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What’s New in 5010?
5010 HIPAA Implementation for
January 1, 2012
2
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
3
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
4
■ 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
5
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)
6
5010 Transactions and Software Modifications
General 837 Claim Changes
7
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.
8
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.
10
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.
12
837 Coordination of Benefits (COB)
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).
13
837I POSC Transactions
837I
Institutional ClaimsBilling and Service Tab -
Billing Information
14
837I POSC Transaction Screen
■ “Last Name” field increased from 35 to 60 characters.
■ “First Name” field increased from 25 to 35 characters.
15
60 Characters 35 Characters
837I POSC Transaction Screen
■ “Other Physician” field renamed “Other Operating Physician”
16
“Other Operating Physician” fields
837I POSC Transaction Screen
■ Patient allowed to assign/refuse benefits to Provider.
■ “Provider Accepts Assignment” dropdown list updated – “Not Applicable” option added.
17
New option added
837I POSC Transaction Screen
■ “Medicare Assignment “field renamed “Provider Accepts Assignment”.
■ “Provider Accepts Assignment” dropdown list updated.– “Patient Refuses to Assign Benefits” removed.
18
837I POSC Transaction Screen
837I
Institutional Claims
Billing and Service Tab –
Service Information
19
837I POSC Transaction Screen
■ “Covered Days” and “Non-Covered Days” fields removed as indicated by arrows pointing to previous location for each field.
20
Removed fields
837I POSC Transaction Screen
■ “Patient Status” entry required
21
Select thePatient Status
Patient Status box
837I POSC Transaction Screen
■ 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
22
Former Admit Source field
837I POSC Transaction Screen
■ “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”.
23
Former “Admission Type” field
837I POSC Transaction Screen
■ “Delay Reason Code” field added with a dropdown box. Supports electronic 90-day waiver and Final Deadline Appeal requests*.
24
Select theDelay Reason Code
New field added with dropdown box
* Please refer to All Provider Bulletins 220 and 221 for additional instructions
837I POSC Transaction Screen
837I
Institutional ClaimsExtended Services Tab
25
837I POSC Transaction Screen
■ List of diagnoses increased from 28 to 41.
26
837I POSC Transaction Screen
■ Principle Diagnosis must be entered for all 837I claims.
27
SelectCode
Enter Description
837I POSC Transaction Screen
■ Type field modified so you can select“PR – Visit” up to three times. All other options can only be selected once.
28
837I POSC Transaction Screen
■ “Present on Admission” field added.■ Dropdown list added on Diagnosis Code Detail
panel.– Valid values are N, U, W, Y or blank.
29
New field
837I POSC Transaction Screen
■ New field allows entry of the accident state.
30
New field
837I POSC Transaction Screen
■ 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.)
31
837I POSC Transaction Screen
837I
Institutional ClaimsProcedure Tab
32
837I POSC Transaction Screen
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
33
837I POSC Transaction Screen
837I
Institutional ClaimsAttachments Tab
34
837I POSC Transaction Screen
■ “Description” field removed from Attachments tab.■ Report Type – List of Values has been updated.
35
Top half of Report Type dropdown list
837I POSC Transaction Screen
■ Report Type – List of Values has been updated.
36
Bottom half of Report Type dropdown list
837I POSC Transaction Screen
837I
Institutional ClaimsCoordination of Benefits Tab
37
837I POSC Transaction Screen■ “Remittance Date” field renamed from “EOB
Date”.■ “Remaining Patient Liability” field added.■ Allowed Amount Field removed.
38
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).
39
COB added
Enter Amount at Claim (COB) or Line Level
Amount Aids inClaim Adjudication
837I POSC Transaction Screen
■ “Claim Filing Indicator” list updated.
40
Dropdown list updated
837I POSC Transaction Screen
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
41
837I POSC Transaction Screen
■ Subscriber Date of Birth and Gender Removed.■ “Group Name” renamed from “Plan Name”.
42
Former “Plan Name” field
837I POSC Transaction Screen
■ Inpatient Adjudication Information – Any COB payer’s remark codes can be entered here.
43
Former “Medicare Inpatient Adjudication Information” field
837I POSC Transaction Screen
■ Outpatient Adjudication Information – Any COB payer’s remark codes can be entered here.
■ “Lifetime Reserve Days” field removed.
44
Former “Medicare Outpatient Adjudication Information” field
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.
45
837I POSC Transaction Screen
■ Maximum Number of COB reason records increased from 10 to 30.
46
COB reason records increased
(DDE) POSC Transactions
837P
Professional Claims
Billing and Service Tab –
Billing Information
47
837P POSC Transaction Screen
■ “Last Name” field increased from 35 to 60 characters.
■ “First Name” field increased from 25 to 35 characters.
48
60 Characters 35 Characters
837P POSC Transaction Screen
■ “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.
49
837P POSC Transaction Screen
■ “Medicare Assignment” field renamed to “Provider Accepts Assignment”.
50
Former Medicare Assignment field
837P POSC Transaction Screen
■ Diagnosis Codes 9 -12 added.■ “Similar Illness Date” field removed.
