Transactions, Code Sets and Identifiers NPI Update

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Transactions, Code Sets and Identifiers (NPI)
Update
The Privacy Symposium The Sixteenth National
HIPAA Summit Cambridge, MA

• Jim Whicker, CPAM
• Intermountain Healthcare
• Director of EDI, A/R Management
• Chair, WEDI
• AAHAM EDI Liaison

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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
• 835s 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!

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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  but has since been rescinded without alternative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.

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"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
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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

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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

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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)

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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
• TRs (Implementation Guides) Free for 4010,
  Must be purchased for 5010

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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

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837 Health Care Claims (contd)

• 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

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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

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834 - Enrollment/Disenrollment 820 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

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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.

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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.

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270/271 Eligibility (contd)

• Nine categories that must be reported
• Medical Care
• Chiropractic Care
• Dental Care
• Hospital
• Emergency Services
• Pharmacy
• Professional Visit Office
• Vision
• Mental Health
• Urgent Care

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270/271 Eligibility (contd)

• Clear requirements for reporting patient
  responsibility with a monetary amount or
  percentage
• Added 38 new service type codes

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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 gt 1 for
  more detailed status information
• Added more examples to clarify instructions

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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

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Thank You!