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Setting Up 837 and 835 for HIPAA 5010

May 18, 2011

Pattie Naumoff Senior Applications Analyst Netsmart Technologies

Why do you care about the 5010 version?

· You like a challenge

· You like being paid for your services · You don't want the HIPAA police to take you away (it's the law)

Why is there a new version?

· To accommodate the new ICD-10 diagnosis coding

· To meet the needs of an ever changing healthcare industry · To correct some previous oversights

How many transaction versions exist?

· Currently, there are FOUR versions:

· 4010 · 4010A1 Initial Version Addenda Version

· 5010 · 5010 A1 & A2

· · · ·

Initial Version Addenda Version

837P 5010 A1 June 2010 Addenda 837I 5010 A2 June 2010 Addenda 837D 5010 A2 June 2010 Addenda Other Transaction Addenda's will be available 2nd & 3rd Quarter

Compliance Time Line

Key Dates to Remember:

January 1, 2011

December 31, 2011

Begin Testing & Implementing with Trading Partners

Last date the 4010 version is accepted

Last date ICD-9 diagnosis codes are accepted on billing claims

October 12, 2013 (except for a short window to wrap up previous billing cycles) * A trading partner may switch over to the 5010 version any time during 2011.

Changes in the 5010

· Every transaction has some changes

· Most are in the 837 claim files

· The types of changes include:

· · · · · · · Fields added and deleted Codes added and deleted Loops and segments added and deleted Loops renumbered Length of fields changed Usage changes (Required, Situational, Not Used) Situational rule changes

5010 Preparation Steps

Buy the "Technical Reports"

· New name for the "Implementation Guides"

· Name changed with the 5010 version

· Available at Washington Publishing Company

· http://www.wpc-edi.com

· As a member of the National User Group you can obtain the guides at a discounted rate.

· Contact Deb Coulter for more information.

Obtain Your Payer Companion Guides

· HIPAA designers hope these are no longer needed , but...

· In reality, payers are still likely to put their own spin on the requirements · Prior to your testing, be sure to contact your payers for this information

Buy External Code Lists You Need

· The National Uniform Billing Committee (NUBC) charges a fee for the code sets they maintain:

· · · · · Admission Source Admission Type CPT Codes Patient Status Bill Type

· See our Website for links to these sources.

Buy Transaction Testing Software

· This type of 3rd party software is helpful:

· during your initial testing period and · as part of your billing cycle to help prevent rejections

· Several products to choose from:

· · · · Claredi (www.claredi.com) Via Track (www.viatrack.com) Only Connect First Pass (www.wpc.com) With a quick web search you'll find others

5010 Implementation Steps

Download 5010 Program Updates

· 837P and 837I Patches

· January 2010

· · · · Program updates for the ANSI 5010 version New Parameters Added Old Parameters Deleted New Function Window for Version 4010 & 5010

· Additional patches since January 2010 for additional functionality.

New Function Window

· ·

Attached Parameter File -Version Parameters

· Item 15. 474 ANSI 837 Billing Prof 4010 & 5010 9999 ANSIP

Example ­ Parameter created "ANSIP"

NSA837P4PARM NSA837OH NSA837P4 Prepare NSA837OH Professional 4010 File NSA837P5PARM NSA5010P NSA837P5 Prepare NSA5010P Professional 5010 File

New Function Window­ 837 Professional

· Functions Window Parameters

· NSA837P4 <Description>

· Prepare 837 P 4010 File Medicaid

· NSA837P4PARM · NSA837P5

<Version 4010 Parameter> <Description>

· Prepare 837 P 5010 File Medicaid

· NSA837P5PARM

<Version 5010 Parameter>

New Function Window ­ 837 Institutional

· Functions Window Parameters

· NSA837I4 <Description>

· Prepare 837 I 4010 File Medicaid

· NSA837I4PARM <Version 4010 Parameter> · NSA837I5 <Description>

· Prepare 837 I 5010 File Medicaid

· NSA837I5PARM <Version 5010 Parameter>

Parameter Changes ­ 837P & 837I

· DOSBRPRTY and DOOSBRPRTY

· Supports 11 Payors

· P, S, T, A, B, C, D, E, F, G, or H.

· NOSAMEPROVCHECK

· Loop 2010BB ­ Pay-To-Provider was deleted in version 5010

· The program doesn't compare the Billing Provider (Loop 2010AA) with the Pay-To Provider (Loop 2010AB) and the Rendering Provider (Loop 2310B)

Deleted Parameters ­ 837P & 837I

· CLIENTSUBSAME

· MUST use ELIGCLIENTSUBSAME · Record DST in the Client Eligibility Record

· Defines the Subscriber Relationship to the Client

· · · · Self Mother Father Spouse

· NOCLMCAS

Deleted Parameters ­ 837 Professional

· ALLOWZEROR128

· COB Allowed Amount (2320)

· ALLOWZEROR129

· COB Patient Responsibility Amount (2320)

· COBPATPAID

· COB Patient Paid Amount (2320)

· COBDISCAMT

· COB Discount Amount (2320)

· COBPERDAYLIMIT

· COB Per Day Limit (2320)

· COBPRAMT

· COB Patient Responsibility Amount (2320)

Deleted Parameters ­ 837 Institutional

· ALLOWZEROR111

· COB Total Allowed Amount (2320)

