HIPAA 5010 March 30 th National Call: Provider Testing and Readiness Resource Mailbox Questions and Answers

Transcription

1 HIPAA 5010 March 30 th National Call: Provider Testing and Readiness Resource Mailbox Questions and Answers Background: As mentioned on previous HIPAA 5010 national calls, there is a resource box that accepts questions for a 72 hour period around these national calls. Below are questions that were submitted along with their answers. 1) Q: Can you explain how the HIPAA 5010 National Testing Days will work? A: The 5010 testing days have been created to generate enthusiasm, awareness and interest to grow trading partner testing with contractors. The testing days will be used to encourage and promote trading partners to contact their contractors to facilitate testing and a better understanding of contractor testing protocols. The concept of trading partner testing was designed to validate the trading partners ability to meet technical compliance and performance processing standards while measuring data integrity through the exchange of the transaction standards. Therefore, the 5010 testing days have been designed to allow trading partner s immediate direct access to the contractors for testing with real-time help desk support. The events will be conducted virtually and will be posted on each contractor s website as well as CMS web site. Trading partner testing should include test files that will generate positive and negative results for the applicable transaction standard. The following transactions will be supported during the testing days: 1. Inbound 837 Institution and Professional Claim; 2. Outbound 835 Remittance Advice; 3. Interchange Acknowledgement TA1; 4. Acknowledgement for Health Care Insurance 999; 5. Health Care Claim Acknowledgement 277CA; and 6. Health Care Claim Request and Response 276/277. 2) Q: If the Billing and Service facility loops are the same, will Medicare be rejecting the claim? What data fields are you basing the denial? A: Not at this time 3) Q: If the Billing and Rendering loops are the same, will Medicare be rejecting the claim? A: Not at this time 4) Q: Can there be a CMS National Call to answer questions only? A: The August 24th HIPAA 5010 National Provider call will include a panel of MAC participants which will be primarily focused on questions and answers. 1

2 5) Q: For Oxygen CMNs, we currently send the test facility information in the Test Facility Loop, 2420C, using a 'TL' (Testing Laboratory) qualifier. The qualifier 'TL' is no longer valid. Should we continue sending this information in this loop, but just change the qualifier to '77' or should we not send the Test Facility information? A: Our answer is based off of the assumption that the claim being billed is from a supplier and is for oxygen. Loop 2420C is for the "service facility", not a "test facility". The purpose for the loop is to identify where the service was rendered, not who performed the laboratory services which justify the need for oxygen. If my assumptions are accurate, then the test facility data should not be sent. 6) Q: We are a software vendor, and have a question about the following mapping. In the I, FL 54 and FL 55 of the UB04 mapped to Loop 2320 AMT (C4 Qualifier Code) and Loop 2300 AMT (C5 Qualifier Code) respectfully. In the I, these two loops are no longer available. Where are the two fields to be mapped to now? A: Per the 2011 NUBC manual, FL54 maps to i 2320 AMT02 (AMT01 = D); FL55 has no i map (see value codes A3, B3, and C3) 7) Q: When submitting claims to the four regional DME MACs for oral cancer drugs that have no HCPCS assigned, how will we populate the SV1 segment in the 2400 loop? Will HCPCS codes be issued for these drugs or can the ZZ modifier in SV101-1 be re-instated? The following is a list of oral anticancer drugs with no HCPCS: Busulfan, Capecitabine, Cyclophosphamide, Etoposide, Fludarabine phosphate, Melphalan, Methotrexate, Temozolomide and Topotecan. A: The 5010 SV101-1 now only allows the use of 'HC' and the 'ZZ' qualifier with 'XXXXX' as the HCPCS used today with 4010A1 is no longer valid for Please refer to sections and of the 5010 TR3, which states (in addition to other guidance): "Drugs are precisely coded with NDC numbers, and the HCPCS provided are S5000 and S5001 for a generic drug and brand drug, respectively." For 5010, when billing an oral anti cancer drug, suppliers shall submit 'HC' in the 2400 SV101-1 and the value of 'S5000' or 'S5001'(generic/brand)in the 2400 SV The NDC should be included in the 2410 LIN as currently done with 4010A1.Please contact your MAC for further guidance. 8) Q: I understand the billing address can t be a P.O. Box or Lockbox number. Please confirm if the Pay To/Remit address can continue to be a P.O. or Lockbox number and does that address have to match the NPI registry? A: The pay-to-address can be a P.O. Box. At this time, the EDI front end will not be running a match of the submitted address to the NPI registry. 9) Q: Once a provider is deemed 5010 compliant by a MAC based upon Errata 837I testing, are they then required to only pass 5010 claims? Or can they choose to go live with I production files at a later date? 2

