a DBA address.

You can now submit up to 12 diagnosis codes per claim, with a maximum of four per service line.

When applicable, claims must include additional drug information and qualifiers, such as NDC code, quantity, composite unit of measure and prescription date and number.

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837 HIPAA Electronic Claim Transaction Providers must report their NPI* on all claim submissions. New pick-up and drop-off codes must be submitted when

billing for ambulance or non-emergency transportation services.

F5 qualifier (Patient Paid Amount) deleted – Providers must use the F3 qualifier (Patient Estimated Amount Due).

Acute inpatient hospitals must provide a POA (Present on Admission) indicator for the Principal, Other, and External Cause of Injury segments.

Taxonomy code qualifier change (ZZ to PXC). The patient reason for visit must appear on all out-patient

claims to comply with the HIPAA Implementation Guide.

* Except providers who are exempt from the NPI requirement (i.e. Atypical Providers)9

837 HIPAA Electronic Claim Transaction When applicable, all ingredients for a compound drug

prescription must be identified on the claim, and have the same prescription number or the same linkage number, if provided without a prescription.

Anesthesia services billed with procedure codes must indicate a specific time period defined in the code description. Otherwise, these services must be reported in minutes.

Anesthesia services reported in units will no longer be accepted.

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837 HIPAA Electronic Claim Transaction All MassHealth providers must enter an ICD-9 diagnosis

code on all claim submissions. All paper claims must also contain diagnosis information.

If prior authorization (PA) is required* for a service on a claim: - Enter the PA at the header level for the entire claim. - Enter the PA at the service line when it differs from the

one entered at the header level. If a referral is required* for a service on a claim:

- Enter the referral at the header level for the entire claim.

- Enter the referral at the service line when it differs from the one entered at the header level.

* Please note that if a PA or referral is on file in POSC, providers can also submit claims without these numbers and the system will match the claim 11

837 Coordination of Benefits (COB)

Payer paid amount must balance at both the service line and the claim level. The provider billed amount on the service line should balance to the sum of the service line payer paid amount and service line adjustment reason code amounts.

The “total non-covered amount” must be submitted in lieu of providing the prior payer amount, and any adjustment segments previously submitted in exception billing.

Check remittance date cannot be submitted at both the claim and service line level. For community health, you must put the date at the service line level.

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Use any of the following electronic options to submit COB claims to MassHealth:

Batch 837P or 837I submission

Coordination of Benefits (COB) / Direct Data Entry (DDE) through the Provider Online Service Center (POSC).

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837I POSC Transactions

837I

Institutional ClaimsBilling and Service Tab -

Billing Information

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837I POSC Transaction Screen

■ “Last Name” field increased from 35 to 60 characters.

■ “First Name” field increased from 25 to 35 characters.

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60 Characters 35 Characters


■ “Other Physician” field renamed “Other Operating Physician”

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“Other Operating Physician” fields


■ Patient allowed to assign/refuse benefits to Provider.

■ “Provider Accepts Assignment” dropdown list updated – “Not Applicable” option added.

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New option added


■ “Medicare Assignment “field renamed “Provider Accepts Assignment”.

■ “Provider Accepts Assignment” dropdown list updated.– “Patient Refuses to Assign Benefits” removed.

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837I

Institutional Claims

Billing and Service Tab –

Service Information

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■ “Covered Days” and “Non-Covered Days” fields removed as indicated by arrows pointing to previous location for each field.

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Removed fields


■ “Patient Status” entry required

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Select thePatient Status

Patient Status box


■ Admit Source – renamed to “Admission or Visit Type” – required for all inpatient and outpatient services. I – Inpatient Hospital L – Long Term Care O – Outpatient H – Home Health

Claims

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Former Admit Source field


■ “Admission Type” renamed to “Admission or Visit Type”. This field requires entry.

■ “Patient Paid” field removed. Please use Value Code FC on the Extended Services Tab.

■ On the Extended Series tab, select the Value Code “FC – Patient Paid Amount – UB 04 Only”.

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Former “Admission Type” field


■ “Delay Reason Code” field added with a dropdown box. Supports electronic 90-day waiver and Final Deadline Appeal requests*.

