Testing the 837

1

• Lesson 3
• Testing the 837

2
Lesson 3 Topics

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set Up Location file
• Set Up Insurer file
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

3
Section 3 Testing the 837

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set Up Location file
• Set Up Insurer file
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

4
What Is Provider Taxonomy Code?

• Each provider must have specific code assigned to
  him/her in RPMS
• Code must be entered into RPMS
• OR entire 837 transaction will be rejected by
  insurer
• Codes are called Provider Taxonomy Codes
• Each code is unique alphanumeric identifier, ten
  characters in length
• Example 207PE0004X Adult Day Care

5
Find the Right Code
6
Taxonomy Code Updates

• Published twice a year
• July 1st (becomes effective October 1st)
• January 1st ( becomes effective April 1st)
• OIT provides updates to be installed into RPMS
  under AUT namespace
• This means that Taxonomy updates are maintained
  separately

7
Taxonomy Code List Structure

• Provider Taxonomy code list indicates specialty
  categories for
• Individuals
• Groups of individuals
• Non-individuals

• Provider Taxonomy is divided into 2 different
  groups
• Individual or group codes
• Classifies type of provider or group
• Non-Individual taxonomies
• Classifies healthcare facilities, agencies,
  nursing units, and suppliers and various vendors

8
Taxonomy Code List Structure (contd)

• Each of 2 groups on code list is structured into
  3 distinct "Levels"
• Level I, Provider Type (major grouping of
  service(s) or occupation(s))
• Level II, Classification (more specific service
  or occupation related to the Provider Type)
• Level III, Area of Specialization (more
  specialized area of the Classification in which a
  provider chooses to practice or make services
  available)
• See example of levels on next screen

9
Example of Levels
10
Tip

• Providers may have more than one Taxonomy code
  associated to them
• When determining what code or codes to associate
  with a provider, review the requirements of the
  trading partner with which the code(s) are being
  used

11
Input the Code

• Codes must be added manually using
• VA Fileman
• User Management options in Kernel Menu
• For help or access, see site manager or system
  manager
• Codes located in PRV segment, piece4
• One-time procedure

12
Input Individual or Group Codes General

• Enter codes in VA Fileman/New Person file
• Set up codes for all billable providers,
  including secondary providers (e.g., RNs,
  Pharmacists) that facilities may have on a claim
• Start by inputting most common providers

13
Input Individual or Group Codes - General (contd)

• Enter Level II description
• For example
• If provider is an Emergency Room Physician, enter
  Emergency into RPMS and system will display the
  following

  Physicians (M.D. and D.O.)
Physician/Osteopath Emergency
Medicine
14
Input Individual or Group Codes - General (contd)

• System is case-sensitive when entering Provider
  Taxonomy
• Provider name is correctly entered with lowercase
  letters
• For more specific categories, such as SPORTS
  MEDICINE, enter Sports
• System will attempt to locate all Sports Medicine
  providers

15
Input Individual or Group Codes - General (contd)

• For specific steps to add Provider Taxonomy, go
  to
• Manually Adding Provider Taxonomy
• http//www.ihs.gov/AdminMngrResources/HIPAA/docume
  nts/HIPAA_Adding_Taxonomy_Codes.pdf
• Quick Reference Guide to 837 and 835 Transactions
  and Code Sets

16
Input Non-Individual Taxonomies - General

• Enter information in VA Fileman/ Location file
• Will need to enter
• Location name
• Classification of facility
• Set up codes for all billing locations

17
Input Non-Individual Taxonomies General (contd)

• To determine facility classification, may choose
  to use RPMS Provider Taxonomy Crosswalk
  http//www.ihs.gov/AdminMngrResources/HIPAA/docume
  nts/TAXONOMY_crosswalk_document.xls
• For standard I/T/U Location Taxonomy codes,
  scroll down to Non-Individual (Facility) Taxonomy
  Code section

18
Input Non-Individual Taxonomies General (contd)

• For specific steps to add Provider Taxonomy, go
  to
• Manually Adding Provider Taxonomy
• http//www.ihs.gov/AdminMngrResources/HIPAA/docume
  nts/HIPAA_Adding_Taxonomy_Codes.pdf
• Quick Reference Guide to 837 and 835 Transactions
  and Code Sets

19
Important Points About Taxonomy Codes

• Crosswalk
• Crosswalk was built into RPMS 3rd Party Billing
  to alleviate sites from having to populate
  numerous locations
• See Provider/Location Taxonomy AUT Patch v98.1,
  Patch 13
•  Billing and Claims Editor
• Provider and location taxonomy codes may be used
  right after entered
• User will not see codes in claim editor
• Access Provider Inquiry (PRTM) option in Table
  Maintenance to view codes

20
Section 3 Testing the 837

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set Up Location file
• Set Up Insurer file
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

21
Set Up Location File

• Location files must be set up on a one-time basis
• Step must be completed for each location that is
  to be billed required for 837
• Step provides physical street address to your
  claims  
• If facility is already testing 837 format with
  other Insurers, this step may already be complete

