Read DSHS_ProviderOne_Reponse_04012010.pdf text version

STATE OF WASHINGTON

DEPARTMENT OF SOCIAL AND HEALTH SERVICES

Health and Recovery Services Administration

626 8th Avenue, S.E. · P.O. Box 45502 Olympia, Washington 98504-5502

April 1, 2010

Mr. Andrew Busz, Director Financial Policy Washington State Hospital Association 300 Elliott Avenue West, Suite 300 Seattle, Washington 98119

Dear Mr. Busz: Thank you for sharing the Washington State Hospital Association (WSHA) ProviderOne Task Force concerns in your letter dated March 26, 2010. The Department of Social and Health Services (the Department) very much appreciates WSHA's facilitation of an open and direct dialog with Task Force members. Please find direct responses to each item raised in the letter. 1. Communication of System Changes: Recognizing the impact to the provider community, the Department has made a concerted effort to minimize changes when implementing ProviderOne. Nonetheless, several changes have been necessary to comply with federal rules associated with the Health Insurance Portability and Accountability Act (HIPAA) including: (1) use of the National Provider Identifier (NPI), (2) taxonomy codes, and (3) the new HIPAA compliant ProviderOne Client ID. Besides these identifier changes, other changes have been made to facilitate greater automation of claims processing. All of these changes have also been communicated via training and informational webinars, presentations, direct mail campaigns, email notices and Billing Instruction updates (see Appendix A for a list of all provider communications activities since 2006). In addition, DSHS still uses its regular, formal communication channels to providers, as follows: a. Policy changes are communicated via numbered memos per state law. b. Companion Guides communicate Washington State specific requirements for batch X12 ANSI transactions. c. Paper and direct data entry instructions are communicated in the new ProviderOne Billing and Resource Guide.

Appendix A: Summary of Provider Outreach

Preparing Providers for Medical & Nursing Home Claims Release

The Department of Social and Health Services (DSHS) is bringing a modern, more efficient Medicaid payment system named ProviderOne into operation. DSHS will implement the first phase of ProviderOne in 2010. To ensure continued payment all provider organizations, billing agents and clearinghouses need to be aware of DSHS' timeline, necessary readiness activities and changes ­ including new identifiers that will be used in ProviderOne. However, given limited resources, DSHS is focusing its outreach efforts on the largest and most critical access-to-care providers representing about 4,000 of the total 14,000 active billing providers. These critical providers are responsible for 85-90% of the Medicaid dollars claimed. Highlighted below are communication and outreach efforts driven by the ProviderOne project team to help providers prepare for ProviderOne Phase 1 Medical and Nursing Home Claims implementation. Additional communication and outreach from approximately 30 coaches and 20 sponsors assigned to specific types of providers are not included. Provider Readiness Activities Published E-Learning modules (recorded webinar for on-demand training) o Security Administration o Registration o Provider Essentials o Client Eligibility, Benefit Packages and Prior Authorization Inquiry o Professional Fee-for-Service Claims o Institutional Fee-for-Service Claims o Dental Fee-for-Service Claims Posting testing status of all billing agents and clearinghouses weekly; 1,571 downloads Published new ProviderOne Billing and Resource Guide Published web-version Short Cut Guide for Getting Ready for ProviderOne; 3,440 downloads Hosted series of readiness webinars; 1435 attended: o 5 Tips/Trouble Shooting Security; 242 attended o 5 Tips/Trouble Shooting Registration; 285 attended o 6 General Readiness Tasks and Cutover Schedule; 386 attended o 5 Using Taxonomy and Other New Identifiers; 330 attended o 5 HIPAA Batch Testing EDI Tips/Trouble Shooting; 192 attended Published 700 questions and answers from readiness webinars Hosted 53 system training go-live webinars; 1319 attended: o 3 Security Administration; 55 attended o 14 Provider Essentials; 431 attended o 11 Client Eligibility, Benefit Packages and Prior Authorization Inquiry; 490 attended o 12 Professional Fee-for-Service Claims; 213 attended o 8 Institutional Fee-for-Service Claims; 95 attended o 5 Dental Fee-for-Service Claims; 35 attended

