HIPAA 5010 It is important to prepare now Deanna Stohl ETP Contracting and Relations e-business Interchange Group Blue Cross Blue Shield Michigan

Transcription

1 HIPAA 5010 It is important to prepare now Deanna Stohl ETP Contracting and Relations e-business Interchange Group Blue Cross Blue Shield Michigan August 31,

2 Housekeeping Please place your phones on mute. We will be using the chat feature to receive questions throughout the presentation. The questions will go only to the host. Questions will be answered at the end of the presentation. The presentation and Q&A is published on our 5010 website. 2

3 Agenda Topics 5010 What is it? Key Changes Impacts Test Plan Approach Migration Concerns Working with your software vendor Additional resources Contact / support information Q&A 3

4 Federal compliance date The deadline for conversion to 5010 version is January 1, Five months remaining At that time, all electronic transactions that you or your vendors send to BCBSM must use HIPAA Federal Compliance Date: January 1,

5 Overview of 5010 What is it? The Health Insurance Portability and Accountability Act (HIPAA) requires that covered entities follow certain standards for electronic health care transactions such as: Claims: professional, institutional and dental Remittance Eligibility and Enrollment Status requests and responses On January 16, 2009, modifications to the HIPAA Electronic Transaction Standards Final Rule were published to replace the current version of ASC X A1 with version 5010 and NCPDP with version D.0. 5

6 Key Changes Introduced with 5010 Prohibits use of P.O. Box for billing provider (2010AA) Requires nine-digit ZIP code at billing and service provider loops Changes made to the AMT segments (approved & allowed deleted) Accept assignment (2300) CLM07 now used for provider to indicate accept assignment with the payer, not Medicare. (old CLM16) New transactions: Implement 999 and 277CA transactions Added an indicator on institutional claims for conditions that were present on admission POA Date of service range only required when from and to are different (RD8) QTY Segment deleted, use value codes to report covered, noncovered, coinsurance or lifetime reserve days 6

7 5010 Impacts What are they? Who is affected by the change? Covered entities affected by transition to the new version include: Professional, institutional, dental and pharmacy providers Health plans Health care clearinghouses Business associates that use the HIPAA transactions, such as billing or service agents and vendors. How does this affect me? Risk of financial penalties included in the federal mandate for failure to convert You should plan on transitioning to version 5010 sometime during 2011 do not wait until Dec. 31, Risk to claims adjudication To avoid rejections and delayed payments, it is important to understand how your software will handle 5010 requirements and changes. 7

8 Test plan approach Target our top 100 commercial vendors and in-house software developers ranked by claim volume and user count. Schedule Validator testing, sub-system testing and deployment within the second and third quarters. Test and deploy the remaining testing partners by Dec. 31, Testing requirements: HIPAA Validator testing began January Validator is a HIPAA compliance self-testing tool - Must pass before moving to subsystem - Available now for trading partners to test 5010 compliance - Not many partners have used the tool so far - Testing taking longer than anticipated Pilot testing for scheduled partners in an end-to-end QA environment beginning in third quarter Selection based on specialties and rank. Subsystem testing third quarter Successful software developers promoted to production. Vendor certification with two trading partners in production required before approval. - Monitoring reports will be shared depicting the number of their users transitioned to Dual Environment September through Dec. 31, 2011 Production Deployment September through Dec. 31,

9 BCBSM testing timeline by transaction Validator Pilot 837 Professional 837 Institutional 270/271 Real Time 834 Enrollment 837 Dental 9

10 Migration concerns Since January 2011, BCBSM has been engaged in a very active outreach program to get our trading partners and vendors scheduled for Validator and subsystem testing so we can ensure that resources are allocated to assist in the migration to BCBSM has nearly 4,000 trading partners that need to be converted by January These are the results as of July 26: Validator Testing 55% of our testing partners are testing in Validator 24% of trading partners and testing partners have passed Validator 60+ average number of days needed to pass Validator 3% of trading partners and testing partners have not yet scheduled testing 25% missed their testing dates Subsystem testing 88% scheduled for subsystem 12% have not responded. 10

11 MGMA Survey Medical Group Management Association recently conducted a survey of physician groups: 27% believe current software supports % Less than half have received communications from PMS Vendor 56% stated no internal testing has started Only 8% have tested 1% plan to start testing after Jan. 1, % have not started their 5010 implementation 11