22
Set Up Location File (contd)

• For specific steps to set up location file, go to
  one of the following
• Quick Reference Guide to 837 and 835 Transactions
  and Code Sets
• Trailblazers Medicare Part A Testing and
  Production Procedures
• Trailblazers Medicare Part B Testing and
  Production Procedures

23
Section 3 Testing the 837

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set Up Location file
• Set Up Insurer file
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

24
Set Up Insurer Files

• Set up each insurer in Insurer file
• Enter trading partners name
• Enter trading partners Associate Operator (AO)
  control number
• This is insurers electronic identification
• All sites use the same number for an insurer
• Enter Electronic Media Claims (EMC) submitter
  identification
• This is login number and password assigned by a
  particular insurer to a particular facility
• Found in the Companion Guide or provided by
  insurer
• Facility cannot test electronic claims submission
  process without EMC number

25
Set Up Insurer Files (contd)

• For specific steps to set up Insurer file, go to
  one of the following
• Quick Reference Guide to 837 and 835 Transactions
  and Code Sets
• Trailblazers Medicare Part A, Testing and
  Production Procedures
• Trailblazers Medicare Part B, Testing and
  Production Procedures

26
Section 3 Testing the 837

• Set Up RPMS
• Set Up Location file
• Set Up Insurer file
• Input Provider Taxonomy Codes
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

27
Populating RPMS for Error-Free Claims

• Enter data correctly or claim will be rejected
• If data element is mandatory, it must have data
  in it
• Data elements must be entered exactly as
  prescribed
• No special characters or punctuation allowed
• Data elements for a patient must be entered the
  same way at every location

28
Examples

• Ft. Defiance
• Entered as Ft Defiance or Fort Defiance
• P.O. Box
• Entered as PO Box
• 5-21-05
• Entered as 05212005
• 610-555-0123
• Entered as 6105550123

29
Common Data Problems

• See Common Errors That Cause an 837 Claim to Be
  Rejected in Quick Reference Guide to 837 and 835
  Transactions and Code Sets

30
Section 3 Testing the 837

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set Up Location file
• Set Up Insurer file
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

31
Two Levels of Testing

• Level 1 HIPAA Compliance Testing
• Level 2 Insurer Testing

Important Even if you pass Level 1 testing and
file is accepted initially, you could still fail
Level 2 testing with insurer. You MUST pass both
levels of testing.
32
Level 1 HIPAA Compliance Testing 6 Types

• Integrity Testing
• Validates basic syntactical integrity of EDI file
• Implementation Guide Requirements Testing
• Involves requirements imposed by HIPAA
  Implementation Guide, including validation of
  data element values specified in Guide

33
Level 1 HIPAA Compliance Testing 6 Types
(contd)

• Balancing Testing
• Verification that summary-level data is
  numerically consistent with corresponding detail
  level data, as defined in HIPAA Implementation
  Guide
• Inter-Segment Situation Testing
• Validates inter-segment situations specified in
  HIPAA Implementation Guide (e.g., for accident
  claims, an Accident Date must be present)

34
Level 1 HIPAA Compliance Testing 6 Types
(contd)

• External Code Set Testing
• Validates code set values for HIPAA mandated
  codes defined and maintained outside HIPAA
  Implementation Guides
• Examples
• Local Procedure Codes for which states were given
  waivers
• NDC Drug Codes
• Claim Adjustment Reason Codes
• Claim Status Codes
• Claims Status Category Codes
• Remittance Remarks Advice Codes
• Last four codes/updates published by Washington
  Publishing Company OIT updates them

35
Level 1 HIPAA Compliance Testing 6 Types
(contd)

• Product Type or Line of Service Testing
• Validates specific requirements defined in HIPAA
  Implementation Guide for specialized services
  such as durable medical equipment (DME)

36
Level 2 Insurer Testing

• Trading partner-specific testing
• Involves testing coding and transaction
  requirements that are required by insurer but
  that are not specifically determined by HIPAA
• These requirements will be found in insurers
  Companion Guide

37
Ready to Begin Level 2 Testing?

• Required software installed. (See Lesson 2)
• Trading Partner Agreement and EDI forms in place.
  (See Lesson 2)
• RPMS set-up complete and correct. (See this
  lesson)
• Have tested for HIPAA compliance. (See this
  lesson)
• Have complied with insurers requirements in
  Companion Guide. (See this lesson)

38
What Does It Mean For You?

• Financial Management OfficerAh, we thought we
  were done! . . . The ultimate benefit is a
  cleaner process that puts money back into the
  facility.