1

2009 ­ 4th Quarter

1

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

Appendix A: Summary of Provider Outreach

Provider Readiness Activities ­ 4th Quarter Continued Published 302 questions and answers from system training for go-live webinars Reallocated resources to provide additional support for provider readiness activities Published schedule of key dates for cutover and transition to ProviderOne; 2,977 downloads Outreach and monitoring of 45 billing agents/clearinghouses Personal coaching and support to 150 critical 1high touch providers Personal coaching and support to 34 Tribal Health Clinics Personal coaching and support to 25 Federally Qualified Health Centers Personal coaching and support for 46 hospitals and pharmacy chains Monitoring and support for 9 Managed Care Organizations Monitoring and support for 13 Regional Support Networks Quarterly updates at Managed Care Organization (MCO)/Regional Support Network (RSN) all plan meetings or conference calls (22 plans) Provided 13 briefings at provider association meetings; 512 attended Distributed 9 project updates through email ListServ; 10,500 subscribers Update/manage ProviderOne Readiness Internet site; 71,073 overall site visits o 28,105 unique visitors to the Internet site o 18,459 visits to the provider general information page o 11,799 page visits to the steps to prepare for and complete registration o 10,917 page visits to information to get secure access to ProviderOne Developed/maintain 16 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Updates to communication managers across the agency

2009 ­ 4th Quarter

Next Steps

Additional Activities Planned Communication & outreach to encourage providers to test in Expanded Provider Readiness Testing (EPRT) Alert on WAMedWeb for providers to test transactions in EPRT Alert on remittance advice for providers to test transactions in EPRT Organize a provider resourced panel (peer to peer) Continue provider readiness monitoring and support Continue system training webinars Provide in-person "cooking show" style training (2 planned ­ 1 Tacoma; 1 Spokane) Provide in-person system training opportunities for Tribes Continue communication updates to providers through email and the ProviderOne Countdown newsletter Host pre- and post-go live check-in conference calls with various provider types to discuss cutover schedule and implementation issues (19 planned prior to; and up to 5 a day planned the first 4 weeks after implementation) Live coaching webinars for users needing additional support beyond training (36 planned) Two more issues of ProviderOne Countdown newsletter planned

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

2

Appendix A: Summary of Provider Outreach

Provider Readiness Activities Hosted 2 conference calls on HIPAA EDI batch testing; 195 attended Developed tool for providers to obtain all assigned taxonomies for billing and rendering providers for each Tax ID and to be refreshed 30 days prior to go live Letters to 12 key associations from Doug Porter with activities to share with members Letters to 9,598 organizations' CEO/CFO from Doug Porter with required readiness activities Letters to 2 nursing home associations from Kathy Leitch with readiness activities Letters to 3 pharmacy associations from Doug Porter with readiness activities Letters/emails to 834 WAMedWeb users from Dr. Thompson notifying them ProviderOne replaces WAMedWeb and key readiness steps Letter template and list of readiness activities provided to 30 coaches to tailor for their specific provider groups and smaller associations Letters/email to 445 providers using a billing agent/clearinghouse with readiness activities Emails to 303 organizations known to submit HIPAA batch transactions with readiness activities; HIPAA Testing fact sheet, invite to conference calls Alert added to WAMedWeb notifying providers it ends and directs them to the ProviderOne website to get a new logon Added message to remittance advice DSHS changing to new payment system Established web page dedicated to information on ProviderOne HIPAA batch EDI testing Developed HIPAA Batch Testing ­ Getting Started fact sheet ­ with pre-requisites; tips Notified 44 billing agents and clearinghouses that their testing status will be posted on our website Oct. 2. Requested a designated contact to share with providers Established phone structure to triage ProviderOne topics to appropriate staff Developed Short Cut Guide for Getting Ready for ProviderOne ­ Six Step tri-fold brochure Posted 31 questions and answers about implementation Hosted 4 readiness webinars; 182 attended: o 2 General Readiness Tasks and Cutover Schedule; 136 attended o 2 HIPAA Batch Testing EDI Tips/Trouble Shooting Webinars; 46 attended Hosted 4 Security Administration webinars; 369 attended Hosted 4 Registration webinars; 349 attended Outreach and readiness monitoring of 44 billing agent/clearinghouse organizations Personal coaching and support to 150 critical 1high touch providers Personal coaching and support to 34 Tribal Health Clinics Personal coaching and support to 25 Federally Qualified Health Centers Monitoring and support for 9 Managed Care Organizations Monitoring and support for 13 Regional Support Networks Published link to vendor website for information on magnetic card readers and services Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 9 briefings at provider association meetings; 162 attended Distributed 10 project updates through email ListServ; 10,500 subscribers Delivered 1 Issue of the ProviderOne Countdown newsletter; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site 42,148* visits (no July data available*) Developed/maintain 14 topic specific facts sheets, checklists and tips Developed/updated 14 provider transition plans Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Updates to communication managers across the agency

