HIPAA COW Spring 2012 HIPAA Provider 5010 Claim Experience. Quick Identification + Quick Notification = Quick Resolutions

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1 HIPAA COW Spring Highlights and Updates Christol Green Sr. EDI Business Consultant HIPAA 5010 Provider 5010 Claim Experience Anthem 5010 Experience Escalating 5010 Questions Anthem EDI 5010 Analysis and Resolutions For Your Information Slides 5010 Testing Notifications Important 5010 Changes EDI Claim Reports Billing Provider and Pay to Address Nine-digit ZIP Code Anesthesia Units vs. Minutes 2 Provider 5010 Claim Experience Rejected Claims Triage Issues -Software, Clearinghouse, Payer Escalation Accounts Receivable Quick Identification + Quick Notification = Quick Resolutions 3 1

2 Anthem 5010 Experience Industry is Adjusting to New Mandate 5010 is Complex Providers, Clearinghouse, Software Vendors, Payers Industry Experiencing 5010 Related Issues Reaction Time-Quick or Slow Providers, Clearinghouse, Software Vendors, Payers Anthem 5010 Approach Monitoring daily reject rates, submission volumes, support calls Work with Trading Partners directly Internal triage and escalation for all 5010 issues Identify and implement changes 4 Escalating 5010 Questions 1 st Point of Contact Clearinghouse Vendor In-House Technical Staff 2 nd Point of Contact EDI Solutions Helpdesk (option 2) Live Chat/ edi-wi@anthem.com 5010 Questions 5010EHTS@anthem.com 3 rd Point of Contact Provider Network Representative 5 Anthem EDI 5010 Research and Resolutions 6 2

3 Anthem EDI 5010 Research and Resolutions Required when different editing 32066, 60028, The Claim Filing Indicator (Loop 2000B, SBR09) must = BL. (Blue Cross/Blue Shield). Secondary Claim Rejections (837I) & (837P)- When Total Charge (2300 CLM02) does Not equal Paid Amount (Loop 2320 AMT02), CAS segments plus Total Paid must equal Total Charge Top EDI Rejects March Member ID Invalid One WI TP -about 1/3 of claim errors were due to a wrong claim filing indicator, they were sending CI instead of BL Anthem Fix 03/16/ Anthem Fix 04/20/ Anthem EDI 5010 Research and Resolutions 837P Claims being returned from our WGS system, stating submit to your home plan? Issue: mapping used Pay To Provider ( Payment/remit address) when Service Facility field (box 32) was blank to determine Provider location of Service. Correction: mapping changed to look first at Service Facility field (box 32) if blank then use Billing Provider field (box 33) to determine Provider location of Service. 8 Anthem EDI 5010 Research and Resolutions Phone number - hyphens/spaces Not allowed 277CA Report-Real-time Delivery Anthem Fix 03/16/2012 ********** 9 3

