MAC J5 and J8
EDI ACT
(June 12, 2014)
Participant Line: (800) 305-2862
Passcode: 84826906
Purpose of Power Point
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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
Current Med A Issues –
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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
Current Med B Issues
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Canadian and military zip codes.
Sporadic delays in sending responses (999,
277CAs or 835s)
MREP issues for Windows 7 or 8 users
MSP Claims - 5010
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MSP claims are not an ASCA (Administrative Simplification
Compliance Act) exception and must be sent electronically.
Avoid front end rejections, delays and Unprocessable
rejections:
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When determining the beneficiary’s 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/msp5010A1.pdf
Operating Rules
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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.
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
EFT and ERA Operating Rule
Impacts
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835 Infrastructure
CARC/RARC combinations
EFT ERA Reassociation
Electronic Enrollments for EFT and ERA
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
CARC/RARC Operating Rules
4 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
EFT ERA Reassociation
(Rule 370)
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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).
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Example EFT: 705TRN*1*8834567890*1391268299~
Example 835: TRN*1*8834567890*1391268299~
Ensure Proper Completion of
ERA Form (Rule 382):
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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
provider’s 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.
ICD-10 Update
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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
Contingency Plans
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Approved vendor, billing services, clearinghouse and
Network Service Vendor (NSV) lists:
http://www.wpsic.com/edi/files/medicare_connection.pdf
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PC-Ace Pro32
Clearinghouse options?
What are your contractual arrangements with vendor
and/or clearinghouse?
Paper claim submission is not a contingency option
Other?
PC-Ace Pro32
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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
New 1500 (02/12)
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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.
Monitor Your Business!!!
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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, you’ll already have an idea what the issue may be.
Help Us Help You…
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When you call, have information available which will
help us identify your file and research your issue:
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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@WPSIC.com,
EDIMedicareB@WPSIC.com
WPS Connectivity Options
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Dial Up Bulletin Board System (BBS).
Network Service Vendor (NSV) into
Medicare EDI Gateway (MEG).
Go Green!!!
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Go Green!!!
Even if you don’t 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
Medicare Remit Easy Print (MREP)
and PcPrint Software
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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.
It’s FREE!
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Future EDI ACTs 2014
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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 1-2:30 pm cst):
Date
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August 14, 2014
October 9, 2014
December 11, 2014
(800) 305-2862
(800) 305-2862
(800) 305-2862
84826989
84826999
84827004
Questions and Answers
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We want to hear from you…
If you have additional questions, you can
also send an email to:
EDIMedicareA@WPSIC.com
EDIMedicareB@WPSIC.com
Also visit our EDI site for additional
information: http://www.wpsic.com/edi/
EDI Addresses & Numbers
EDIMedicareA@WPSIC.com
EDIMedicareB@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:
(608) 223-3824
New Single Point of Contact Numbers!!!
J5 Single Point Of Contact (SPOC):
(866) 518-3285 opt 1
J8 Single Point Of Contact (SPOC):
(866) 234-7331 opt 1
Resources
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CMS 5010 and D.0 Webpage
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Educational Resources:
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http://www.cms.gov/version5010andD0
http://www.cms.gov/Versions5010andD0/70_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.shtml
NACHA: www.nacha.org, www.electronicpayments.org
CAQH CORE: www.caqh.org