2009 ­ 3rd Quarter

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

3

Appendix A: Summary of Provider Outreach

Provider Readiness Activities Completed pre-production pilot test with sample group of providers; 6,053 total claims processed of which 678 keyed from production claims by DSHS Launched test environment for HIPAA batch file submitters Web based PIC to Client ID crosswalk available for test purposes; refreshed at 30 days before and just before go live Posted Registration E-Learning (recorded webinar for on-demand training) Developed and launched security spreadsheet tool to expedite security set up Hosted 6 Security Administration webinars; 1,043 attended Hosted 4 Registration webinars; 633 attended Developed provider training webpage with links to tools; resources and opportunities Posted 6 online tutorials providers can review at their own pace 24/7: o Introduction to ProviderOne o Security Administration o Group Provider Registration o Individual Provider Registration o Submitting Claims o Confirming Client Eligibility Developed and posted ProviderOne Provider System User Manual Outreach and readiness monitoring of 44 billing agent/clearinghouse organizations Personal coaching and support to 150 critical 1high touch providers Personal coaching and support to 34 Tribal Health Clinics Personal coaching and support to 25 Federally Qualified Health Centers Monitoring and support for 9 Managed Care Organizations Monitoring and support for 13 Regional Support Networks Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 3 briefings at provider association meetings; 60 attended Distributed 5 project updates through email ListServ; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site; 15,571 visits Developed/maintained 9 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

2009 ­ 2nd Quarter

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

4

Appendix A: Summary of Provider Outreach

2009 ­ 1st Quarter 2008 ­ 4th Quarter

Provider Readiness Activities Outreach and readiness monitoring of 44 billing agent/clearinghouse organizations Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 7 briefings at provider association meetings; 145 attended Distributed 3 project updates through email ListServ; 10,500 subscribers Delivered 1 issue of the ProviderOne Countdown newsletter; 10,500 subscribers Update/manage ProviderOne Readiness Internet site; 10,763 visits Developed/maintained 9 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

Provider Readiness Activities Hosted 9 Security Administration webinars; 949 attended Hosted 8 Registration webinars; 613 attended Hosted Security Administration lab for 13 Regional Support Network organizations Hosted Security Administration lab for 12 Tribes Outreach and readiness monitoring of 44 billing agent/clearinghouse organizations Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 13 briefings at provider association meetings; 260 attended Distributed 3 project updates through email ListServ; 10,500 subscribers Delivered 1 issue of the ProviderOne Countdown newsletter; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site; 15,292 visits Developed/maintained 9 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

5

Appendix A: Summary of Provider Outreach

Provider Readiness Activities Establish Security webpage with instructions; links to all tools and training materials Establish Registration web pages for 9 billing transaction methods (DDE, EDI, Paper, etc.) with specific steps, instructions, and links to relevant tools and materials Survey on providers using HIPAA batch transactions; 357 responses Hosted 6 Security Administration webinars; 652 attended Hosted 2 Registration webinars; 173 attended Hosted 2 conference calls with billing agents/clearinghouses Outreach and readiness monitoring of 44 billing agent/clearinghouse organizations Published ProviderOne Provider Registration & Security Manual Published 41 client eligibility and ProviderOne questions and answers Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 15 briefings at provider association meetings; 300 attended Distributed 5 project updates through email ListServ; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site; 12,870 visits Developed/maintained 9 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

2008 ­ 2nd Quarter 2008 ­ 1st Quarter

2008 ­ 3rd Quarter

Provider Readiness Activities Client Eligibility Road Show (23 events in 12 cities); 2103 attending Posted 10 new DSHS ProviderOne HIPAA Companion Guides Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 12 briefings at provider association meetings; 240 attended Distributed 4 project updates through email ListServ; 10,500 subscribers Delivered 1 Issue of the ProviderOne Countdown newsletter; 10,500 subscribers Survey on ProviderOne Client Eligibility Workshop information; 1179 responses Updated/managed ProviderOne Readiness Internet site (no data available) Developed/maintained 8 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

Provider Readiness Activities Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 7 briefings at provider association meetings; 140 attended Distributed 2 project updates through email ListServ; 10,500 subscribers Delivered 2 Issues of the ProviderOne Countdown newsletter; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site (no data available) Developed/maintained 5 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

6

Appendix A: Summary of Provider Outreach

Provider Readiness Activities Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 12 briefings at provider association meetings; 240 attended Distributed 1 project update through email ListServ; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site (no data available) Developed/maintained 5 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

2007 ­ 4th Quarter 2007 ­ 3rd Quarter 2007 ­ 2nd Quarter

Provider Readiness Activities Survey of ProviderOne Awareness; 89% indicated they heard of ProviderOne Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 16 briefings at provider association meetings; 320 attended Updated/managed ProviderOne Readiness Internet site (no data available) Developed/maintained 5 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

