MAC J5 and J8

1

• MAC J5 and J8
• EDI ACT
• (June 12, 2014)
• Participant Line [phone]
• Passcode 84826906

2
Purpose of Power Point

• Current issues
• Operating Rules
• HIPAA Security and Windows XP
• ICD-10 Update
• Monitor Your Business
• Go Green
• Upcoming EDI ACT 2014
• Contacting EDI Toll Free Numbers

3
Current Med A Issues

• PCPrint  - PC Print version 4.3.1 and above, are
  not compatible with Windows XP. Part A providers
  using Windows XP should continue to use version
  4.2.6 of PC Print until they are able to upgrade
  to a newer version of Windows
• 999 and 277CA not received

4
Current Med B Issues

• Canadian and military zip codes.
• Sporadic delays in sending responses (999, 277CAs
  or 835s)
• MREP issues for Windows 7 or 8 users

5
MSP Claims - 5010

• MSP claims are not an ASCA (Administrative
  Simplification Compliance Act) exception and must
  be sent electronically.
• Avoid front end rejections, delays and
  Unprocessable rejections
• When determining the beneficiarys insurance
  coverage, it is important to determine the
  correct insurance type code.
• Always give the MSP insurance type code.
• Other Insured's Adjustment Quantity 2430/CAS
  must not be equal to zero.
• Primary paid amount should not exceed the billed
  amount.
• Primary paid amounts at the claim level should
  agree with the amounts submitted at the line
  level.
• Instructions http//www.wpsic.com/edi/files/msp5
  010A1.pdf

6
Operating Rules

• Affordable Care Act (ACA) defines operating rules
  as the necessary business rules and guidelines
  for the electronic exchange of information that
  are not defined by a standard or its
  implementation specifications.
• Operating rules address gaps in standards, help
  refine the infrastructure that supports
  electronic data exchange and recognize
  interdependencies among transactions.
• Goal Create as much uniformity in the
  implementation of electronic standard as
  possible.

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Operating Rule Named for Eligibility and Claim
Status (effective 1/1/2013)
Phase 1 CORE 152 Eligibility and Benefit Real Time Companion Guide
Phase 1 CORE 153 Eligibility and Benefit Connectivity Rule
Phase 1 CORE 154 Eligibility and Benefit 270/271 Data Content Rule
Phase 1 CORE 155 Eligibility and Benefit Batch Response Time Rule
Phase 1 CORE 156 Eligibility and Benefit Real Time Response Time Rule
Phase 1 CORE 157 Eligibility and Benefit System Availability Rule
Phase 2 CORE 250 Claim Status Rule
Phase 2 CORE 258 Eligibility and Benefit Normalizing Patient Last Name Rule
Phase 2 CORE 259 Eligibility and Benefit 270/271 AAA Error Code Reporting Rule
Phase 2 CORE 260 Eligibility and Benefit Data Content (270/271) Rule
Phase 2 CORE 270 Connectivity Rule
8
EFT and ERA Operating Rule Impacts

• 835 Infrastructure
• CARC/RARC combinations
• EFT ERA Reassociation
• Electronic Enrollments for EFT and ERA

9
EFT and ERA Operating Rules Named (effective
1/1/2014)
Phase 3 CORE 360 Health Care Claim Payment/Advice (835) Infrastructure Rule
Phase 3 CORE 350 Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule
Phase 3 CORE 360 CORE-required Code Combinations for CORE-defined Business Scenarios
Phase 3 CORE 370 EFT ERA Reassociation (CCD/835) Rule
Phase 3 CORE 380 EFT Enrollment Data Rule
Phase 3 CORE 382 ERA Enrollment Data Rule
10
CARC/RARC Operating Rules4 Business
Scenarios Defined (Rule 360)

• Specific combinations of CARC and RARC are
  allowed for each business scenario.
• Scenario 1 Additional Information Required -
  Missing/Invalid/Incomplete Documentation
• Scenario 2 Additional Information Required
  Missing/Invalid/Incomplete Data from Submitted
  Claim
• Scenario 3 Billed Service Not Covered by Health
  Plan
• Scenario 4 Benefit for Billed Service Not
  Separately Payable

11
EFT ERA Reassociation (Rule 370)

• Reassociation is the process of matching an
  Electronic Remittance Advice (ERA) in the ASC X12
  835 format to the associated Electronic Funds
  Transfer (EFT).
• EFT must match 835 transaction.
• Reconcile actual cash received to check amounts
  in the 835 PRIOR to posting to patient accounting
  system.
• Bank need to ensure the 7 record is sent to
  provider (typically sent upon request only).
• Example EFT 705TRN188345678901391268299
• Example 835 TRN188345678901391268299

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Ensure Proper Completion of ERA Form (Rule 382)

• DEG1 the address must match what is on file with
  Provider Enrollment.
• DEG2 Medicare must be listed in Assigning
  Authority
• DEG2 Medicare PTAN must be listed in other
  identifier
• DEG2 Valid WPS submitter id/trading partner ID
• DEG3 Provider contact information must be someone
  from the providers office (not a biller, billing
  service or clearinghouse).
• DEG7 NPI is required
• DEG8 is required if using a clearinghouse.
• DEG10 Mark the submission information -
• ex New Enrollment, Change Enrollment, Cancel
  Enrollment.