12 Working with Vendors Your business partners must also be compliant with HIPAA You should: Confirm your vendors, clearinghouses and other partners will be able to support 5010 requirements. Open a dialogue with them now. Review contracts for terms related to honoring federal mandates or amend contracts as needed. Obtain timelines and project plans. Ensure your vendor is scheduling testing with BCBSM and your other trading partners to ensure 5010 capabilities and remediate where needed. 12

13 Provider Checklist Complete upgrades to internal systems Confirm if vendor is completing testing on your behalf Will your software support both 4010A1 and 5010A1 concurrently? Any business changes that may be impacted by 5010 claims data reporting changes? Complete internal testing Test with your trading partners Migrate to production for each trading partner If you work with a clearinghouse or billing service, contact them about their status on

14 Methods of communication Letters, s, bulletins and publications The Record Web-DENIS broadcast messages Webinars Surveys Web page Fliers and handouts Provider forums Formal presentations (road shows) Medical associations Direct outreach 14

15 Resources Where can I learn more about HIPAA 5010? GetReady5010: Supporting Industry Readiness for January 1, * The Centers for Medicare and Medicaid Services (CMS) MLN Matters article about 5010: An Introductory Overview of the HIPAA 5010 The Centers for Medicare and Medicaid Services (CMS)- Downloads // The Workgroup on Electronic Data Interchange (WEDI)* Web site also has valuable information. TR3s (IG) can be purchased from Washington Publishing Company *Blue Cross Blue Shield of Michigan does not control this website or endorse its general content. 15

16 BCBSM EDI Contact Information How can I contact BCBSM with questions? For questions related to 5010, contact us by at: ebigbusiness5010support@bcbsm.com For more information on 5010, see our website at: 16

17 Questions 17 NPI 5010 ICD-10 HIPAA??

18 Q & A The questions below were posed during the Aug. 17 th and 31 st, 2011, webinar presentations. Wherever possible, duplicate questions have been combined. Q: We are a very small provider and do only paper claims (1500) - will these changes affect us at all? A: The 5010 mandate applies to electronic transactions only. We encourage all paper submitters to submit electronically. BCBSM has an Internet Claims Tool that you may be eligible to use. For more information on this tool, please see our website at Q: The AMA sent us an stating they are calling for a testing week (next week)-is EDI ready for this? A: BCBSM will be testing with our pilots only next week. Q: Would you repeat the informational websites please? A: Please see slide 15. Q: We bill electronically and on paper. Can I use the same 1500 claim form. A: Yes Q: My software vendor is ready for the 5010 submissions. For me, it s as simple as clicking a button. Will I need to make an appointment with Blue Cross before sending in the 5010 format? A: Your vendor should be testing with BCBSM. BCBSM is asking for each vendor to test with two submitter s files prior to us approving that vendor for production. Your vendor will need to coordinate the 5010 implementation date with BCBSM. 18

19 Q & A continued Q: Can I print this presentation? A: Yes Q: Everyone talks about testing...how do we start testing? A: Your vendor should be testing with BCBSM. BCBSM is asking for each vendor to test with two submitter s files prior to us approving that vendor for production. Your vendor will need to coordinate the 5010 implementation date with BCBSM. For more information on testing, please see our website at Q: Does BCBSM EDI have a list of vendors and their testing status? A: Please contact your vendor directly to ensure they are testing with BCBSM and ask them for their project plan and timelines for testing and implementation. Providers need to take an active role with their vendors to ensure there will be no claims rejections or cash flow disruption effective Jan. 1, Q: Is there a list on those vendors that you are testing with? I want to know if you have tested with my vendor? A: Please contact your vendor directly to ensure they are testing with BCBSM and ask them for their project plan and timelines for testing and implementation. Providers need to take an active role with their vendors to ensure there will be no claims rejections or cash flow disruption effective Jan. 1, Q: Are you working with Genius Solutions as a vendor? A: Yes Q: I thought the 5010 was started because of the ICD-10? When will Blue Cross publish anything on the ICD-10? A: Please see our website at 19