Provider Readiness Activities Develop tool for providers to map NPI to legacy provider ID Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 20 briefings at provider association meetings; 400 attended Distributed 1 project update through email ListServ; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site (no data available) Developed/maintained 3 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Published 61 ProviderOne and NPI questions and answers Updates to communication managers across the agency

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

7

Appendix A: Summary of Provider Outreach

Provider Readiness Activities

2007 ­ 1st Quarter 2006

Establish ProviderOne Response Team to triage and track calls about ProviderOne Quarterly updates at MCO/RSN all plan meetings or conference calls (22 plans) Provided 13 briefings at provider association meetings; 260 attended Distributed 1 project updates through email ListServ; 10,500 subscribers Updated/managed ProviderOne Readiness Internet site (no data available) Developed/maintained 3 topic specific facts sheets, checklists and tips Updates to 30 provider readiness coaches and 20 sponsors assigned to each provider type Developed/updated 14 provider transition plans Updates to communication managers across the agency

Provider Readiness Activities Hosted 18 half-day workshops in 9 cities on ProviderOne and the new National Provider Identifier (NPI); 1100 attended Hosted 2 tribal specific ProviderOne/NPI workshops; 50 attended Survey on how providers verify client eligibility; 904 responses Survey on NPI workshop; 682 responses Offered recorded CD/DVD copies of the ProviderOne/NPI workshop Site visit to 6 Managed Care Organizations Provided 23 briefings at provider association meetings; 460 attended Updated/managed ProviderOne Readiness Internet site (no data available) Developed 1 topic specific facts sheet Established DSHS provider readiness infrastructure of 30 coaches and 20 sponsors assigned to specific types of providers

Data updated through December 31, 2009. Numbers of attendees are based on best data available. High touch providers represent about 85% of claim volume and/or provide critical access to care.

1

8

Appendix B: ProviderOne Changes Cross-Reference to Communication Method

The following ProviderOne changes were summarized and included with the final go live announcement of May 9, 2010. The intent of this communication was to remind providers of the collective changes and new features available in ProviderOne. In response to WSHA Taskforce concerns about a single source for communicating these changes, the Department has included a cross-reference to the communication method below. Change Providers self-manage information and apply on-line Paper Remittance Advice (RA) will be discontinued WAMEDWEB to be replaced with ProviderOne portal Claims require new identifiers (NPI, taxonomy and client ID) Batch submitters must sign new Trading Partner Agreements (TPA) and comply with new Companion Guides Edits to validate client's date of birth and gender Full compliance with Correct Code Initiative (CCI) edits Baby on Mom's ID1 Source of Communication Training Tutorials, webinars and the ProviderOne Billing and Resource Guide Numbered memo in 2009 Alert on WAMEDWEB, training tutorials, webinars and the ProviderOne Billing and Resource Guide Numbered memo in 2008, training tutorials, webinars, Fact Sheets, and the ProviderOne Billing and Resource Guide Training tutorials, webinars, and Washington State Companion Guides Training Tutorials, webinars and the ProviderOne Billing and Resource Guide Numbered memo, training tutorials, webinars and the ProviderOne Billing and Resource Guide ProviderOne Billing and Resource Guide, interim email communication, numbered memo to be published in early April Training and documentation for Regional Support Networks (RSNs), hospital conference calls and RSN/Hospital roundtable discussion Training tutorials, webinars, and the ProviderOne Billing and Resource Guide Training tutorials, webinars and the ProviderOne Billing and Resource Guide Training tutorials, webinars and the ProviderOne Billing and Resource Guide Training tutorials, webinars and the ProviderOne Billing and Resource Guide Numbered memo, training tutorials, webinars and the ProviderOne Billing and Resource Guide Training tutorials, webinars and the ProviderOne Billing and Resource Guide Training tutorials, webinars, Fact Sheets, and the ProviderOne Billing and Resource Guide

Prior Authorization (PA) process for in-patient psychiatric claims (voluntary and involuntary)1 Nursing Homes need to include claim and line level dates Ability to attach electronic back-up documentation to claims New cover sheet for paper back-up documentation Discontinuing paper adjustment forms New Prior Authorization (PA) form and must be typed New managed care enrollment form for clients Replacing paper Medical Coupon (MAID) with permanent Services Card

1

Not included in original summary of changes that accompanied the final go live announcement

Appendix B: ProviderOne Changes Cross-Reference to Communication Method Change Source of Communication Optional Card Reader to verify client eligibility Training tutorials, webinars, Fact Sheets, and the ProviderOne Billing and Resource Guide Training tutorials, webinars, Fact Sheets, and the Expanded Interactive Voice Response (IVR) ProviderOne Billing and Resource Guide features

