98 - Professional (Physician) Visit - Office

Transcription

1 June 2011 Dear New Jersey Medicaid MEVS Switch Vendor: The Centers for Medicare & Medicaid Services (CMS) has published its final rule adopting updated versions of the standards for electronic healthcare and pharmacy transactions originally adopted under the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The mandatory compliance date for American National Standards Institute (ANSI) version 5010 and the Accredited Standards Committee (ASC) X.12 version X279A1 for 270 and 271 Eligibility Inquiry and Response transactions sets is January 1, Molina Medicaid Solutions has completed the required enhancements to the New Jersey Medicaid Management Information System (NJMMIS) to support the use of the new ANSI version 5010 transactions. We are pleased at this time to provide you with the procedures you will need to follow for implementing the use of these transactions for New Jersey Medicaid. Noteable Revisons include: (refer to the Companion Guide on NJMMIS.com for additional details) The return of Specific Service Type codes: 1 - Medical Care 33 - Chiropractic 35 - Dental Care 47 - Hospital 86 - Emergency Services 88 - Pharmacy 98 - Professional (Physician) Visit - Office AL - Vision (Optometry) MH - Mental Health UC - Urgent Care 45 Hospice Molina Medicaid Solutions 3705 Quakerbridge Road, Suite 101, Trenton, NJ Fax: NJMMISEDI@Molinahealthcare.com

2 For a single eligibility segment returned, the eligibility dates will be located in the 2100C DTP segment. For multiples, the dates will be located in the 2110C DTP segment. The returned beginning eligibility date was previously limited to the 270 inquiry beginning eligibility date. With 5010, this returned date may be earlier if the beginning of the eligibility segment is before the 270 inquiry date. Many of the eligibility messages have been revised. Those that referenced coverage or benefits associated with Third Party Liability Payors or Plans have been removed entirely. This document has the following sections: Section 1: Section 2: Identifies where to find the New Jersey Medicaid 270/271 HIPAA Companion Guide for Version 5010 Testing Section 1: New Jersey Medicaid 270/271 HIPAA Companion Guide for Version 5010 You can access the New Jersey HIPAA Companion Guide from the public area of the New Jersey Medicaid web site ( Specific instructions for accessing the NJ HIPAA Companion Guide for Version 5010: Access the New Jersey Medicaid website at Under the Information Tab located on the lower left hand side of your screen, click on Forms & Documents For the Choose a Type field you want to select the value of All For the Choose a Topic field you want to select the value of HIPAA Click on the Submit Request button Click on the document titled 270/271 HIPAA Companion Guide for Version Section 2: Testing You may begin testing with Molina Medicaid Solutions on June 13, You may submit test transactions at your discretion Monday thru Friday during the hours of 9:00 AM to 3:00 PM eastern time. Your test transactions should be submitted using the Interchange Usage Indicator value T in field ISA15. For each test 270 transaction received, the system will generate a real-time 271 response transaction. You must use the delimiters specified in the

3 New Jersey Medicaid 270/271 HIPAA Companion Guide for Version 5010 which are also listed below. Any 270 transactions received that do not use the specified delimiters will not be processed. HEX VALUE NAME DELIMITER 1D GS Group Separator Data Element Separator 1F US Unit Separator Subsequent Separator 1C FS File Separator Segment Terminator 1E RS Record Separator Repetition Separator When you have completed your testing and you are confident that your solution is ready to submit 270 version 5010X279A1 compliant transactions in production, you are to prepare a letter to the Molina Medicaid Solutions EDI Unit that includes the 3 character New Jersey Medicaid Switch Vendor ID assigned to you and state that you have completed your testing activities and you are confident that your application is ready to submit production 270 transactions in the 5010X279A1 format. This letter must be signed and dated by a representative of the switch vendor. A sample of this letter is attached. The letter may be signed electronically and returned via to NJMMISEDI@Molinahealthcare.com. When this letter is received by the EDI Unit, the EDI Unit will process your request. An confirmation will be sent to you within two weeks of the processing of your request advising you as to your approval to begin production submission of 270 version 5010X279A1 transactions. The Molina POS/MEVS Helpdesk telephone number is (609) You are strongly encouraged to include test transactions for many of the eligibility scenarios being supported by the providers for whom you are submitting eligibility request transactions. It is your responsibility to establish a comprehensive test plan that when successfully executed, establishes your readiness for submission of the new transactions in a production environment. Molina Medicaid Solutions will not be certifying your system as part of this process. The authorization that you receive from Molina Medicaid Solutions that you are now approved for production submission of the new transactions is not a guarantee of your transactions being error-free using the new standard. Listed below are some test eligibility scenarios that Molina Medicaid Solutions and the State of NJ strongly suggest be submitted as part of your test plan. Testing of service type processing is being emphasized as significant changes have been made to the new standard relative to the inquiry and response of service type codes. Your individual test plan should include many more test transactions to cover all types of inquiries/responses you may need to process.

4 1. Submit inquiry with 30 service type code and repeating service type codes in response. 2. Submit inquiry with 1 single supported service type code and beneficiary is eligible for it (single service type code returned) 3. Submit inquiry with 1 single supported service type code and beneficiary is not eligible for it (single service type code returned with 2110C EB01 = I ) 4. Submit inquiry with 1 single unsupported service type code and beneficiary has eligibility (results in repeating service type codes in response) 5. Submit inquiry with 1 single unsupported service type code and beneficiary is not eligible on date of service (results in 2110C EB01 = 6) 6. Submit inquiry with repeating service type codes and beneficiary has eligibility 7. Submit an inquiry for beneficiary with Managed Care 8. Submit an inquiry for beneficiary with commercial private insurance (type of coverage messages no longer returned) 9. Submit an inquiry for beneficiary not found on file (change to error number returned) 10. Submit an inquiry that results in only 1 EB segment returned (dates returned in 2100C DTP) 11. Submit an inquiry that results in multiple EB segments returned (date returned in 2110 C DTP)

5 SAMPLE LETTER Letterhead of MEVS Switch Vendor Date: EDI Unit Molina Medicaid Solutions P.O. Box 4804 Trenton, New Jersey Dear Molina Medicaid Solutions EDI Unit: We ( ) MEVS Switch Vendor name ( ) MEVS Switch Vendor ID have completed our testing of the 270 version 5010X279A1 transaction set and are confident that our sample test transactions are representative of our provider submissions and we are ready to submit 270 version 5010X279A1 compliant transactions in production. ( ) ( ) MEVS Switch Vendor Representative's Signature Date signed By completing the Representative s name and date you are performing an electronic version of a signature.