ACS DOL. Electronic Submission Standard Changes. Provider Training X12N 5010

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1 ACS DOL Electronic Submission Standard Changes Provider Training X12N 5010

2 AGENDA Purpose Acronyms and Definitions What is an Electronic Submission? Electronic Submission Overview What s New? Submission of Electronic Bills 5010 WEB Portal Changes Summary/Closing Page 2

3 Purpose The purpose of this training is to provide an overview and understanding of the modifications to the systems that support the DOL Contract as it relates to being compliant with the new Electronic Standards. Additionally, it is to ensure that all providers will be able to accommodate additional diagnosis and inpatient surgical procedure codes on the 837P and 837I transactions. All entities must be compliant with the X12N 5010 Electronic Standard by the DOL implementation date of February 1, Page 3

4 Acronyms and Definitions CMS Centers for Medicare and Medicaid Services CBP - Central Bill Processing System DHHS Department of Health and Human Services EDI Electronic Data Interchange, a standard (X12N) for translating data from one format to another EDI Gateway ACS EDI entity used to submit bills to Achieve via billing agent, clearinghouse or software vendor HIPAA Health Insurance Portability and Accountability Act Page 4

5 Acronyms and Definitions Institutional An entity providing medical services requiring a prolonged stay P2P Non-ACS EDI entity used to submit bills to CBP via billing agent, clearinghouse, or provider Professional An entity or individual providing medical services not requiring a prolonged stay Providers provide medical services or supplies to OWCP claimants OWCP Office of Workers Compensation Program Submitter A billing agent, clearinghouse or software vendor submitting electronic transactions using EDI methods Page 5

6 Acronyms and Definitions Transactions Bills submitted electronically for payment Web Portal Internet access that allows claimants and providers access to OWCP data X12N American Standards for submitting electronic transactions for health care 4010 HIPAA current mandated format for submitting electronic transactions 5010 HIPAA new mandated format for submitting electronic transactions Page 6

7 Acronyms and Definitions 824 Electronic transaction used to inform submitters of bill submission status 837P Electronic transaction used for submitting professional health care services for payment 837I Electronic transaction used for submitting institutional health care services for payment 835 Electronic transaction used to provide payment status to health care providers 227CA Electronic bill status of pre-processed bills out of the CBP Page 7

8 Acronyms and Definitions Electronic transaction forwarded to submitters by EDI to acknowledge receipt of data file Electronic transaction forwarded to submitters by EDI to acknowledge receipt of data file Page 8

9 What is an Electronic Submission?

10 What is an Electronic Submission? Electronic submission is the structured transmission of data by electronic means. Bills are submitted electronically from providers to CBP through ACS EDI Gateway and P2P for payment of medical services rendered to OWCP claimants. The electronic formats used are listed below: 837P the electronic form of a professional bill (HCFA 1500) 837I the electronic form of a institutional bill (UB-04) 835 the electronic form of the remittance voucher 277CA the electronic format of the bill status 999 the electronic acknowledgement for bills submitted Page 10

11 Electronic Submission Overview As an OWCP provider, you can submit bills electronically or on paper. Bills submitted on paper will follow the standard OWCP processing procedures. Submitting bills electronically offers you the advantage of speed in processing, response time, and payment. Providers are able to receive immediate feedback on the acceptance or rejection of the data submitted for electronic processing. Your bills for payment are submitted electronically to the Central Bill Processing (CBP) system by your billing agent, clearinghouse or software vendor. The Billing agents, clearinghouses and software vendors are known as submitters. Page 11

12 Electronic Submission Overview ACS EDI Gateway and P2P submit the bills to CBP for processing and adjudication. CBP receives the bill (transaction) and processes the bill for payment. CBP returns the status of the bills to the submitters via ACS EDI Gateway or P2P in the approved format. Submitters provide the status of the bills back to the you. Page 12

13 What s New?

14 What s New: Provider Electronic Submission Today, OWCP professional providers can electronically submit a maximum of 8 diagnosis codes and OWCP institutional providers can electronically submit a maximum of 9 diagnosis codes and 6 surgical codes for all three OWCP programs (FECA, Black Lung and Energy). Providers will have the capability to submit up to 12 diagnosis codes associated with the claimants accepted conditions for professional services rendered (HCFA 1500 form), electronically. Providers will have the capability to submit up to 25 diagnosis codes and 25 inpatient surgical procedure codes associated with the claimant s accepted conditions for institutional services (UB-04 form), electronically. Providers will be able to use diagnosis code pointers to indicate which of the submitted diagnosis code should be used in positions 1-4. Page 14

15 What s New: Submitter Electronic Submission Today, submitters receive an acknowledgement file called a 997 which indicates whether or not the bill was received by ACS EDI Gateway or P2P successfully (accept/reject). The bill processing system returns an error report called the 824 to the EDI entity to notify the submitter of any errors. For example, if your assigned OWCP provider number is submitted incorrectly, the error message, invalid provider number will be returned on the 824. What s New: The file acknowledgement will provide additional information and be renamed from 997 to 999. The error message will be returned on the 277CA transaction along with additional information regarding the bill status. Page 15

