CMS Full Encounter Data by January, 2012

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Veronica Carpenter
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1 SCAN Health Plan Provider Partners Webinar CMS Full Encounter Data by January, 2012 Presentation: May 25, 2011

2 CMS Full Encounter Data Agenda Introduction SCAN FED Project Status Updates on CMS Requirements Impacts on Providers Resources Q&A 2 Next Steps

3 Introduction Oct 29th, 2010: CMS formally announced decision to transition to a new Encounter Data Processing System (EDPS) from the current Risk Adjustment Processing System (RAPS). Measuring healthcare utilization in MA organizations Calibrating MA specific Risk Adjustment models Calculating disproportionate share hospital payments EDPS Target Production Date of January 2nd, 2012 RAPS data submission will continue side-by-side during transition 3

4 Introduction This mandates increased: Scope of encounter data collection We still want all the data but now CMS wants it all too. Accuracy of data Provider identification Codes and reference data 4 Timeliness and completeness supplemental data submissions encounter data rejects response

5 Introduction Complete Data Submission MA must submit all data from all types of service, including: 5 Inpatient Hospital Inpatient Rehab Inpatient Psychiatric Long Term Care Skilled Nursing Inpatient/Swing Bed Skilled Nursing Outpatient Outpatient Hospital Community Mental Health Home Health (DME) End-Stage Renal Disease Critical Access Hospital Inpatient/Swing Bed Critical Access Hospital Outpatient Rural health Clinic Federally Qualified Health Center Outpatient Rehab Physician/Professional Clinical Laboratory Durable Medical Equipment Ambulatory Surgical Centers Ambulance Radiology

6 CMS Full Encounter Data SCAN FED Project Status 6

7 SCAN FED Project Status SCAN is: Developing an assessment readiness tool (a Provider Readiness Assessment )and consulting program to help you independently determine your current status and needs Preparing a CMS Full Encounter Data-specific SCAN website and address to allow dialogue with Provider Partners on specific questions 7

8 SCAN FED Project Status SCAN is: Working with our clearinghouses to put together planning and tracking for all Provider Partner implementations of CMS Full Encounter Data Office Ally and DDD are alerted and planning to be ready on their end 8

9 SCAN FED Project Status Q: What do you envision in terms of sharing the rejects with IPA/Medical Groups? Are you going to modify the existing provider portal to share the rejects there? Or are you going to produce reports? A: Existing portal and sharing rejects for providers will be opened up to all providers for direct remediation of encounter rejection. We may produce other reports like the CMS rejection report so that they can send corrections back. 9

10 CMS Full Encounter Data Updates on CMS Full Encounter Data Requirements 10

11 CMS Requirements Status Encounters will be required for all Medicarecovered and non-medicare-covered services DME encounters will not be included in the January 2012 start date, but instead will be implemented separately by June SCAN will require all encounters be sent in the 837v5010 format as of January 1, 2012 and will be operating under Full Encounter Data Processing Guidelines as of that date

12 CMS Requirements Status Timely Filing Encounter must be to CMS (cleanly passing all EDI and Adjudication Edits) within 13 months of the date of service Chart Review Data (ex HCC Programs or RADV) can be submitted within the same Sweep Date timeframes as today Direct Submissions (Alternative Submission Format) Format will remain the same or very similar (TBD) Encounter must first be on file at SCAN or direct submission record will be rejected Must be used to delete specific DX codes from an encounter Replacing and Voiding Encounters Resub/replace entire encounter Claim Frequency Code = 7 Must include SCAN s DCN for encounter Void entire encounter Claim Frequency Code = 8 Must include SCAN s DCN for encounter 12

13 CMS Requirements Status Encounters/Claims to Submit All Paid & Denied (for contractual/payment reasons) must be submitted Rejected (for bad/incomplete date) should not be submitted Pending (not yet paid) should not be submitted Submission Frequency SCAN recommends submitting encounter data on a weekly or bi-weekly basis. This helps with maintain a workable submission and rejection process 13

14 CMS Requirements Status Provider Identification NPI is required; CMS still too provide final guidance for those providers without an NPI (NPPES will allow almost all provider specialties to enroll for an NPI) All addresses (Billing Provider, Servicing Facility, Ambulance Pick Up, etc) must have 9 digit zip code Billing address must be the physical address and cannot be a PO Box or lockbox. CMS/SCAN may require identifiers such as: CLIA and Mammography Certification Number Multi-Specialty Providers CMS Specialty 70 is no longer allowed for rendering provider and will be rejected by SCAN Must have individual providers NPI/specialty Taxonomy Codes Not required for submission to SCAN; will be derived from NPPES database 14

