5010 Claims Filing. Aida Anderson HealthSystems Chandra Ross GE Healthcare

Transcription

1 5010 Claims Filing Aida Anderson HealthSystems Chandra Ross GE Healthcare

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3 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

4 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,

5 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.

6 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)

7 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

8 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)

9 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

10 Administration Module Changes Responsible Provider Referring Provider Company Facility Insurance Carrier List Editor

11 Administration Module Responsible Provider - Information Tab Field Lengths extended to support new 5010 guidelines An address Subdivision field has been added to the Responsible Provider and will accept a 3 characters

12 Administration Module Referring Provider - Information Tab Field Lengths extended to support new 5010 guidelines Referring Provider address subdivision has been added to the product and will accept 3 characters

13 Administration Module Company - Information Tab Used to report the 2010AB Pay-To Address when different than the A company Specialty field has been added Billing Provider address to the Information tab to support Taxonomy A Company address subdivision field has been added to the product and will accept 3 characters

14 Administration Module Facility - Information Tab Field Lengths extended to support new 5010 guidelines A Subdivision field for the Facility address was created and will accept 3 characters

15 Administration Module Insurance Carrier - Information Tab Field Lengths extended to support new 5010 guidelines A Subdivision field for the Insurance carriers address has been added to the Information tab and will accept 3 characters

16 Administration Module List Editor Code Lists New 5010 Qualifiers added to all applicable Code Lists

17 Registration Module Changes Patient Case Management

18 Registration Module - Patient Field Lengths increased to support 5010 guidelines Subdivision: New field that supports 3 characters for non-us Addresses

19 Registration Module Case Mgt Field Lengths increased to support 5010 guidelines Subdivision: New field that supports 3 characters for non-us Addresses

20 Registration Module Case Mgt Separate Fields for storing Authorization and Referral Number

21 Registration Module Case Mgt Ability to set the Present on Admission Indicator on a case basis

22 Registration Module Case Mgt Five Additional Condition Codes added for Case Mgt

23 Billing Module Changes Visit Info Visit Filing 1 Visit Filing 2 Visit Filing 3 Visit Filing 4 Visit Ambulance Visit Charge Entry

24 Billing Module Visit Info Separate Fields for storing Authorization and Referral Number

25 Billing Module Visit Filing 1

26 Billing Module Visit Filing 1 Generates the LQ segment when populated By 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.

27 Billing Module Visit Filing 2 Five Additional Condition Codes have been added Used for Institutional and Professional 5010 Claims Filing

28 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

29 Billing Module Visit Filing 4 Property/Casualty Date of First Contact: Field added to support new DTP segment All Ambulancerelated fields have been migrated to the new Ambulance Tab.

30 Billing Module Visit Ambulance New Pick-up and Drop-off Fields added to support Ambulance Billing for 5010 Migrated from Filing 4 Tab

31 Billing Module Visit Ambulance Ability to set User Preferences for the tab display

32 Billing Module Visit Charge 1 Separate Fields for storing Authorization and Referral Number

33 Billing Module Visit Charge 2 Ability to assign a Provider at the procedure level

34 Billing Module Visit Anesthesia OB Anesthesia Additional Units: New field to accommodate 5010 Requirements

35 Billing Module Visit Anesthesia When Anesthesia is not checked in the Procedure setup, all Anesthesia fields are grayed out.

36 Billing Module Visit Test/Drug/Vision Four additional Test Results fields added Four additional Replacement Reason Vision fields added Link Sequence Number: New Field to support 5010 guidelines Prescription Date: New Field to support 5010 guidelines

37 Billing Module Visit Other Specialty Ambulance Patient Count: New Field to support 5010 guidelines

38 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.

39 Billing Module Charge Entry New field to support 837 Institutional reporting of Present on Admission

40 Transaction Module Transaction Distribution

41 Transaction Module Trans. Dist. Remaining Patient Liability: Replaces Patient Responsibility Non-Covered Amount: Replaces COB Total Non- Covered

42 Transaction Module Trans. Dist. Medicare Remark Codes: Additional fields added and grouped together; Field length increased to 50 characters

43 EDI Plug-in Changes Overall Changes File Creators File Processor Behind-the-scenes Changes

44 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

45 EDI Plug-in Changes User is able to select the either the 4010 or 5010 File Creator based upon the Insurance Carrier

46 EDI Plug-in Changes Professional File Creator 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

47 EDI Plug-in Changes Institutional File Creator 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 Loop 2010 Settings Removed: Send Insured ID in 2010BA NM1 Send Qualifier 23 in 2010BA REF Send Provider Telephone in 2010AA PER Loop All 2300 the Settings Insurance Removed: Carrier Send settings Payer Estimated have been Amount moved Due in 2300 to one AMTscreen, instead of Do having Not Send multiple Patient tabs Paid for Amount in 2300 the AMT user to select

48 EDI Plug-in Changes Eligibility File Creator Eligibility Status Criteria has been removed; additionally, the schedule follows specific rules for creating a 5010 transaction

49 EDI Plug-in Changes Eligibility File Creator Loop 2100B NM109 Settings Removed: Send Additional ID2 w/qualifier SV Send PIN with Qualifier SV Send EMC with Qualifier SV

50 EDI Plug-in Changes Eligibility File Creator Qualifiers have been updated to reflect the 5010 transaction standards

51 EDI Plug-in Changes Eligibility File Creator Additional Service Type Codes have been added to both the Insurance Carrier dialog and the Clearinghouse dialog for Service Type Codes

52 EDI Plug-in Changes Remittance File Processor Non-Payment Codes have been moved to a button display rather than a full tab; the screen look is the same

53 EDI Plug-in Changes Eligibility File Processor Service Type Codes have been updated for processing as well

54 EDI Plug-in Changes Behind-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~

55 EDI Plug-in Changes Behind-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* ~ REF*LU*4H23T7~

56 EDI Plug-in Changes Behind-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

57 EDI Plug-in Changes Behind-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* *EX*123~ Patient Information PER*IC*SUBSCRIBERLAST, SUBFIRST*TE* ~.Facility Information PER*IC*FACILITY MULTISPECIALTY GROUP*TE* ~

58 EDI Plug-in Changes Behind-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* *211***12:B:1*Y*A*Y*Y~ CLM* *211***12:B:1*Y*C*W*Y~

59 New EDI Reports All existing clearinghouse reports will continue to be supported for Two new reports will be added: Implementation Acknowledgement for Health Care Insurance 277-CA Health Care Claim Acknowledgement

60 New EDI Reports 999 Acknowledgement Similar to current 997 Functional Acknowledgement Will update the Visit Status Will process report details into the Claims tab of the Visit

61 New EDI Reports 277-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

62 CPS 10 Non-5010 EDI Changes In addition to the 5010 changes made in CPS 10, there were also EDI content changes made to improve product functionality.

63 CPS 10 Non-5010 EDI Changes 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.

64 CPS 10 Non-5010 EDI Changes 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.

65 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.

66 CPS 10 Non-5010 EDI Changes 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.

67 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.

68 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.

69 CPS 10 Non-5010 EDI Changes 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.

70 CPS 10 Non-5010 EDI Changes 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.

71 CPS 10 Non-5010 EDI Changes 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.

72 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.

73 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.

74 CPS 10 Non-5010 EDI Changes 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.

75 CPS 10 Non-5010 EDI Changes 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.

76 Thank you for joining us today! Are there any questions?