20 Q & A continued Q: We are a small provider who bills through the BCBSM claims tool, only not through our software. Do I need to do anything? Or will the BCBSM claims tool have the updates for me, and I can bill as I have been? A: There is nothing you need to do. BCBSM will be handling the upgrade to HIPAA version 5010 for our Internet Claim Submission Tool product. As we get closer to implementing v5010, we will notify our users of any new requirements or changes that may affect their claims. Changes will be communicated through messages and alerts on the tool. Until that time, please continue to send claims as you currently do. Q: Are you working with Chirotouch? A: Yes Q: Are you working with GE as a vendor? A: Yes Q: Are you working with PTOS for physical therapy offices? A: I do not see that we are working with PTOS. Please contact your vendor. Q: Are you working with Relay Health with testing. A: Yes Q: Are you working with TriTech as a vendor? A: I do not see that we are working with TriTech. Please contact your vendor. Q: Are you working with Office Medicine as a vendor? A: I do not see that we are working with Office Medicine. Please contact your vendor. 20

21 Q & A continued Q: Can you explain how this will affect dental practices? A: There are changes for electronic dental claims for Please contact your vendor or clearinghouse to make sure you have a clear understanding of any changes that may affect you. We will begin testing 5010 for dental in November. Q: We use Allscripts and we are having a hard time having one point of contact regarding our 5010 needs and questions...does anyone out there have any contacts with them? A: To contact support, please call The website address is *Blue Cross Blue Shield of Michigan does not control this website or endorse its general content. Q: Don't know if you are the one to answer this or could you tell us who is: Our payments come to a lock-box which is a P.O. Box. If we can no longer submit using a P.O. Box, do you have any suggestions? A: A P.O. Box can still be used in the Pay To address. However, BCBSM will send payment to the provider address that is in our corporate provider file database. Q: Are you working McKesson as a vendor? A: Yes Q: Are you testing with Networks? A: We are working with Netwerkes. Q: Are you working with E-Medical notes? A: Yes 21

22 Q & A continued Q: I am not sure if you will have a detailed answer, but am curious about how COB claims will be handled without allowed amounts. A: Amounts will be calculated from the AMT and CAS segments reported at claim level and service line level in the 837 transaction. These segments include the paid amount, coinsurance, deductible, etc. Q: Does the actual CMS form change--or just the info on it? A: The 1500 claim form will not change with 5010; however, the information you will be required to report may be different. Q: Do we need 9 digit zip from our patients or just our address? A: The nine digit ZIP code requirement is only for the billing and service provider addresses. Q: I saw that all status claims must be electronic. What if that fails and we have to send a paper status to resolve an issue. A: A paper status claim will be accepted if it cannot be successfully submitted electronically. Q: Are you working with Allscripts as a vendor? A: Yes Q: I feel totally LOST. I don't understand any of the "transactions" and what their meaning are...you say transaction 277 and I am totally clueless. Am I the only one? I'm assuming that my system FIRST needs to be updated with my IT, then contact my clearinghouse. A: Transactions are the electronic data versions of whatever you produce from software or practice management systems. For example, if you key a claim on your computer and transmit the claim electronically, you have generated an 837 transaction. Depending upon how your system works, you may need to contact your clearinghouse or software vendor/developer first, and then work with your IT department to implement any necessary changes. 22

23 Q & A continued Q: My clearinghouse is Navicure. Have they been testing? A: Yes, Navicure has begun testing. Q: In relation to the 1500 form does PO Box & street address have to be in both box 32 & 33? A: The requirement for a physical street address applies to claims submitted electronically. If you only submit hard copy claims, you may still report a P.O. box. Q: Are you working with Claims Remedi as a vendor? A: Yes Q: Are you still going to be accepting claims from providers that submit paper claims? A: Yes, paper claims will still be accepted. We encourage you to begin submitting your claims electronically. The benefits include faster reimbursement and reduced administrative costs. If you are unable to submit electronically, please contact us. Q: Can we get a list of approved vendors? A: For HIPAA version 5010, we are no longer providing a list of approved or preferred vendors. Q: Is there a 5010 example of how all claims should be filled out properly? A: Each claim type will have its own set of requirements and each payer will have specific requirements. You will need to obtain billing guidelines from each payer that you submit claims to, i.e. Medicare, Medicaid, commercial payers, etc. 23

24 Q & A continued Q: If 5010 is not being made mandatory until October 2013 why is BCBSM doing it so early? A: 5010 is mandated by Jan 1, 2012 the second phase, ICD-10, will be implemented in If you have not started 5010 preparation, we recommend you do so now. Effective 1/1/12, all version 4010A1 transactions will reject. Q: Do we have to have 9 digit zip codes in the system for all the ins companies we send claims to? A: Regardless of the insurance company, under HIPAA version 5010, a nine digit ZIP code must be reported for the billing and service providers. 24