3 A: Trading partners will have up until December 31, 2011 to pass all claims in version Therefore, they may test anytime and choose to transition to production at a later date. 10) Q: This question deals with the 2410 Loop, the drug identification loop. Currently in the HIPAA version 40101A the 2410 loop can be repeated up to 25 times per service (2400 Loop), but HIPAA version 5010, the 2410 loop can only be repeated once per service. For our ESRD clients, they administer Epoetin using different doses. These doses are sometimes made up of more than one vile of Epoetin in different sizes and/or different manufacturers. This means we will have multiple NDC codes for one administration of a dose of Epoetin. In the HIPAA version 40101A, we could list all of the NDC codes for that service using multiple 2410 loops. How should this Epoetin service be submitted under HIPAA version 5010 that only provides for one NDC code per service? A: The i TR3 allows for a single NDC (Loop ID 2410) be linked to a single HCPC (Loop ID 2400). If there are multiple ingredients (NDCs) that link to a given HCPC, the HCPC is reported as a separate line (Loop ID 2400) for each associated ingredient. 11) Q: In the , there was a way to indicate multiple NDC numbers related to the compound drug. In the 5010, it appears that the requirement is to just submit one NDC (related to loop L2400 and L2410. Although you can have a quantity of 2, there may be two different NDC numbers for two different drugs, each with a different unit price, but the requirement is just to send one. A: The i TR3 allows for a single NDC (Loop ID 2410) be linked to a single HCPC (Loop ID 2400). If there are multiple ingredients (NDCs) that link to a given HCPC, the HCPC is reported as a separate line (Loop ID 2400) for each associated ingredient. 12) Q: For the 5010 format, when the Place of Service, CLM05, is 12 for patients home, what information will be required, if any, in the service facility loop, 2310C? A: At this time, the front end system will not require any data in the service facility loop. 13) Q: I am a billing agency that enter claims in a software system, then sends claims through a clearinghouse. Do I start with calling the software vendor to find out if they started the compliance yet with Medicare or do I call the clearinghouse first? I am located in Massachusetts. A: Both are crucial steps to the 5010 transition. Contact your software vendor and clearinghouse to ensure they are compliant with the transition. Don't assume that someone else is taking care of the 5010 transition for you! 3

4 14) Q: Do providers have to formally change their billing address with Medicare using an 855B/855I or can they just update their NPI profile to reflect our business office address? A: Yes, if you re billing address changes you must formally change your address with Medicare by filling out an Enrollment Application: CMS 855A--Medicare Enrollment Application for Institutional Providers CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers Mail your completed application and all supporting documentation to the Medicare feefor-service contractor (also referred to as a carrier, fiscal intermediary, Medicare Administrative Contractor, or the National Supplier Clearinghouse) serving your State or geographic location. To find the Medicare fee-for-service contractor serving your State or geographic location, please return to the "Overview" section of this web site and select the first download titled, "Medicare Fee-For-Service Contact Information." To avoid delays in application processing, do not mail your application to the Centers for Medicare & Medicaid Services in Baltimore, Maryland. Please go to the following link for further information: 15) Q: We know that the 2010AA Billing Provider address must be a physical address and not a P.O. Box. When the electronic claims come in the front door of the A/B MACs, will the A/B MACs validate the address with what is on file at Medicare customer service/provider relations? For example, if a provider sends 123 Any Street on their claim but they are actually enrolled with Medicare as 123 Any Place Avenue, must there be an exact match on the address before the claims will pass EDI s edit? Or is EDI not going to be that specific and will just looking to see if the address contains P.O. Box, if so then reject? A: At this time, the front end system will only be looking for the presence of "P.O. Box" or "Lock Box" in its many different forms. Claims that contain "Post Office Box", "P.O. Box", "P.O. Box", "P.O. Box", "Lock Box", "Lock Bin" as the address in 2010AA will be rejected. 16) Q: Will all MAC s use the same translators in their front end systems? A: No, MACs are currently operating using three different translators. 17) Q: Will you have one web site that vendors and providers can check to see when Errata testing can be started for each state (MAC) for the 837? 4

