HIPAA 5010 Implementation FAQs for Health Care Professionals

Transcription

1 HIPAA 5010 Implementatin FAQs fr Health Care Prfessinals Updated September 27, 2012 Key Messages In January 2009, the Department f Health and Human Services published the final rule cntaining the requirements fr the health care industry t upgrade electrnic data interchange transactins t HIPAA versin 5010 by January 1, The new rules apply acrss the health care industry t health plans, physicians, hspitals, and ther health care prfessinals, and emplyer grup health plans and vendrs that currently use HIPAA versin 4010 t transmit data. Versin 5010 replaces the current versin f the X12 standard that the abve mentined entities must use when cnducting electrnic transactins, including: Claims (prfessinal, institutinal and dental) 837 Payment remittance t health care prfessinals 835 Eligibility inquiries and respnses 270/271 Claims status inquiries and respnses 276/277 Precertificatin requests and respnses 278 Enrllment and disenrllment in a health plan 834 Crdinatin f Benefits and premium payments 820 Cigna is currently accepting and sending 5010 transactins in supprt f 5010 cmpliance and is cmmitted t helping physicians and hspitals successfully migrate t When the transitin t 5010 is cmplete, we expect that health care prfessinals and custmers will benefit frm even quicker and mre accurate claim prcessing n Cigna's new gateway. Questins and Answers abut HIPAA 5010 General Questins 1. What d I need t d t becme 5010 cmpliant? Yu shuld wrk directly with yur trading partner t determine what is needed t becme 5010 cmpliant. Trading partners are wrking with Cigna t ensure all files are 5010 cmpliant. 2. Why is it imprtant fr me t wrk directly with my trading partner? Trading partners are upgrading their systems t be able t handle 5010 transactins. It is imprtant fr yu t understand yur trading partner s requirements, because the trading partner may have built cmpliance checks r ther helpful capabilities int their prcess. 3. Am I required t update my cmputer sftware? Required sftware updates are based n yur sftware r system. Yu shuld cntact yur trading partner t verify if any updates are needed.

2 4. Is a natinal prvider identifier (NPI) required t submit 5010 transactins? Yes. A NPI is required when submitting 5010 transactins. 5. Will Cigna audit my current address and cntract files? N. Yu shuld review and update yur Billing Prvider and Pay t Prvider name and address infrmatin as needed t avid claim rejectins, delays, r prcessing errrs, especially if yu have changed hw yu submit claims. 6. Has Cigna prvided 5010 cmpanin guides? Cigna prvided clearinghuses with technical cmpanin guides fr each trading partner. Yur trading partner shuld use the infrmatin prvided in that guide t prduce a less technical dcument fr yu r yur sftware vendr t use. The fllwing cmpanin guides were distributed in April 2011: 837 Institutinal inbund 837 Prfessinal inbund 837 Dental inbund 837 Institutinal utbund (Alliance) 837 Prfessinal utbund (Alliance) 835 The fllwing cmpanin guides were distributed in May 2011: The fllwing cmpanin guides were distributed in June 2011: 277 RFAI 277 PEND 276/277 Batch and interactive 278 Request/respnse batch and interactive 270/271 Batch and interactive 837 Institutinal utbund (redirects) 837 Prfessinal utbund (redirects) 7. What cmpliance level des Cigna validate n incming transactins? Cigna currently validates cmpliance Levels 1 thrugh 4: Level 1 Valid segments, segment rder, element attributes, verifying that numeric data elements have a numeric value, validatin f X12 syntax and cmpliance with X12 rules Level 2 HIPAA implementatin guide specific requirements like repeat cunts, used vs. unused cdes, elements and segments, and required r intra-segment situatinal data elements Level 3 Balancing: balanced field ttals, recrd r segment cunts, financial balancing f claims and balancing f summary fields Level 4 Specific inter-segment situatins described in the HIPAA implementatin guides (i.e. if A ccurs then B must be present) 8. What cmpliance level des Cigna validate n utging transactins? Transactins sent frm Cigna's gateway are first validated fr cmpliance Levels 1 thrugh 4. Level 1 Valid segments, segment rder, element attributes, verifying that numeric data elements have a numeric value, validatin f X12 syntax and cmpliance with X12 rules Level 2 HIPAA implementatin guide specific requirements like repeat cunts, used vs. unused cdes, elements and segments, and required r intra-segment situatinal data elements Level 3 Balancing: balanced field ttals, recrd r segment cunts, financial balancing f claims and balancing f summary fields Level 4 Specific inter-segment situatins described in the HIPAA implementatin guides (i.e. if A ccurs then B must be present) Cigna runs reprts fr Level 5 cmpliance t identify future imprvement pprtunities. Level 5 Cde set testing: valid implementatin guide specific cde set values; accepted cde set values are internatinal classificatin f diseases, ninth editin, clinical mdificatin (ICD 9CM), vlumes ne thrugh three, health care financing administratin cmmn prcedure cding system (HCPCS) except fr level three r lcal cdes and current prcedural terminlgy, 2