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Select theDelay Reason Code

New field added with dropdown box

* Please refer to All Provider Bulletins 220 and 221 for additional instructions


837I

Institutional ClaimsExtended Services Tab

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■ List of diagnoses increased from 28 to 41.

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■ Principle Diagnosis must be entered for all 837I claims.

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SelectCode

Enter Description


■ Type field modified so you can select“PR – Visit” up to three times. All other options can only be selected once.

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■ “Present on Admission” field added.■ Dropdown list added on Diagnosis Code Detail

panel.– Valid values are N, U, W, Y or blank.

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New field


■ New field allows entry of the accident state.

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New field


■ Home Health Care Information – entire panel section containing the following removed:– Prognosis Indicator, Certification Type, Surgical

Procedure Type, Patient Location Code, Medicare Coverage Ind and Skilled Nursing Facility Ind.

– Most services require PA and/or documentation to be kept by the provider. Some fields removed were duplicative of our regulations in subchapter 4 of the HHA manual (treatment plans, etc., that have to be kept &/or submitted with a PA request, etc.)

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837I

Institutional ClaimsProcedure Tab

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Drug Identification section with five new fields.NDC Units – changed from 8 to 11 with three numbers after

the decimal point allowed.Units of Measurement (F - International Unit removed.) Rx Qualifier Rx Number

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837I

Institutional ClaimsAttachments Tab

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■ “Description” field removed from Attachments tab.■ Report Type – List of Values has been updated.

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Top half of Report Type dropdown list


■ Report Type – List of Values has been updated.

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Bottom half of Report Type dropdown list


837I

Institutional ClaimsCoordination of Benefits Tab

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837I POSC Transaction Screen■ “Remittance Date” field renamed from “EOB

Date”.■ “Remaining Patient Liability” field added.■ Allowed Amount Field removed.

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Former “EOB Date” field

837I POSC Transaction Screen■ Total “Non-Covered Amount” field added.■ “Payer Paid Amt” renamed to “COB Payer Paid

Amount”.■ User must enter an amount in either the “COB

Payer Paid Amount” field or the “Total Non-Covered Amount” field (but not both).

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COB added

Enter Amount at Claim (COB) or Line Level

Amount Aids inClaim Adjudication


■ “Claim Filing Indicator” list updated.

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Dropdown list updated


Claim Filing Indicator dropdown list updated. Codes Deleted:

09 - Self-pay 10 - Central Certification LI - Liability

Codes Added: 17 - Dental Maintenance Organization FI - Federal Employees Program

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■ Subscriber Date of Birth and Gender Removed.■ “Group Name” renamed from “Plan Name”.

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Former “Plan Name” field


■ Inpatient Adjudication Information – Any COB payer’s remark codes can be entered here.

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Former “Medicare Inpatient Adjudication Information” field


■ Outpatient Adjudication Information – Any COB payer’s remark codes can be entered here.

■ “Lifetime Reserve Days” field removed.

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Former “Medicare Outpatient Adjudication Information” field


Payer paid amount must balance at both the service line and the claim level. The provider billed amount on the service line should balance to the sum of the service line payer paid amount and service line adjustment reason code amounts.

The “total non-covered amount” must be submitted in lieu of providing the prior payer amount, and any adjustment segments previously submitted in exception billing.

Check remittance date cannot be submitted at both the claim and service line level. For community health, you must put the date at the service line level.

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■ Maximum Number of COB reason records increased from 10 to 30.

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COB reason records increased

(DDE) POSC Transactions

837P

Professional Claims

Billing and Service Tab –

Billing Information

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837P POSC Transaction Screen

■ “Last Name” field increased from 35 to 60 characters.

■ “First Name” field increased from 25 to 35 characters.

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■ “Patient Refuses to Assigns Benefits” removed from the “Provider Accepts Assignment” dropdown box.

■ “Not Applicable” option allows the patient to refuse to assign benefits to the provider.

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■ “Medicare Assignment” field renamed to “Provider Accepts Assignment”.

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Former Medicare Assignment field


■ Diagnosis Codes 9 -12 added.■ “Similar Illness Date” field removed.