39
Testing Process 1

• Choose bills for initial test batch
• Bills should include variety of visit types that
  you already bill to insurer
• E.g., Institutional, Professional, Dental
• If appropriate, include variety of locations
• See Companion Guide for how many bills to include
  in test batch
• At least 3 of each type
• See Companion Guide for file naming conventions
  max 16 characters

40
Testing Process 2

• Check each bill carefully to make sure that it is
  correctly populated
• Mandatory fields are filled in
• Data entered adheres to 837 conventions

41
Testing Process 3

• Set EMC Test Indicator to identify file as test
  file
• In 3P, go to Add/Edit Insurer (EDIN)
• Select INSURER Indicate insurer you are testing
• EMC TEST INDICATOR change value to T

42
Testing Process 4

• On each claim, change mode of export
• Go to Claim Editor.
• EDTDgtEDCL.
• Desired ACTION enter E (Edit).
• Desired FIELDS Enter 7.
• Mode of Export Enter ??.
• Select appropriate form 837 UB or 837 1500

43
Testing Process 5

• Submit different batches for each 837 format
• Once claims (3 or more) of one 837 format are
  approved, export batch in usual process via RPMS
  Pub Directory

44
Testing Process 6

• Once you submit batch via FTP or your usual
  process
• E-mail insurer that file has been submitted
• Request verification from insurer that file was
  received
• Consult local or Area IT if you have problems
• Wait for response or error report from insurer
• If no word within 24 hours, call insurer contact
  to find out status of file

45
Testing Process 7

• If you receive error report, make fixes locally
• Either by Business Office or Patient
  Registration, depending on error
• If you cant figure out how to fix error, consult
  with local or Area IT contact
• Once fixes made, resubmit claims to insurer
• Repeat process until claims pass with no errors

46
Testing Process 8

• After initial claims go through with no errors,
  prepare a larger batch (_at_ 25 claims) of each 837
  format
• Test these claims following steps in Testing
  Process 2 - 7
•  NOTE See Lesson 4 for how to read error
  reports and make corrections

47
Testing Realities

• Testing process may be lengthy
• Testing time varies by
• Time you put into it
• Insurer
• Process used
• Number of claims that have to be tested
• If clearinghouse involved, another level of
  preparation and testing is required
• May also be more labor intensive

48
Testing Realities (contd)

• If claims have errors, they will not be paid
  until they are corrected
• If testing involves several locations and/or
  insurers, there are more possibilities for errors
• Monitor each batch submitted and provide timely
  corrections

49
Testing Tips

• Evaluate staffing before you begin testing
• Demands on staff time will increase
• Anticipate this and assign adequate resources
• For example
• Cleaning up patient database may require a
  massive effort
• You now have a double workload in Billing Office
• Maintaining regular claims process so payments
  continue
• Creating and submitting test files

50
More Testing Tips

• Be as prepared as you can but dont delay testing
  
• The sooner you jump in, the sooner you will be
  through it

• Keep everyone informed of progress being made in
  testing process through e-mail group
• Insurer contacts
• OIT contacts
• Area contacts
• Service Unit contacts

51
What Does It Mean For You?

• Assistant Site ManagerTheres no reason why
  anyone shouldnt start.

52
More Testing Tips

• Keep in frequent communication with insurer
  contacts
• Insurer may be willing to provide training on
  what plan covers and what needs to be included on
  837

53
More Testing Tips

• Document the process
• Teaching tool for you and others
• Will also show patterns that need to be addressed
• If you need help
• Turn first to own IT person
• If cant figure it out locally, follow local
  procedures to get assistance

54
More Testing Tips

• Submit batches frequently to keep them small
• You will have to correct errors and small batches
  are more manageable

55
Section 3 Testing the 837

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set Up Location file
• Set Up Insurer file
• Populating RPMS for Error-Free Claims
• Test Mode
• Production Mode

56
Production Mode

• Once all test claims are accepted as error free,
  insurer will place facility in production status
• NOTE You may have to request to go into
  production
• At this point, you will need to
• Change T to P in Insurer file for each
  insurer at time granted approval for production
  (see next slide for steps)
• Change mode of export on a permanent basis (see
  following slide for steps)

57
Edit Insurer File

• Set EMC Test Indicator to identify file as test
  file
• Set EMC Test Indicator to identify file as test
  file
• In 3P, go to Add/Edit Insurer (EDIN)
• Select INSURER Indicate insurer you are testing
• EMC TEST INDICATOR change value to P

58
Change Export Mode

• For Visit Type, change each mode of export to
  default 837 HIPAA format
• In Table Maintenance/Insurer file
• TMTPgtINTM
• Scroll down to Select VISIT TYPE Enter
  appropriate selection
• Mode of Export Enter ??.
• Select appropriate form
• Must be done for each insurer

59
Trailblazers Testing and Production

• Trailblazers Medicare Part A 837 Testing and
  Production Procedures
• http//www.ihs.gov/AdminMngrResources/HIPAA/docu
  ments/HIPAA_837_TB_PartA.pdf
• Trailblazers Medicare Part B 837 Testing and
  Production Procedures
• http//www.ihs.gov/AdminMngrResources/HIPAA/docu
  ments/HIPAA_837_TB_PartB.pdf

60
What Does It Mean For You?

• Site ManagerOnce you set up one major payer,
  it moves very quickly.
• Compliance/Privacy OfficerAnything electronic
  is just more efficient. Thats just good
  management.

61
Lessons Learned

• Set Up RPMS
• Input Provider Taxonomy Codes
• Set up Location file
• Set up Insurer file
• Make sure that data elements are entered
  correctly
• Implement two levels of testing using steps
  described
• Make RPMS changes prior to beginning production