5 A: Testing for ERRATA Medicare Part B (837P) and Part A (837I) has begun as of the week of April 4th, 2011.Therefore, please contact your MAC and begin testing. 18) Q: Of the two offices we have, one will be compliant. However, our other office has software that is not. Does the 5010 only affect electronic billing and if so, does the waiver we have to bill on paper allow us to bypass anything affected by the 5010? A: HIPAA 5010 only affects electronic billing. Paper bills are not impacted. 19) Q: On previous National Provider calls, we were informed that if you are a software vendor, and each facility/provider had their own Submitter ID number, that each provider had to test. I just want to clarify that we do not need to test for each submitter, but only test and be approved as a vendor. A: As a software vendor, you are only required to test and be approved as a vendor by each MAC that processes your customers claims. Each one of your customers is not required to test prior to being turned over to production once your software is approved. Your customers will need to contact their MAC to request to be turned over to production status on version ) Q: We were on the 15th National Provider Call and there wasn t anyone representing J3. Who do we contact for J testing questions and webinar calls? A: Please contact Noridian Administrative Services, LLC at or visit their web site at 21) Q: Could you explain what is the "pay to plan" in loop 2010AC? A: The "pay-to-plan" loop was added to allow for subrogation. Subrogation in its most common form refers to the process in which an insurance company tries to recoup expenses for a claim it paid out when another party should have been responsible for paying for all or a portion of that claim. In this situation, the claim is being sent from one "plan" to another and the "pay-to-plan" loop indicates the plan which should be reimbursed for the earlier claim payment. It is not used for Medicare FFS. 22) Q: Is the approved vendor list maintained by CMS or each individual MAC? A: The approved vendor list is maintained by the individual MACs. The approved vendor list can be located on the MACs Web sites. 23) Q: We deal in multiple jurisdictions, do we have to test with "every" MAC? A: Yes, it is advised that you test will all MACs that you conduct business with. 5

6 24) Q: We were signed up to listen to the 5010 National Call today and missed it due to the Eastern time on our registration (we are Central). Can we re-register for another call soon? A: Yes, registration will begin approximately three weeks prior to the next scheduled call on May 25, You will be able to download the transcript and audio cast from this call by visiting: 25) Q: In reviewing the companion guides, we come across conflicts between CMS and NGS. Which one is right? A: Currently all 5010 companion guides are being updated to remove any possible contradictions. In the mean time, if a contradiction arises please follow the guidance provided by CMS and bring it to the attention of your MAC to facilitate collaboration. 26) Q: Please send me the link to the slide deck for today s 5010 Medicare FFS National Call. A: The slides for the 15th National Call may be located at: D=-99&sortByDID=1&sortOrder=ascending&itemID=CMS &intNumPerPage=10. 27) Q: I am looking for when each MAC will be ready to test 5010 Errata (5010a1) version and if there is any information on testing procedures. A: All MACs are now ready to begin 5010 ERRATA testing. Please reference slide 26 of the 15th National Call for links directly to the contractors to obtain information related to testing protocols. 6