3 furth editin (CPT-4) 9. What s been the respnse t industry-wide challenges with meeting migratin deadlines? Recgnizing the challenges facing the industry, CMS issued updated guidance in March 2012 annuncing an additinal 90-day discretinary enfrcement perid fr penalties an extensin that was welcmed by the entire industry. The discretinary enfrcement perid began n January 1, 2012 and ended n June 30, This extensin allwed fr cntinued reslutin f issues in the end-t-end prcess. 10. Are materials available abut Cigna s 5010 plans and readiness? Yes. In additin t these FAQs, yu can find mre infrmatin n the 5010 page n Cigna.cm (Cigna.cm > Health Care Prfessinals > Resurces fr Health Care Prfessinals > Ding Business with Cigna > 5010 Transactin Standards). 11. Will any standard transactins remain n versin 4010? N standard transactins will remain n versin 4010 after all trading partners have migrated. Hwever, ther frmats may exist fr emplyers and ther entities nt subject t the regulatin, wh submit enrllment and payrll deductin infrmatin, similar t the infrmatin cntained in the 834 and 820 transactins. 12. Wh can I cntact with 5010 inquiries? Our eservice Leads can assist yu with HIPAA 5010 inquiries. Please cntact the eservice Lead fr yur regin: West Elizabeth Bet: [email protected] Sutheast Justine Durant: [email protected] Nrtheast Vera Papalk: [email protected] Natinal cntracts Ana Isabella: [email protected] Electrnic Claim (837) and Claim Acknwledgments (999 and 277CA) 1. Wh shuld I cntact t determine what has changed and which fields are required n an 837 claim submissin? Cigna prvided all trading partners with ur technical guides (cmpanin guides). Yu shuld wrk with yur trading partner t determine what has changed. 2. Will Cigna accept a PO Bx in the Billing Prvider field fr 5010? N. With the 5010 changes, a PO Bx can be submitted in the Pay t Prvider field nly. Yu must submit a street address in the Billing Prvider field. In rder t avid claim rejectin and delays, submit any demgraphic r billing ID (TIN r NPI) changes fllwing standard prcesses. 3. Will Cigna utilize 999 and 277CA transactins? Yes, Cigna will utilize the 999 and 277CA with any trading partner that can accept them. 4. Will Cigna be supprting a 277X213 [277 request fr additinal infrmatin (RFAI)]? Cigna will implement the 277RFAI in 2012 t any trading partner that can accept them. Additinal cmmunicatins will annunce when this transactin becmes available. 5. Will Cigna supprt unique member IDs fr dependents? 6. Will Cigna prvide a TA1 Interchange Acknwledgment? Yes, Cigna will prvide this infrmatin when a TA1 is requested n the submissin. 7. Can the service lcatin still be submitted in the Service Facility field under 5010? Yes, if it is different than the Billing Prvider. The Service Facility NPI shuld nly be submitted if the service facility is nt a subpart f the rganizatin. 8. Will Cigna audit my current address and cntract files? N. Yu shuld review and update yur Billing Prvider and Pay t Prvider name and address infrmatin as needed t avid claim rejectins, delays, r prcessing errrs, especially if yu have 3