· ALLOWZEROR114

· COB Total Medicare Paid Amount (2320)

· DOCLMQTY

· Claim Quantity - Loop 2300

· BEDDAYRT

· service activity codes to be counted Claim Quantity

· DONASV2

· Calculate Non-Covered Days - Claim Quantity - Loop 2300

· DOSTATE

· Indiana and Wisconsin

New Parameters ­ 837P & 837I

· REPSEPARATOR

· Specify the Repetition Separator (ISA11)

· Adjacent occurrences of the same repeating simple data element or composite data structure in a segment

· ROUNTOHUNDRETHS

· Rounds the Quantity value to hundredths

· ISNLISTPROMPT

· ISN Saved List for processing

New Parameters ­ 837P & 837I

· LINEPRICESUM

· Summarizes the Monetary Amount for each event included in the claim line · Outputs the total amount to the HCP segment

· NOOSBRLOWERPRTY

· Don't create Other Subscriber loops for fund sources with a lower priority

New Parameters ­ 837 Professional

· NTE096SUBDELIM

· Specifies a sub-element separator for the NTE description for record 096 · Use if if you want a sub-element separator other than a colon

· Or what is used with the SUBELEMENT parameter

· NOMODMOVE237

· Prevents the program from moving procedure modifiers in the SVD segment

New Parameters ­ 837 Institutional

· CLMUNIQID20NOMAXSERV

· Create a program-assigned unique value for the Claim Submitter ID (CLM01 Loop 2300) without use of the MAXSERV parameter

· DOSTATE

· NY - New York

· APG Medicaid billing requirements

Miscellaneous Changes

· Contract Processor

· Include the Program version to be executed

· ANSI 837 (4010 version)

· NSA837 · NSA837I · NSA837D

· ANSI 837 (5010 version)

· NSA837P5 · NSA837I5 · NSA837D5

System Setup Steps ­ CMHC/MIS

Doc

· Review documentation manuals (ANSI, XREF, CAPP, MCO) · Review HIPAA Technical Reports (implementation guides) · Review payer companion guides as needed · Review CMHC/MIS Documentation

Codes

· Modify data code tables (DCTs) · Modify recode tables · Event Rules and Event Rule DSTs

Fields

· Add/remove DSTs · Modify data entry screens (TCF Maint, MIS Designer, uScript, DB Search) · Modify your report specs as needed (AGS, uScript)

· Copy and modify your existing HIPAA related parameter files

Def

System Setup Steps ­ MIS Documentation

Field 5 is gone

Field 250 is New ­ AND not in numerical order....

System Setup Steps ­ Technical Report

Loop Number Included

Segment Identifier Included

Examples of Changes...

System Setup Steps ­ Documentation

· Compare Payor's 5010 Companion Guide with you current Payor's 4010 parameter file · Determine if you must report new data elements that you currently don't collect at your organization.

· Determine if you are using deleted data elements, segments and/or loops.

System Setup Steps ­ Codes

· Compare the 5010 code sets with your existing DCTs, Recode Tables and/or Event Rules

· Determine if the code values added apply to your organization. · Determine if you are using codes that have been deleted.

System Setup Steps ­ Codes

· Update existing DCTs with code changes

· Do not inactivate codes until you no longer need to submit 4010 files

· Add new DCTs as needed · Add new Recode Tables as needed · Add new DSTs to Event Rules as needed

.

System Setup Steps ­ Fields

· Add new DSTs as needed

· · · · · Client Staff Provider ISN Event Rule

· Add to Transactions

· Modify existing Reports if needed

System Setup Steps ­ Definition

· Copy existing 4010 parameter file to a 5010 parameter

· Remove all the Loops, Segments, fields that have been deleted

· Using Spreadsheet of changes

· Add new Loops, Segments, fields required by payer

· User Payer Companion Guide

System Setup Steps ­ Definition

· OR - You can also Contact Customer Support

· They will email to you a sample 5010 Parameter File containing all the Loops, Segments, Data Elements and Parameters

· Comment out what is not needed

· Change DSTs to match yours

· Change DCTs and Recode Tables to match yours

Internal Testing

·

· · · ·

Create test files for the payer

Submit to a 3rd Party Testing software Work any noted errors Modify your setup as needed Repeat as needed

External Testing

Testing with your trading partners (e.g. payers):

·

· · · · ·

Identify the testing process required by each partner

Update your system definition to indicate a test file Create the files Send the files to your trading partners Modify your system definition based on feedback Resubmit test files as needed

Live Submission

· As trading partners are ready, begin submitting the 5010 version of the transactions · The date when each partner is ready will vary

· Before creating the live files change the definition setting from Test to Production (field ISA15)

835 Remittance

· Minor Changes to the Record Layouts

835 Remittance ­ New Parameters

· REFRBVAL

· Select which Payments to convert from an 835 · Use when you need to process the file multiple times · Specifies value to process

· REF segment (Loop 2110)

835 Remittance ­ New Parameters

· FIELDnnn

· Parse data (separate out) and store in converted file · Example - NM1segment, field 8, the payer combined separate pieces of information in the format aa,bb,ccccccccc,dd,e.

· FIELD060 NM1.74.2100.8.7.9

· · · · · 74 2100 8 7 9 = Qualifier = Loop = Field Number of Segment = Starting Position of Data to Parse = Length of Data to Parse

Thank You for Attending

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