13
ICD-10 Update

• ICD-10 is the biggest change in standard
  healthcare coding systems in decades.
• ICD-10 will impact every system, process and
  transaction that contains or uses a diagnosis
  code.
• This past March, the Centers for Medicare
  Medicaid Services (CMS) conducted a successful
  ICD-10 testing week.
• This testing week allowed an opportunity for
  testers and CMS alike to learn valuable lessons
  about ICD-10 claims processing.  
• HHS expects to release an interim final rule in
  the near future that will include a new
  compliance date that would require the use of
  ICD-10 beginning October 1, 2015. The rule will
  also require HIPAA covered entities to continue
  to use ICD-9-CM through September 30, 2015

14
Contingency Plans

• Approved vendor, billing services, clearinghouse
  and Network Service Vendor (NSV) lists
• http//www.wpsic.com/edi/files/medicare_connectio
  n.pdf
• PC-Ace Pro32
• Clearinghouse options?
• What are your contractual arrangements with
  vendor and/or clearinghouse?
• Paper claim submission is not a contingency
  option
• Other?

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PC-Ace Pro32

• Providers may download PC-Ace Pro-32 software at
  the link below to submit 5010 file formats
  http//www.wpsic.com/edi/pcacepro32.shtml
• This free 5010 errata software with instruction
  regarding set up posted on web site.
• New PC-Ace users must test.
• Existing PC-Ace users are not required to test.
• Import 277CA or 835 into readable reports.
• A common piece of providers contingency plans!
• Current version 2.52

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New 1500 (02/12)

• Paper billing NOT A CONTINGENCY! ASCA Rules
  still apply.
• Does your billing software need updating in order
  to accommodate the new form (02/12)?
• Do your printer settings need to be modified?
• Item - 14 multiple date field, requires date
  qualifier.
• Item 21 ICD-9 or ICD-10 indicator, up to 12
  diagnosis.
• Item 24E must use the appropriate alpha (A-L)
  diagnosis code pointers.

17
Monitor Your Business!!!

• Use the tools available to you to monitor your
  business
• Identify contingencies
• Read your 999 responses
• Read your 277CA responses
• Review your remittances
• Monitor your cash flow
• Identify and correct in a timely manner any
  issues identified.
• Use these tools to monitor your business so when
  you call, youll already have an idea what the
  issue may be.

18
Help Us Help You

• When you call, have information available which
  will help us identify your file and research your
  issue
• Submitter ID
• NPI
• ISA Control Number that was sent to WPS Medicare
• (this is especially important for clearinghouse
  customers. ISA13 is NOT Protected Health
  Information)
• Claims Count
• Date of Submission
• Dollar Amount of submission
• Other ways to contact EDI
• EDIMedicareA_at_WPSIC.com,
• EDIMedicareB_at_WPSIC.com

19
WPS Connectivity Options

• Dial Up Bulletin Board System (BBS).
• Network Service Vendor (NSV) into Medicare EDI
  Gateway (MEG).

20
Go Green!!!

• Go Green!!!
• Even if you dont post electronically you can
  take advantage of 835.
• Over 78 of all remittances are sent
  electronically in 5010-835 format.
• PcPrint and MREP are free and easy to use.
• You can download MREP and PcPrint from
• http//www.wpsic.com/edi/tools.shtml

21
Medicare Remit Easy Print (MREP) and PcPrint
Software

• MREP for Part B PC Print for Part A
• Will enable physicians and suppliers to view and
  locally print a Medicare Part B / DMERC HIPAA
  compliant 835 file in a format that mirrors the
  Medicare Standard Paper Remittance Advice (SPR).
• Eliminates physical filing and storage space
  needs.
• Print remit same day as 835 is available.
• Print and forward claims for other payers.
• Quick and easy access to claim information.
• No waiting for mail.
• Several useful reports.
• Save time and money.
• Its FREE!

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Sign Up for E-News
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Future EDI ACTs 2014

• These teleconferences are to address your EDI
  questions.
• No reservations are required.
• Who should attend? Providers, billing staff,
  vendors and clearinghouses with Medicare EDI
  questions.
• 2014 calls (all times 1-230 pm cst)
• Date
• August 14, 2014 [phone] 84826989
• October 9, 2014 [phone] 84826999
• December 11, 2014 [phone] 84827004

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Questions and Answers

• We want to hear from you
• If you have additional questions, you can also
  send an email to EDIMedicareA_at_WPSIC.com
  EDIMedicareB_at_WPSIC.com
• Also visit our EDI site for additional
  information http//www.wpsic.com/edi/

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EDI Addresses Numbers EDIMedicareA_at_WPSIC.com
EDIMedicareB_at_WPSIC.com

• MAC J5, J8 Part A B
• (Iowa, Kansas, Missouri, Nebraska and J5
  National) (Indiana, Michigan)
• WPS Medicare EDI
• 1717 West Broadway
• Madison, WI. 53713
• Fax [phone]
• New Single Point of Contact Numbers!!!
• J5 Single Point Of Contact (SPOC) [phone]
  opt 1
• J8 Single Point Of Contact (SPOC) (866)
  234-7331 opt 1

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Resources

• CMS 5010 and D.0 Webpage http//www.cms.gov/versi
  on5010andD0
• Educational Resources http//www.cms.gov/Version
  s5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
  
• 5010 Technical Review Type 3 guides
• X12 www.X12.org
• Washington Publishing www.WPC-EDI.com
• WPS Medicare EDI www.wpsic.com/edi/med_index.sht
  ml
• NACHA www.nacha.org, www.electronicpayments.org
• CAQH CORE www.caqh.org