4 changed hw yu submit claims. 9. Will paper claims be affected by the 5010 changes? Paper claims will nt be affected by any 5010 changes until we are fully migrated t 5010 with ur mail rm vendr. The actual timing fr when paper claims will be fully implemented t 5010 has nt been determined at this time. 10. Is there a limit t the number f lines that can be submitted n a claim? Yes. Claims with mre than 700 claim lines shuld be split int mre than ne claim. 11. What date f service shuld be submitted n a dental predeterminatin claim? A date f service shuld nt be submitted n a predeterminatin claim. If a date f service is submitted at the claim level, it will nt be cnsidered a predeterminatin claim. 12. Will Cigna reject claims if the billing r service facility ZIP cde cntains all 0 s fr the last fur digits? N. Cigna will send a warning n the 277CA that the ZIP cde received is nt a valid ZIP cde, but will nt reject the claim. 13. Will Cigna require the license number be submitted n the dental claim? N. The natinal prvider identifier (NPI) and the billing prvider tax ID are required. If yu wuld like t cntinue t send yur license number, Cigna will nt reject the claim. 14. What des a claim status f A3/21 mean? This is a claim rejectin fr missing r invalid infrmatin that prevented Cigna frm being able t accept r prcess the claim. A3 Acknwledgement/returned as unprcessable claim. The claim/encunter has been rejected and has nt been entered int the adjudicatin system 21 Missing r invalid infrmatin In mst instances, Cigna will prvide an additinal status cde identifying the missing r invalid infrmatin. If an additinal status cde is nt prvided, the claim was rejected fr a wrkgrup fr electrnic data interchange (WEDI) strategic natinal implementatin prcess (SNIP) Level 1 r 2 errr. An additinal errr is nt identified because an equivalent claim status cde is nt available fr the errr. Please wrk with yur trading partner t review the errr n the 999 Acknwledgment. Level 1 cmpliance checks fr valid segments, segment rder, element attributes, verifying that numeric data elements have a numeric value, validatin f X12 syntax and cmpliance with X12 rules Level 2 cmpliance checks fr HIPAA implementatin guide specific requirements like repeat cunts, used vs. unused cdes, elements and segments, and required r intra-segment situatinal data elements 15. What infrmatin is needed n a newbrn claim t assist with patient identificatin? Subscriber infrmatin shuld be submitted with the fllwing: The plicyhlder s Cigna ID number withut the suffix (fr example, U shuld be submitted as U ) The plicyhlder s first and last name Patient infrmatin shuld be submitted with the fllwing: The first name r Newbrn, Baby By, Baby Girl, r Twin A, etc. The newbrn s last name The newbrn s date f birth The newbrn s gender 16. What payer ID shuld be used when submitting claims t Cigna? Fr medical (including GWH-Cigna r Payer Slutins netwrk), behaviral, dental, and Arizna Medicare Advantage HMO claims, use payer ID

5 Fr Emplyee Assistance Prgram (EAP) claims, use SX071. Fr Starbridge Beech Street claims, use payer ID Cigna is cntinuing ur effrts t mve t a single payer ID, hwever an effective date has nt yet been determined. 17. Hw shuld I submit a rendering address n dental claims (837D)? The dental claim has a new Service Facility Address field that must be used t submit the address where services were rendered. 18. If I see a claim rejectin reasn that was nt seen under 4010, was the claim rejected crrectly? There are sme cmmn, but valid rejectins that may ccur under HIPAA versin View the list f these rejectins and the actins yu shuld take t reslve them fr mre details. 19. Why is Cigna accepting ld payer IDs, even thugh I received a cmmunicatin saying I shuld use a single payer ID f 62308? While we cntinue ur transitin t a single payer ID, Cigna's trading partners have agreed t accept ld Cigna payer IDs t help imprve the service experience. Fr medical (including GWH-Cigna r Payer Slutins netwrk), behaviral, dental, and Arizna Medicare Advantage HMO claims, use payer ID Fr Emplyee Assistance Prgram (EAP) claims, use SX071. Fr Starbridge Beech Street claims, use payer ID Cigna is cntinuing ur effrts t mve t a single payer ID, hwever an effective date has nt yet been determined. 20. Why did I receive a duplicate claim denial when I nly submitted the claim nce? Sme claims must be split befre they can be prcessed. When sme f the claims were split the claims were sent inadvertently t claim engines multiple times, which resulted in yu receiving the duplicate claim denial. 21. Why am I receiving a patient nt cvered rejectin when the patient is a dependent? We have identified an errr during the eligibility verificatin prcess that is causing claims fr dependents cvered by mre than ne Cigna plan t be returned as n cverage fund. Subscriber/member claims and dependent claims with single cverage are prcessing crrectly. This issue is being crrected as quickly as pssible. Electrnic Remittance Advice (ERA) Wh can I cntact t determine which fields are changing n the 835 remittance advice? Cigna has prvided all trading partners with ur technical guides (cmpanin guides). Yu shuld wrk with yur trading partner t determine what is changing. 2. Will Cigna be able t prvide test files frm data t health care prfessinals r grups? Cigna is nt testing directly with health care prfessinals r grups. Cigna is testing with ur cnnected trading partners. Yu shuld wrk directly with yur trading partner t make certain they are prepared t accept 5010 infrmatin. 3. Will Cigna supprt unique member IDs fr dependents? 4. Will Cigna require a TA1 Interchange Acknwledgment? Yes, Cigna will request a TA1 acknwledging receipt f the