16 What s New: EDI Entities Electronic Submission Today, ACS EDI Gateway and P2P accept and process electronic formats for all three OWCP programs in the 4010 version of HIPAA which includes the 837P, 837I, 835, 997, and 824. What s New: The 5010 version of HIPAA will contain existing 4010 fields and new fields. The transactions 837P, 837I, and 835 will remain, with additional fields. The 997 and 824 will be replaced by the 999 and 277CA, both with additional fields. For example, on the 277CA a totals fields was added, and on the 837I the Health Care Provider Taxonomy Code was added. Page 16

17 Summary of Electronic Submissions Changes Data submitted on the X12N transactions for payment of medical services rendered is used to process bills according to policies/guidelines Transactions 5010 Transactions Maximum of 8 diagnosis codes allowed for submission on the 837P Maximum of 9 diagnosis codes allowed for submission on the 837I Maximum of 6 surgical procedure codes allowed for submission on the 837I Will not be accepted after 1/31/2012 Provides submission status using the 997 and 824 Maximum of 12 diagnosis codes allowed for submission on the 837P Maximum of 25 diagnosis codes allowed for submission on the 837I Maximum of 25 surgical procedure codes allowed for submission on the 837I All providers must be compliant by 2/1/2012 Provides submission status using 277CA and 999 Page 17

18 Submission of Electronic Bills

19 OWCP and Electronic Submission OWCP professional and institutional providers that renders health care services can submit bills electronically. Electronic submission reduces paper, time, manual effort, and increases accuracy and quality. OWCP providers can submit bills electronically for payment of services rendered to OWCP claimants for all programs. Energy Black Lung FECA Page 19

20 How will Electronic Bills be Submitted? You can submit bills through the following entities: Clearinghouse Billing agent Software vendor You may select a submitter based on bills processed (volume). Software vendors and billing agents provides the capability to submit a small volume of bills daily i.e. physician office. A clearinghouse provides the capability to submit large volumes of bills for multiple clients at one time, as well as accept paper bills from providers to submit electronically i.e. hospital. All OWCP providers can submit electronically to ACS EDI Gateway or P2P via a submitter. P2P accepts medical documents/attachments ACS EDI Gateway can not accept medical documents/attachments Page 20

21 Web Portal System Changes

22 Web Portal Changes OWCP providers are able to use the ACS Web Bill Processing Portal to monitor, research and view detail and summary information on bills submitted using their assigned OWCP provider number. The WEB Bill Status Inquiry screen will display all the diagnosis codes submitted on an institutional or professional bill. Changes: The bill status inquiry screen for professional (OWCP 1500) will display up to 12 diagnosis codes The bill status inquiry screen for institutional (UB04) will display up to 25 diagnosis codes Providers and Claimants will be able to view this data. Page 22

23 Web Bill Inquiry HCFA Diagnosis codes must be associated with claimant accepted conditions /00/ Up to 12 Diagnosis codes will also be viewable on ACS Web Portal under Bill Status Inquiry. (Currently only 4 DX codes are viewable on Web Portal) Page 23

24 Web Bill Inquiry UB /00/0000 Up to 25 diagnosis codes will also be viewable on the ACS Web Portal under Bill Status Inquiry New Hospital Page 24

25 Summary/Closing

26 Dates to Remember Beginning December 2011, ACS will support the X12N 5010 formats for EDI providers ready to submit prior to the mandatory date. ACS will work with the clearinghouse, billing agent and software vendors to complete end-to-end testing. By January 31, 2011, electronic submitters must convert the current X12N 4010 formats to the X12N 5010 format. On February 1, 2012, ACS must support X12N 5010 formats only. Electronic bills will no longer be accepted in the 4010 format. Page 26

27 Frequently Asked Questions 1. Will providers be able to submit the additional codes via paper bills? No, providers submitting paper bills on the OWCP 1500 or the UB-04 will not be allowed to submit the additional diagnosis codes and/or surgical procedure codes. 2. Will Vocational Rehabilitation and Contract Nurses be able to submit the additional codes? No, nurse bills submitted via the Web Portal will not be allowed to submit the additional codes. 3. Will PBM submissions change for 5010? No, PBM submissions will not be affected by 5010 changes. 4. Will previously submitted bills be affected? No, electronic history bills will not be affected. 5. Will the Remittance Voucher (RV) or 835 have any additional information? RV and the 835 will not have additional data resulting from 5010 changes. Page 27

28 Notification/Contacts Electronic Submissions ACS-EDI Technical Help Desk P2P Bill Inquiries FECA Customer Service FECA IVR Energy Customer Service Black Lung Customer Service Page 28

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