DEPARTMENT OF SOCIAL AND HEALTH SERVICES HEALTH AND RECOVERY SERVICES ADMINISTRATION Olympia, Washington To: All Providers Memo #: 08-59 Issued: August 18, 2008 For information, contact: 1-800-562-3022, option 2, or go to: http://maa.dshs.wa.gov/contact/prucontact.asp

From:

Douglas Porter, Assistant Secretary Health and Recovery Services Administration (HRSA)

Subject: National Provider Identifier - NPI and Taxonomy Code Requirements Upon implementation of ProviderOne, the Health and Recovery Services Administration (HRSA) will require all providers to submit both their National Provider Identifier (NPI) and Taxonomy Code on their claims.

What Claim Forms Will Require Both the NPI and the Taxonomy Code?

Providers must list both the National Provider Identifier (NPI) and the Taxonomy Code on the following claim forms: · · · · 837 electronic claim (Professional, Institutional and Dental); CMS-1500 Claim Form (version 08/05); UB-04 Claim Form; and 2006 ADA Dental Claim Form.

Note: HRSA will not pay claims unless they include both the NPI and the taxonomy code.

What Is a Taxonomy Code?

The Healthcare Provider Taxonomy Code (HPTC) is a unique, 10-digit, alphanumeric code that allows a provider to identify its specialty category. Providers applying for an NPI will be required to submit taxonomy information. A Provider may have one or more than one taxonomy associated with it. More taxonomy information can be found at: http://www.wpc-edi.com/taxonomy/more_information

Memo # 08-59 August 18, 2008 Page 2

What Loops and Data Elements Will Be Affected for 837 Professional Claims?

The loops and data elements affected for the 837 Professional Claims are: Loop 2000A ­ BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION Data Element PRV03 ­ Billing/Pay-To Provider Taxonomy Code Loop 2010AA ­ BILLING PROVIDER NAME Data Element NM109 ­ Billing Provider NPI Loop 2010AB ­ PAY-TO-PROVIDER NAME Required if the Pay-to Provider is a different entity than the Billing Provider Data Element NM109 ­ Pay-To Provider NPI Loop 2310A ­ REFERRING PROVIDER NAME Data Element NM109 ­ Referring Provider NPI HRSA does not require the Taxonomy Code of the Referring Provider Loop 2310B ­ RENDERING PROVIDER NAME Data Element NM109 ­ Rendering Provider NPI Data Element PRV03 ­ Rendering Provider Taxonomy Code

Memo # 08-59 August 18, 2008 Page 3

What Loops and Data Elements Will Be Affected for 837 Institutional Claims?

The loops and data elements affected for the 837 Institutional Claims are: Loop 2000A ­ BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION Data Element PRV03 ­ Billing/Pay-To Provider Taxonomy Code Loop 2010AA ­ BILLING PROVIDER NAME Data Element NM109 ­ Billing Provider NPI Loop 2010AB ­ PAY-TO PROVIDER NAME Required if the Pay-to Provider is a different entity than the Billing Provider Data Element NM109 ­ Pay-To Provider NPI Loop 2310A ­ ATTENDING PHYSICIAN NAME Data Element NM109 ­ Attending Physician NPI Data Element PRV03 ­ Attending Physician Taxonomy Code Loop 2310B ­ OPERATING PHYSICIAN NAME Data Element NM109 ­ Operating Physician NPI Loop 2310C ­ OTHER PROVIDER NAME Data Element NM109 ­ Other Provider NPI

Memo # 08-59 August 18, 2008 Page 4

What Loops and Data Elements Will Be Affected for 837 Dental Claims?

The loops and data elements affected for the 837 Dental Claims are: Loop 2000A ­ BILLING/PAY-TO PROVIDER SPECIALTY INFORMATION Data Element PRV03 ­ Billing/Pay-To Provider Taxonomy Code Loop 2010AA ­ BILLING PROVIDER NAME Data Element NM109 ­ Billing Provider NPI Loop 2010AB ­ PAY-TO PROVIDER NAME Required if the Pay-to Provider is a different entity than the Billing Provider Data Element NM109 ­ Pay-To Provider NPI Loop 2310A ­ REFERRING PROVIDER NAME Data Element NM109 ­ Referring Provider NPI HRSA does not require the Taxonomy Code of the Referring Provider Loop 2310B ­ RENDERING PROVIDER NAME Data Element NM109 ­ Rendering Provider NPI Data Element PRV03 ­ Rendering Provider Taxonomy Code

Memo # 08-59 August 18, 2008 Page 5

CMS-1500 Claim Form (Version 08/05)

