Medicare Fee For Service (FFS) 5010 and Testing

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• Medicare Fee For Service (FFS)5010 and Testing

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Purpose of Todays Call

• Discuss readiness
• Transactions and errata
• Testing requirements and procedures
• Companion Guide
• Going into production

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5010 and Affected Business Processes

• Claims (837 Institutional, Professional, COB,
  Dental, NCPDP)
• Claim Status (276/277)
• Claim Payment (835)
• Enrollment (834)
• Premium Payment (820)
• Eligibility (270/271)
• Referrals and Prior Authorizations (278)
• Claims Acknowledgements (277CA)
• Acknowledgement for Health Care Insurance (999)

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5010 Errata
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Medicare Implementation of 5010Common Edits and
Enhancement Module (CEM)

• Standardized Claim Editing
• One set of edits per line of business
• Consistent editing
• Consistent results for transaction exchange
• Standardized Error Handling
• TA1 Interchange Acknowledgement
• High level report of the ISA-IEA
• Complete file failure

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Medicare Implementation of 5010Common Edits and
Enhancement Module (CEM) contd

• 999
• Replaces the 997 transaction
• Communicates X12 and IG syntax violations
• Can result in all claims being returned (unless
  999E)
• 277CA (claims acknowledgement)
• Used to communicate the status of individual
  claims (accepted or rejected)
• Replaces proprietary reports

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Medicare Implementation of 5010Common Edits and
Enhancements Module (CEM) contd

• Receipt, Control, and Balancing
• System of internal checks and balances
• Flags out of balance situations
• Claim Number Assignment
• Immediate assignment of DCN to accepted claims
• DCN will be included in the acknowledgments
• Allows faster access to status inquiry/IVR

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Timeline

• Current contractor activities
• January through March 2011 translator level 1
  and 2 testing (TA1 and 999s)
• April 2011 Errata testing including
  translator level 1 and 2, Common Edit Module
  responses (277CA) including Medicare business
  rules, 835 testing
• April 2011 through December 31, 2011
  Testing/Migration
• Must be 5010 Errata ONLY by January 2012!!!

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Are you preparing for 5010?

• Start now
• Ask your vendor and/or clearinghouse about their
  plans and timeframes implementing 5010
• Communicate and coordinate
• Test internally and externally
• Know your vendors schedule
• Know your trading partners schedule
• Communicate within entire organization to insure
  all impacts identified early

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Compliance Dates

• Compliance deadlines were set per public comments
• CMS expects compliance deadlines to be met no
  extensions
• Success will depend on starting early!

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Ready, Set, Go

• Dont Wait to test or go into production!
• Short migration period
• Not just a Medicare issue
• CMS does not anticipate any delays to compliance
  date
• In order to receive the customer service and
  support you are accustomed to from your payers,
  vendors and clearinghouses it is important that
  you test early and go into production early.

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Direct Submitters Testing Procedures

• 25 claim minimum
• Testing in errata version only
• 100 syntax
• 95 Medicare business rules
• ISA14 highly recommended to 1
• ISA15 must T
• Submitter is considered in test until approved by
  contractor

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Testing Continued

• Know your Trading Partners plan
• What is your Trading Partner doing to prepare??
• Get on their schedule
• Review with your office what you need to do to
  implement 5010
• Test what is applicable to you
• Know what needs to be changed

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More testing information

• January 1, 2012 Compliance Date
• CMS does not anticipate extensions to this
  deadline.
• Dual submission of 4010A1 and 5010 transactions
  are allowed until December 31, 2011.
• Test under your current submitter ID
• Consult with Software Vendor to confirm the 999
  and 277CA will be returned in a readable format!
• The timeline for testing the errata version
  begins now. Make sure your updates are scheduled
  before the compliance date.

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WPS is ready to test NOW!