4 EDI Claim File Reports 999 Interchange Acknowledgment (for Inbound Transactions) The Enterprise EDI Gateway generates a 999 Interchange Acknowledgment in response to an EDI file submission. This process applies Level 1 edits and reports the results. Recognize errors occurred and begin a correct/resubmit action, or Recognize that all transactions were accepted. 277CA Claims Acknowledgment (for Inbound 837 Transactions) The Enterprise EDI Gateway generates a 277CA in response to an EDI file submission. This process applies edits and reports the results. Recognize errors that occurred and begin a correct/resubmit action on specific claims, Recognize transactions were accepted and, use returned claim numbers for future status inquiries. EDI Response Report (Level 2) Anthem reports are delivered within 24hours after receipt of the electronic file. Reports are often re-formatted by the clearinghouse as a service to the provider. Review reports daily or as often as submissions occurs and reconcile claim totals and dollars submitted. Anthem s Level 2 Response reports can be used to support timely filing. Contact your clearinghouse or vendor for questions about reformatted reports. Correct errors and resubmit claims electronically 10 Billing Provider and Pay-to Address For 5010, the Billing Provider must contain a physical street address only and the Pay-to Address is available for the P.O. Box or Lock Box address, if needed. Additionally, the Pay-to Address, submitted only when different from the Billing Provider, may include a P.O. Box, Lock Box, and/or street address, as applicable. Actual claim payment is sent to the address established on system during the initial set-up and/or contracting, based on the provider's 1099 form. Therefore, ACTION IS REQUIRED by providers for the following situations: 1. Provider currently submits a P.O. Box or Lock Box address in the Billing Provider Determine a physical street address Determine if P.O. Box or Lock Box address needed, and submit in Pay-to Address Verify with software vendor, clearinghouse, or billing service that correct address is being submitted 2. Provider changes destination for claim payment; different from that contractually established. Notify Provider Relations representative (billing/contracting) Verify with software vendor, clearinghouse, or billing service that correct address is being submitted 11 Billing Provider and Pay-to Address - Example Currently, Dr. Provider submits his billing address as "P.O. Box 1234" and is in process of having his payments sent to a pay-to address different from what was set up contractually, "1111 Payto Street, P.O. Box 1111". He knows that for 5010, he must submit a physical street address in the Billing Provider loop. To ensure that his claims are processed and payments made to the correct address, he contacts his provider representative with his updated information. BILLING address N301 = P.O. Box 1234 BILLING address N302 = 123 Billing Street BILLING address N301 = 123 Billing Street Pay-to address N301 = P.O. Box 1234 BILLING address N301 = 123 Billing Street Pay-to address N301 = 1111 Pay-to Street Pay-to address N302 = P.O. Box 1111 FAIL: P.O. Box is not allowed PASS: payment made to address on system PASS: payment made to address on system 12 4

5 Nine-digit ZIP codes When reporting the ZIP code for U.S. addresses in the Billing Provider and Service Facility Location, the full nine digit ZIP code must be provided. Dental - Billing Provider (2010AA, N403), Service Facility Location (2310C & 2420D, N403) Institutional - Billing Provider (2010AA, N403), Service Facility Location (2310E, N403) Professional - Billing Provider (2010AA, N403), Service Facility Location (2310C & 2420C, N403) All valid codes are identified in Code Source 932: Universal Postal Codes, and also accessible from the internet look-up tool: Example: Currently, Dr. Bill Provider submits his ZIP code as '90212'. But he knows that for 5010, he must submit his full nine-digit ZIP code in the Billing Provider loop. He verifies the last four digits of his ZIP code as '2403'. Claim submission with N403 = FAIL: ZIP code is not valid Claim submission with N403 = FAIL: ZIP code is not valid, requires 9 digits Claim submission with N403 = FAIL: spaces are not allowed Claim submission with N403 = FAIL: hyphens are not allowed Claim submission with N403 = PASS: ZIP code is valid, format is correct 13 Anesthesia Services - Units vs Minutes Administration of anesthesia must be reported with the correct measurement per the 837 TR3. Institutional (837I) - Service Line (2400, SV204), Quantity measured using 'UN' (units) Professional (837P) - Service Line (2400, SV103), Quantity measured using 'MJ' (minutes) Providers no longer need to apply a conversion factor to calculate units when reporting on anesthesia services on 837P claim submissions. *If the conversion factor is a concern, please contact your Provider Representative or Relations area. Example: Today, Dr. Rendering A. Provider submits a claim for laser eye surgery; anesthesia reported in units. But he knows that for 5010, he must submit his anesthesia services in minutes. He verifies the use of the qualifier 'MJ' for future 5010 claim submissions for anesthesia services. Service = SV1*HC:00142:QK:QS:P1*2600*UN*7***1~ Service = SV1*HC:00142:QK:QS:P1*2600*MJ*104***1~ FAIL: Units are not accepted PASS: Minutes are accepted Example: Today, Dr. Rendering B. Provider submits a claim for laser eye surgery; anesthesia reported in minutes. And he knows that for 5010, anesthesia services are accepted in minutes only. He determines that no change is needed. Service = SV1*HC:00142:QK:QS:P1*2600*MJ*104 ***1~ PASS: Minutes are accepted Anthem BCBS WI EDI Contact Information EDI Solutions Help Desk Monday Friday, 8:00 a.m.- 4:30 p.m. Telephone: (option 2) anthem.edi@anthem.com Website: (select state) LIVE CHAT 15 5

6 Questions Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association