Upon implementation of ProviderOne, HRSA will require all providers who bill using the CMS-1500 Claim Form (version 08/05) to submit both their NPI and Taxonomy Code(s) in the fields listed below: Billing Provider Number Field number 33 A ­ NPI Field number 33 B ­ Taxonomy Code If the claim requires a referring or rendering provider to be identified, that information must be submitted in the following fields: Rendering Provider Number Field number 24 J ­ NPI (lower field) Field number 24 J ­ Taxonomy Code (upper field) Referring Provider Number Field number 17B ­ NPI HRSA does not require the taxonomy code of the Referring Provider. HRSA will not pay claims and will return all CMS-1500 Claim Forms that do not include: · · NPI; and Taxonomy Code.

To view a copy of the new CMS-1500 Claim Form (Version 08/05) go to: http://www.nucc.org then click on "1500 Claim Form" at the top of the screen.

Memo # 08-59 August 18, 2008 Page 6

UB-04 Claim Form

Upon implementation of ProviderOne, HRSA will require all providers who bill using the UB-04 Claim Form to submit both their NPI and Taxonomy Code(s) in the fields listed below: Billing Provider Number Field - Form Locator 56 ­ NPI Field - Form Locator 81 ­ Taxonomy Code If the claim type requires an attending, operating, and/or other provider to be identified, that information must be submitted in the following fields: Attending Physician Number Field - Form Locator 76 NPI ­ NPI Field - Form Locator 76 QUAL ­ Taxonomy Code Operating Physician Number Field - Form Locator 77 NPI ­ NPI Other Provider Number Field - Form Locators 78 and 79 NPI ­ NPI HRSA will not pay claims and will return all UB-04 Claim Forms that do not include: · · NPI; and Taxonomy Code.

To view a sample of the new UB-04 Claim Form, go to: http://maa.dshs.wa.gov/download/sample_UB-04_Claim_Form.htm.

Memo # 08-59 August 18, 2008 Page 7

2006 ADA Dental Claim Form

Upon implementation of ProviderOne, HRSA will require all providers who bill using the 2006 ADA Dental Claim Form to submit both their NPI and Taxonomy Code(s) in the fields listed below: Billing Provider Number Field number 49 ­ NPI Field number 52A ­ Taxonomy Code If the claim type requires a rendering provider to be identified, that information must be submitted in the following fields: Rendering Provider Number Field number 54 ­ NPI Field number 58 ­ Taxonomy Code HRSA does not require the taxonomy code of the Referring Provider. HRSA will not pay claims and will return all 2006 ADA Dental Claim Forms that do not include: · · NPI; and Taxonomy Code.

To view a copy of the current ADA Dental Claim Form, go to: http://www.ada.org/prof/resources/topics/claimform.asp

How Do I Find More Information About the NPI or ProviderOne?

To learn more about the NPI, go to the HRSA NPI website http://maa.dshs.wa.gov/dshshipaa. To learn more about the ProviderOne project, go to the ProviderOne website at http://mmis.dshs.wa.gov/. To obtain your federal NPI number, visit https://nppes.cms.hhs.gov/NPPES/Welcome.do or call the toll-free numbers listed below: 1-800-464-3203; and 1-800-692-2336 (TTY).

Memo # 08-59 August 18, 2008 Page 8

How do I conduct business electronically with HRSA?

You may conduct business electronically with HRSA by accessing the WAMedWeb at http://wamedweb.acs-inc.com.

How can I get HRSA's provider documents?

To obtain DSHS/HRSA provider numbered memoranda and billing instruction, go to the DSHS/HRSA website at http://hrsa.dshs.wa.gov (click the Billing Instructions and Numbered Memorandum link). These may be downloaded and printed

Appendix D: Suspended Claim Volumes and Frequency Last 30 days Dispostion Applied on Claim Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Super Suspend Super Suspend Suspend Super Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend

Error Code 04010 03805 03755 16035 98325 03740 11120 16095 03993 01510 02205 03335 02190 03645 05015 98326 00500 98329 03390 00835 02160 03185 05110 05000 03650 02360 01300 03175 02250 03610 98360 02325 14205 16030