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Four fields added forDiagnosis

Codes 9-12


■ AP - ANOT PYT RESP(another party responsible) removed from “Related Causes Type” dropdown list.

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837P POSC Transactions

837P

Professional ClaimsExtended Services Tab

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■ New value added to Delay Reason Code list:

15 – Natural Disaster

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New value added


■ “Type” field removed.

Former Service Facility types used: • 77 – Service Location• FA – Facility• LI – Independent Lab• Tl – Testing Laboratory

■ MMIS will default to 77 – Service Location in all instances.

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■ The “PMT – Payment” field removed from the dropdown box in Claim Note Type.

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■ Entire “Home Health Care Plan” section removed

■ Fields formerly in this section:– Discipline Type Code– Total Visits Rendered– Certification Period Projected Visit Count

■ Data covered in other sections of POSC.

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■ “Transport Code” field removed.

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837P

Professional ClaimsProcedure Tab

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■ “Unlisted Procedure Description” fieldstores and displays information in a panel.

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Can receive 80 charactersof free text from Providers.

Displays information for suspended claim review.


■ Providers can enter Diagnosis Cross-Ref values with up to eight values per detail line (two values per box).

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Can enter either singleor double-digit Diagnosis Code in each box. (System adds preceding zero for single-digit codes in each box.)

Codes entered in boxes 1 & 4 will concatenate.


■ “Units” field increased to 11 numbers with 3 numbers allowed to the right of decimal point

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Length of “Units” field increased.


■ “Additional Units of Obstetric Anesthesia” added■ “Similar Illness Date” removed

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Indicates need formore anesthesia for obstetric units


■ F2 – International Unit (Dosage Amount) removed from Units of Measurement dropdown list.

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■ Emergency field has “blank” or “Yes” value only.– This field no longer required.– Defaults to blank value.

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■ Drug Identification Section added■ Rx date appears only in 837P – not 837I■ VY– Link Sequence Number added – when drug

has no prescription number

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Only appears in 837P

New option added


■ If you enter a value in one of these four fields – the other three must also contain a value.

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■ “Patient Count” field added■ “Transport Code” field removed from this section

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Indicates number ofpatients transported

837P POSC Transaction Screen■ “ Ambulance Pickup Location” and “Drop-off

Location” data fields added

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■ Home Oxygen Therapy Information section and the following fields removed: Certification Type Code, Aerial Blood Gas, Oxygen Test Condition, Treatment Period Count, Oxygen Saturation, Oxygen Test Findings Code 1-3.

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Home Oxygen Therapy Section removed


837P

Professional Claims

Attachments Tab

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■ “Description” field removed from Attachments tab■ List of Values updated on Report Type (top half)

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■ List of Values updated on Report Type (bottom half)

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837P

Professional ClaimsCoordination of Benefits (COB) Tab

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The Coordination of Benefits (COB) tab no longer displays the following fields:

– Allowed Amount - calculated using payer paid amount and coinsurance/deductible amt (based on adjustment reason codes). • Allowed amount is being calculated by

MMIS. Please refer to the HIPAA Implementation Guide for allowed amt calculation

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Discontinued fields continued:– Patient Responsibility Amount - This was a

duplicate field. Patient responsibility was reported in the adjustment reason panel with reason code (for example: 1 for deductible; 2 for coinsurance etc.)

– Subscriber Date of Birth removed– Subscriber Gender removed– Approved Amount removed– Discount Amount removed

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■ “Remittance Date” renamed from “EOB Date”

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Renamed from “EOB Date” field


■ “Remaining Patient Liability” field added

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Renamed from “Allowed Amount” field


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■ “Total Non-Covered Amount” field added:– When payer’s cost avoidance policy allows

providers to bypass claim submission to the prior payer.

Amount Aids inClaim Adjudication


■ User must enter an amount in either the “COB Payer Paid Amount” field or the “Total Non-Covered Amount” field (but not both).

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Enter amount in this fieldor in other indicated “Amount” field (but not both).

Enter amount in this fieldor in other indicated“Amount” Field (but not both).


■ Values updated on Claim Filing Indicator list

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Valuesupdated


■ Release of Information list now indicates only two values – I and Y.