• Testing has begun!
• We have already received and reviewed tests
• Test results returned within 3 business days

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PC-Ace Pro32

• Providers may download PC-ACE Pro-32 software at
  the link below to submit 5010 file formats
  http//www.wpsic.com/edi/pcacepro32.shtml
• This free 5010 software may be downloaded and
  tested now
• Additional instruction regarding set up to follow
  and will be posed on above web site
• New PC-Ace users must test and go into production
  with 5010 errata version after April 2011

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Companion Guide

• To assist trading partners and their business
  associates with exchanging transactions
• Companion Guide provides technical and
  connectivity specification for the following
• 837 Health Care Claim Institutional
• 837 Health Care Claim Professional
• 835 Health Care Claim Payment Advice
• 276/277 Status Inquiry and Response
• Companion guides posted to http//www.wpsic.com/e
  di/pdf/med_a_837i_companion.pdf
• http//www.wpsic.com/edi/pdf/med_b_837p_companion
  .pdf

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Links to Edit Spreadsheets
Transaction URL Link
Professional Claim 837P http//www.cms.gov/MFFS5010D0/Downloads/ProfessionalClaim4010A1to5010.pdf
Institutional Claim 837I http//www.cms.gov/MFFS5010D0/Downloads/InstitutionalClaim4010A1to5010.pdf
Remittance 835 http//www.cms.gov/MFFS5010D0/Downloads/Remittance4010A1to5010.pdf
Claim Status 276/277 http//www.cms.gov/MFFS5010D0/Downloads/ClaimStatus4010A1to5010.pdf
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CMS National Provider Calls

• CMS will be hosting a variety of national
  education calls that will inform the provider
  community of the steps that they need to take in
  order to be ready for implementation. These calls
  will also give participants an opportunity to ask
  questions of CMS subject matter experts
• Delivery of a series of National Provider Calls
  presentations, transcripts and audio files
  available at http//www.cms.gov/Versions5010andD0/
  V50/list.as
• Next call, March 30, 2011, topic
• 5010 National Call Provider Testing and
  Readiness
• Registration for upcoming events
  http//www.eventsvc.com/palmettogba/

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Future EDI ACTs 2011

• These teleconferences are to address your EDI
  questions.
• No reservations are required.
• Who should attend? Providers, billing staff,
  vendors and clearinghouses with Medicare EDI
  questions.
• 2011 calls (all times 1-230pm cst)
• Date Dial In
  ID
• May 12, 2011 800-305-2862 23353258
• July 14, 2011 800-305-2862 23353259
• September 8, 2011 800-305-2862 23353260
• November 10, 2011 800-305-2862 23353261

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Our Message to you

• Start preparing now!
• Work with your vendor and/or clearinghouse
• Know your vendor and clearinghouse schedule
• It is your responsibility to be compliant
• CMS expects compliance deadlines to be met no
  extensions
• If you fail to prepare, it will be your business
  and cash flow that will be affected!

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EDI Addresses Numbers EDIMedicareA_at_WPSIC.com
EDIMedicareB_at_WPSIC.com

• Medicare Part A Legacy A Medicare J5 MAC Part
  A B
• (multiple states) (Iowa, Kansas, Missouri,
  Nebraska)
• WPS Medicare EDI WPS Medicare EDI
• PO Box 1602 1717 West Broadway
• Omaha, NE 68101 Madison, WI. 53713
• Fax [phone] Fax
  [phone]
• Med A Hotline [phone] J5 Hotline
  [phone]
• Medicare Part B Legacy Medicare Part B
• (Illinois, Michigan, Minnesota, Wisconsin) (EFT
  Only)
• WPS Medicare Electronic Data Services WPS
  Medicare Electronic Data Services
• 912 N Pentecost Drive 8120 Penn Ave. S., Suite
  200
• Marion, IL 62959 Bloomington, MN 55431
• Fax [phone] Fax [phone]
• Med B EDI Hotline [phone] Phone
  [phone]
• [phone]
• [phone]

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Resources

• CMS 5010 and D.0 Webpage http//www.cms.gov/versi
  on5010andD0
• Educational Resources http//www.cms.gov/Version
  s5010andD0/70_Medicare_Fee-For-Service_Stems.aspys
  
• 5010 Technical Review Type 3 guides
• X12 www.X12.org
• Washington Publishing www.WPC-EDI.com
• WPS 5010 http//www.wpsic.com/edi/5010-Readiness
  .shtml
• CMS National Provider Calls http//www.eventsvc.
  com/palmettogba/