Error Description CLAIM HAS COMMENTS THAT MAY AFFECT ADJUDICATION REVENUE CODE NOT ALLOWED FOR CLAIM TYPE DIAGNOSIS IS NOT REIMBURSEABLE MISSING CHARGE MODE DATA CLAIM IS AN EXACT DUPLICATE INVALID PROVIDER TAXONOMY FOR PROCEDURE PROCEDURE REQUIRES PRIOR AUTHORIZATION NURSING HOME PATIENT RESPONSIBILITY DOES NOT EQUAL MONTHLY TOTAL ON FILE UNITS BILLED EXCEED LIMITS Missing Provider Statewide Vendor Number CLIENT IS COVERED BY MEDICARE DIAGNOSIS NOT ALLOWED WITH PROCEDURE Service not covered under client Benefit Service Package PROCEDURE CODE INVALID WITH NDC CLAIM INDICATES OTHER PAYER INFORMATION CLAIM IS A POSSIBLE DUPLICATE CLAIM CONTAINS A PAYMENT AMOUNT FROM ANOTHER PAYER POSSIBLE DUPLICATE PAID TO A DIFFERENT PROVIDER MODIFIER INVALID WITH PROCEDURE UNABLE TO DETERMINE CLAIM TYPE REFERRAL BY THE CLIENT'S PRIMARY CARE PROVIDER IS REQUIRED. PROCEDURE CODE REQUIRES MANUAL PRICE CLAIM WITH POSSIBLE CASUALTY COVERAGE CLIENT HAS COVERAGE FROM ANOTHER PAYER FOR THIS SERVICE Unable to derive NDC Units(Values Missing) GAU CLIENTS HAVE LIMITED SERVICE COVERAGE PATIENT CLASS NOT VALID FOR THIS CLAIM INVALID PLACE OF SERVICE FOR PROCEDURE BILLING PROVIDER NUMBER NOT FOUND IN THE RECIPIENT NURSING HOME RECORD PROCEDURE REQUIRES MODIFIER SURGERY SUSPEND FOR REVIEW NURSING HOME PATIENT CLASS DOES NOT MATCH HISTORY POSSIBLE DUPLICATE PAID TO ANOTHER MEMBER IN PROVIDER GROUP UNABLE TO PRICE FOR THE DATE OF SERVICE

Frequency 4150 635 520 510 478 468 298 298 242 215 197 188 175 174 171 169 163 150 132 128 125 123 116 115 112 89 83 83 82 76 76 73 68 65

Page 1 of 4

Appendix D: Suspended Claim Volumes and Frequency Last 30 days Dispostion Applied on Claim Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Super Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend

Error Code 02206 02130 16005 00120 98321 02115 03845 02255 02280 13475 01420 02240 00720 11065 02235 00210 02035 03310 03920 16050 14210 03145 12430 13720 00190 00530 05015 01430 01400 01470 11035 03850 11005 14175

Error Description CLIENT IS COVERED BY MEDICARE AND THERE IS AN AUTH PRESENT ON CLAIM RECIPIENT ON MEDICAL REVIEW BILLED AMOUNT REQUIRES REVIEW MISSING LINE ITEM SUBMITTED CHARGE CC/ADMIT/CNSLT NOT ALLOWED IN COMBINATION WITH SURGICAL SERVICES RECORDS INDICATES RECIPIENT DECEASED DRG STATUS IS SUSPEND. CLIENT IS NOT ELIGIBLE FOR THIS DATE OF SERVICE NURSING HOME DISCHARGE DOES NOT MATCH ELIGIBILITY DATA FITTING OF SPECTACLES ADULT LIMIT TAKE CHARGE CLIENT NOT ALLOWED TO SEE A NON TAKE CHARGE PROVIDER NO NURSING HOME RECORD EXISTS FOR THIS RECIPIENT FQHC CLAIM WITH MISSING MEDICAL ENCOUNTER CODE/UNITS PROCEDURE REQUIRES PRIOR AUTHORIZATION CLIENT PENDING SPEND DOWN REVIEW VERIFIES THAT THE TOTAL DAYS STAY MATCHES THE FROM AND TO DATE SPAN CLAIM PAYMENT COVERED BY MANAGED CARE PLAN CONSENT FORM MUST BE COMPLETELY FILLED OUT PER GUIDELINES VACCINE ADMINISTRATION FEE NOT ALLOWED MISSING CHARGE MODE RATE EXACT DUPLICATE FOR COMMUNITY HEALTH AND/OR FQHC'S SERVICE NOT ALLOWED FOR CLIENT'S AGE VISION NEW PATIENT INTERMEDIATE EXAM LIMIT ENTERAL FEEDING SUPPLY KIT LIMIT CLAIM PAST TIMELY FILING LIMITATION A CARRIER CODE HAS BEEN ENTERED ON THE CLAIM WITHOUT A PAYMENT CLAIM INDICATES OTHER PAYER INFORMATION DENIAL OF PAYMENT STATUS FOR NEW NURSING HOME ADMITS PROVIDER NURSING HOME REVIEW MEDICAL INPATIENT DETOX REQUIRES REVIEW PRIOR AUTHORIZATION, PROVIDER NUMBER MISMATCH DRG STATUS IS DENY PRIOR AUTHORIZATION NUMBER NOT FOUND ON FILE INVALID DAYS BETWEEN DISCHARGE AND NEW ADMISSION