■ Prior M, N and O values removed.

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Indicates only two values – I & Y


■ Patient Signature Source Code List defaults to blank.

■ Displays only one option for provider-generated signature for absent patient.

83Defaults to blank

837P POSC Transaction Screen■ “Group Name” field renamed from “Plan Name”

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Renamed from “Plan Name” field


■ Select the Insurance Type dropdown list if Medicare A or B is not the primary payer

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■ Outpatient Adjudication Information no longer restricted to Medicare. Any COB payer’s remarks can be submitted here.

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“Medicare” removed from title


837P

Professional ClaimsProcedure Tab - COB Line Details

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■ “Paid Units of Service” field increased to 11 numbers with 3 numbers allowed to the right of decimal point

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Length offield increased


■ “Approved Amount” field removed.– Approved amount is the same as the allowed amount,

with the difference being that the approved amount was being reported at the line level and the allowed amount was reported at the header level. This field is calculated by MMIS.

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835

Electronic

Remittance Advice

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835 Transactions

835 Transactions

■ During testing, MassHealth will generate 835s for all testing phases.

■ Claims that are reversed or voided will appear on the 835 with a claim adjustment group code of OA.

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New 999 Acknowledgement Transaction

999

File Acknowledgement

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New 999 Acknowledgement Transaction

MassHealth will no longer support the 997 Acknowledgement as of January 1, 2012

Receipt of a 999 acknowledgement file indicates receipt and status of each segment of 5010 transaction testing

The 997 Acknowledgement has been eliminated

A 999 implementation acknowledgement is generated for all batch files that do not fail and includes interchange (ISA) errors

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270/271 POSC Transactions

270/271

Eligibility Verification

Eligibility Transaction Search

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270/271 POSC Transaction Screen

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■ Last Name – This field increased from 35 to 60 characters.■ First Name – This field increased from 25 to 35 characters.



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■ Phone Number (day, night, cell) fields remain, but will appear blank. These values were removed per guidance from HIPAA 5010 regulations.

276/277 POSC Transactions

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276/277Claim Status

Inquire Claim Status

276/277 POSC Transaction

■ Last Name or Organization Name – This field increased from 35 to 60 characters.

■ First Name – This field increased from 25 to 35 characters.

■ Phone Number (day, night, cell) Fields remain but will appear blank.

■ HC Claim Status field displays EOB Code, Claim Status Category Code, Claim Status Code and Entity Code.

■ Currently these fields will only show the original number of characters indicated in 4010, if you are looking at a claim submitted under 4010.

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■ HC Claim Status field displays all EOB HC claim statuses for all corresponding multiple EOBs.

EOB Code – details explanation of benefits. Claim Status Category Code – indicates the

payer’s current system status of the claim. Claim Status Code – provides more

specific information about the claim or line item.

Entity Code – identifies an organizational entity, a physical location, property, or an individual.

276/277 POSC Transaction Screen■ HC Claim Status field displays all EOB HC claim

statuses and the respective HC status code and description.

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Displays EOB HC Claim Statuses


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■ Services Detail Screen displays a list of services rendered for each claim as indicated by the Service Code.

EVSpc Transactions

EVSpc Highlights

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Eligibility Verification System (EVSpc) Changes

EVSpc software is now modified to include HIPAA 5010 requirements. EVSpc is only supported on Windows XP & Windows Vista.

MassHealth does not recommend using Windows 7 to install EVSpc 5.0 software.

If any issues arise using Windows 7, MassHealth will not be able to provide support.

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EVSpc Transactions

All inquiries occur in Real Time. Can submit eligibility in either batch mode or as a single

inquiry. EVSpc 5.0 enables providers to verify MassHealth

member eligibility, claim status, primary care clinician (PCC), managed care, long-term care and third-party liability.

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Eligibility Verification System (EVSpc) Changes

Number of characters have increased for the following fields: First Name – 25 to 35 characters Last Name – 35 to 60 characters

Name Normalization – These changes are effective January 1, 2012 in HIPAA 5010

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Member Information

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Questions…

…Answers

Documents

What's New in 5010 - Version III