6 5. Will Cigna send 835s fr Medicare Advantage HMO patients? Yes. Cigna is implementing the 835 fr Medicare Advantage HMO patients, althugh the date the 835 is available thrugh yur trading partner may be later than the date 835s are available fr ther Cigna prducts. A separate enrllment is nt needed t receive 835 fr Cigna Medicare Advantage HMO patients. Cigna will autmatically enrll any health care prfessinals already receiving 835s fr Cigna's ther prducts. 6. Why is returned in the REF payer ID f the 835? is returned n the 835 t help yu identify 835s fr patients n the GWH-Cigna netwrk. Eligibility and Benefits (270/271) 1. Wh can I cntact t determine what is changing and which fields are required n a 270/271 benefits and eligibility submissin? Cigna will require the fields mandated by the 5010 Technical Reprt (TR3). Cigna has prvided all trading partners with ur technical guides (cmpanin guides). Yu shuld wrk with yur trading partner t determine what is changing. 2. Is Cigna currently able t accept and send 270/271 eligibility transactins? Yes. Cigna currently cnducts the 270/271 eligibility, cverage and benefit inquiry transactin with many trading partners. Cigna is CORE Phase I certified. 3. What kind f infrmatin des Cigna have available fr the 270/271 eligibility transactins? Fr details n the type f infrmatin Cigna returns n the 271, please access the ecurse n the Cigna fr Health Care Prfessinals website (CignafrHCP.cm > Educatin and Help > EDI Eligibility and Benefits. 4. Will Cigna supprt 270 alternate name searches detailed in the TR3? Yes. Cigna will supprt the alternate member search ptins. If Cigna is unable t make a unique match based n the search ptins entered, an AAA segment will be returned t request additinal search criteria. 5. Will Cigna supprt unique member IDs fr dependents? 6. Will Cigna prvide a TA1 Interchange Acknwledgment? Yes, Cigna will prvide this infrmatin when a TA1 is requested n the submissin. Claim Status Inquiries (276/277) 1. Wh can I cntact t determine what is changing and which fields are required n a 276/277 claim status submissin? Cigna will require the fields mandated by the 5010 Technical Reprt (TR3). Cigna has prvided all trading partners with ur technical guides (cmpanin guides). Yu shuld wrk with yur trading partner t determine what is changing. 2. Will Cigna supprt unique member IDs fr dependents? 3. Will Cigna prvide a TA1 Interchange Acknwledgment? Yes, Cigna will prvide this infrmatin when a TA1 is requested n the submissin. Client Benefit Enrllment and Maintenance (834) 1. What 834 clients f Cigna are affected by this 5010 change? Any client that is a cvered entity (health plan, health care prfessinal, r clearinghuse) is affected by this change. 6

7 2. Hw shuld a Cigna client r designated third party administratr start the prcess fr EDI 834? T cnnect with Cigna and start sending 834 transactins, the client shuld cntact their Eligibility Accunt Specialist r Implementatin Manager. 3. Wh can the client r designated third party administratr wrk with at Cigna t help them with the 834 file frmat? They shuld cntact their Eligibility Accunt Specialist. Cigna is a registered service mark and the Tree f Life lg is a service mark f Cigna Intellectual Prperty, Inc., licensed fr use by Cigna Crpratin and its perating subsidiaries. All prducts and services are prvided by such perating subsidiaries and nt by Cigna Crpratin. Such perating subsidiaries include Cnnecticut General Life Insurance Cmpany, Cigna Health and Life Insurance Cmpany, Cigna Behaviral Health, Inc., and HMO r service cmpany subsidiaries f Cigna Health Crpratin and Cigna Dental Health, Inc. THN