Frequency 59 52 50 42 41 34 33 32 28 28 24 21 21 20 19 18 18 18 17 15 15 13 11 10 9 9 9 8 8 7 7 6 6 6

Page 2 of 4

Appendix D: Suspended Claim Volumes and Frequency Last 30 days Dispostion Applied on Claim Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Super Suspend Super Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Super Suspend Super Suspend Suspend Suspend Suspend

Error Code 03800 02195 00710 02225 02260 12580 98355 16030 03005 04015 12350 03765 03630 03810 00550 03360 05160 98330 11065 12940 00200 01445 13930 02050 13825 03705 00510 01490 05045 00999 03875 98180 14910 02200

Error Description NO DRG RECORD CLIENT HAS ELECTED HOSPICE SERVICES MISSING ADMIT DIAGNOSIS CLIENT NOT ELIGIBLE FOR ALL DATES OF SERVICE DISCHARGE STATUS ON THE CLAIM INDICATES RECIPIENT IS DECEASED PHYSICAL THERAPY EVALULATION LIMIT SURGERY codes previously billed UNABLE TO PRICE FOR THE DATE OF SERVICE PROCEDURE CODE NOT COVERED GENERAL ANESTHESIA IS ONLY ALLOWED FOR CERTAIN CLIENTS CRITICAL CARE LIMIT EXCEEDED PROCEDURE IS A TAXABLE PROCEDURE PROVIDER TAX RATE NOT FOUND SERVICE IS INCLUDED IN NURSING HOME PER DIEM BIRTH WEIGHT LESS THAN 100 GRAMS ASSISTANT/CO SURG/TEAM MAY BE ALLOWED FOR THIS SERVICE TPL ADJUSTMENT REASON INVALID FOR REIMBURSEMENT AMOUNT Claim Suspending After Re-Adjudication PROCEDURE REQUIRES PRIOR AUTHORIZATION MONAURAL HEARING AID LIMIT INVALID TOTAL CLAIM CHARGE PROVIDER HAS BEEN TERMINATED FOR MEDICAID PAYMENT NON-STERILE GLOVE LIMIT OF 9 UNITS EXCEEDED CLAIM PAYMENT COVERED BY MANAGED CARE PLAN MULTIPLE/CONCURRENT ANESTHESIA SERVICES REQUIRE REVIEW SPLIT BILL PROVIDER W/O MOD INTERIM BILLING REQUIRES REVIEW REVENUE CODE NOT PAYABLE TO THIS BILLING TAXONOMY MEDICARE COVERAGE REVIEW REQUIRED FOR PAYMENT HISTORY CLAIM PENDING ADJUSTMENT/VOID CLAIM MANUALLY SUSPENDED FOR REVIEW T4537 WITH MODIFIER NU LIMIT OF 42 PER YEAR EXCEEDED DIAGNOSIS NOT ALLOWED FOR SKIN BARRIER RECIPIENT HAS QMB COVERAGE ONLY

Frequency 6 6 5 5 5 5 5 4 4 4 4 4 4 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1

Page 3 of 4

Appendix D: Suspended Claim Volumes and Frequency Last 30 days Dispostion Applied on Claim Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend Suspend

Error Code 00520 13955 03685 13090 13585 14375 00685 02230 12470 00535

Error Description Frequency ADMIT DATE NOT EQUAL TO FROM DATE 1 A4335 BILLED WITH EPA #870000852 AND 870000851 NOT ALLOWED TOGETHER DURING THE 1 MISSING OR INVALID DIAGNOSIS CODE 1 MSS 6 UNITS PER CLIENT, PER DAY FOR ANY COMBINATION OF SVCS 1 DISPOSABLE CANISTER USED WITH SUCTION PUMP LIMIT OF 5 PER 30 DAYS EXCEEDED 1 ANTEPARTUM/POST PARTUM CARE AND DELIVERY CONFLICT 1 TRANSPLANT CENTER OF EXCELLENCE PROCEDURE CONFLICT 1 CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE 1 SERVICE ALLOWED ONCE IN A LIFETIME 1 FIRST DATE OF SERVICE MORE THAN 3 YEARS OLD 1 Total Suspended Claims in last 30 days (as of 3/26/10) 11572

Page 4 of 4

Information

26 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1064796


Notice: fwrite(): send of 210 bytes failed with errno=104 Connection reset by peer in /home/readbag.com/web/sphinxapi.php on line 531