15 CMS Requirements Status Diagnosis Codes 837P = 12 fields 837I = 23 Fields If more than allotted then: Can send duplicate encounter with remaining DX codes Can add DX codes in SCAN s Encounter Data Portal Can submit additional DX codes on Direct Submission format (after SCAN confirms initial encounter processing) Other ideas? Amount Fields 15 Fields such as billed amount, paid amount, and patient responsibility should be populated If capitated and no dollar amount is available, then may populate with $0 The patient responsibility must be populated for Medicare Out of Pocket Max calculations 837 EDI encounter must balance to pass validation Claim amounts must equal the sum of the Claim line amounts

16 CMS Requirements Status CMS Implementation Schedule 16

17 CMS Full Encounter Data Outstanding Questions For CMS 17

18 Outstanding Questions for CMS What is the definition of an encounter? One claim form? One DOS? One service? 18

19 Outstanding Questions for CMS Q: How will provider data differentiate between a capitated claim versus a FFS claim in the 5010 file somehow? A: How is not yet completely clear. CMS may allow us to put zero dollars in an encounter indicating that it was for a capitated service. SCAN may make this differentiation on your data as part of the data scrubbing / preparation for transmission to CMS. More information will be provided when CMS provides the answers. 19

20 Outstanding Questions for CMS Q: Can you define the scope and types of validation edits (FFS edits) that are going to be used for this project? A: We don t know for sure the scope and pricing of FFS edits. 20

21 Outstanding Questions for CMS Q: What is CMS s logic for dups in the 5010? What will be SCAN s dup logic when this is implemented? A: CMS has not published their dup logic yet but it will be similar to their FFS side dup logic, based on information regarding the visit / service. True duplicates will reject. However, we will still need to send multiple versions of the encounter in order to get more than 6 diag codes. CMS will accommodate these addendums. 21

22 CMS Full Encounter Data Impacts on Providers 22

23 Impacts on SCAN Provider Partners Identify a specific individual to maintain contact and coordination with SCAN for the duration of this transition there will be more webinars and Q&As Alert and prepare all of your downstream providers of the upcoming changes Prepare to work with SCAN on assessment Assess your current technical (IT) status and transition capabilities Assess workflow and resources for Encounter Data rejections Develop a plan to accomplish the transition 23

24 Impacts on SCAN Provider Partners Provider partners must submit valid Procedures and DX codes. Diagnosis Code V70.0 is routinely rejected in Medicare FFS claim adjudication. Providers partners must submit claims on the correct forms (UB-04 vs. CMS-1500). 24 Providers partners must keep their physicians NPPES NPI, Addresses(!), and Taxonomy information up to date.

25 Impacts on SCAN Provider Partners Providers will need to begin submitting 100% of all encounter data for all services by 1/1/2012 SCAN provider partners will need to ensure that ALL your providers begin submitting claims or encounter data to you by 1/1/2012 Providers will need to change many files, formats, business operations and processes to comply with the CMS Full Encounter Data requirements 25

26 Impacts on SCAN Provider Partners 2011 Second and Third Quarter Provider Tasks: Providers will need to assess and adjust systems, data controls, file formats, workflows and down stream communications Providers will need an encounter extraction process which has access to all required and situational-required ANSI 5010-data elements 26

27 Impacts on SCAN Provider Partners 2011 Third and Fourth Quarter Provider Tasks Test in the third and fourth quarter of 2011 your new formats and processes with SCAN and our clearinghouses 27

28 CMS Full Encounter Data Q&A Session 28

29 SCAN Full Encounter Data Resources Publishing industry-wide CMS Full Encounter data updates and information to Marc Carren Stacey Hernandez 29

Transition to Full CMS Encounter Data Submission by 2012 Frequently Asked Questions

Transition to Full CMS Encounter Data Submission by 2012 Frequently Asked Questions Table of Contents OVERVIEW... 2 Why is CMS implementing a Full Encounter Data requirement?... 2 Why is CMS mandating the Encounter submissions be changed to the 5010 format?... 2 Why is it important for