51
Four fields added forDiagnosis
Codes 9-12
837P POSC Transaction Screen
■ AP - ANOT PYT RESP(another party responsible) removed from “Related Causes Type” dropdown list.
52
837P POSC Transactions
837P
Professional ClaimsExtended Services Tab
53
837P POSC Transaction Screen
■ New value added to Delay Reason Code list:
15 – Natural Disaster
54
New value added
837P POSC Transaction Screen
■ “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.
55
837P POSC Transaction Screen
■ The “PMT – Payment” field removed from the dropdown box in Claim Note Type.
56
837P POSC Transaction Screen
■ 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.
57
837P POSC Transaction Screen
■ “Transport Code” field removed.
58
837P POSC Transaction Screen
837P
Professional ClaimsProcedure Tab
59
837P POSC Transaction Screen
■ “Unlisted Procedure Description” fieldstores and displays information in a panel.
60
Can receive 80 charactersof free text from Providers.
Displays information for suspended claim review.
837P POSC Transaction Screen
■ Providers can enter Diagnosis Cross-Ref values with up to eight values per detail line (two values per box).
61
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.
837P POSC Transaction Screen
■ “Units” field increased to 11 numbers with 3 numbers allowed to the right of decimal point
62
Length of “Units” field increased.
837P POSC Transaction Screen
■ “Additional Units of Obstetric Anesthesia” added■ “Similar Illness Date” removed
63
.
Indicates need formore anesthesia for obstetric units
837P POSC Transaction Screen
■ F2 – International Unit (Dosage Amount) removed from Units of Measurement dropdown list.
64
837P POSC Transaction Screen
■ Emergency field has “blank” or “Yes” value only.– This field no longer required.– Defaults to blank value.
65
837P POSC Transaction Screen
■ Drug Identification Section added■ Rx date appears only in 837P – not 837I■ VY– Link Sequence Number added – when drug
has no prescription number
66
Only appears in 837P
New option added
837P POSC Transaction Screen
■ If you enter a value in one of these four fields – the other three must also contain a value.
67
837P POSC Transaction Screen
■ “Patient Count” field added■ “Transport Code” field removed from this section
68
Indicates number ofpatients transported
837P POSC Transaction Screen■ “ Ambulance Pickup Location” and “Drop-off
Location” data fields added
69
837P POSC Transaction Screen
■ 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.
70
Home Oxygen Therapy Section removed
837P POSC Transactions
837P
Professional Claims
Attachments Tab
71
837P POSC Transaction Screen
■ “Description” field removed from Attachments tab■ List of Values updated on Report Type (top half)
72
837P POSC Transaction Screen
■ List of Values updated on Report Type (bottom half)
73
837P POSC Transactions
837P
Professional ClaimsCoordination of Benefits (COB) Tab
74
837P POSC Transaction Screen
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
75
837P POSC Transaction Screen
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
76
837P POSC Transaction Screen
■ “Remittance Date” renamed from “EOB Date”
77
Renamed from “EOB Date” field
837P POSC Transaction Screen
■ “Remaining Patient Liability” field added
78
Renamed from “Allowed Amount” field
837P POSC Transaction Screen
79
■ “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
837P POSC Transaction Screen
■ User must enter an amount in either the “COB Payer Paid Amount” field or the “Total Non-Covered Amount” field (but not both).
80
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).
837P POSC Transaction Screen
■ Values updated on Claim Filing Indicator list
81
Valuesupdated
837P POSC Transaction Screen
■ Release of Information list now indicates only two values – I and Y.
■ Prior M, N and O values removed.
82
Indicates only two values – I & Y
837P POSC Transaction Screen
■ 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”
84
Renamed from “Plan Name” field
837P POSC Transaction Screen
■ Select the Insurance Type dropdown list if Medicare A or B is not the primary payer
85
837P POSC Transaction Screen
■ Outpatient Adjudication Information no longer restricted to Medicare. Any COB payer’s remarks can be submitted here.
86
“Medicare” removed from title
837P POSC Transaction Screen
837P
Professional ClaimsProcedure Tab - COB Line Details
87
837P POSC Transaction Screen
■ “Paid Units of Service” field increased to 11 numbers with 3 numbers allowed to the right of decimal point
88
Length offield increased
837P POSC Transaction Screen
■ “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.
89
835
Electronic
Remittance Advice
90
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.
91
New 999 Acknowledgement Transaction
999
File Acknowledgement
92
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
93
270/271 POSC Transactions
270/271
Eligibility Verification
Eligibility Transaction Search
94
270/271 POSC Transaction Screen
95
■ Last Name – This field increased from 35 to 60 characters.■ First Name – This field increased from 25 to 35 characters.
60 Characters 35 Characters
270/271 POSC Transaction Screen
96
■ 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
97
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.
98
276/277 POSC Transaction Screen
99
■ 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.
100
Displays EOB HC Claim Statuses
276/277 POSC Transaction Screen
101
■ Services Detail Screen displays a list of services rendered for each claim as indicated by the Service Code.
EVSpc Transactions
EVSpc Highlights
102
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.
103
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.
104
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
105
Member Information
106
107
Questions…
…Answers