Title NPI enumeration/subpart standardized reporting Issue ID 1

Transcription

1 Title NPI enumeration/subpart standardized reporting Issue ID transactions enforce the intent of the NPI final rule. Providers must use the same enumeration strategy regardless of the health plan that claims are being sent to. Today, many providers were forced to submit their NPIs differently based by health plan requirements. If providers utilize a different NPI enumeration strategy they must elect which one they wish to use & inform all their health plans in the change. DISCUSSION:Comment This is not just a problem between provider and payer if provider changes anything, then the other payers will need to be contacted. Tied to this is the additional issue that you can send the Taxonomy Code at the Billing provider level. How does the payer really know what the enumeration is? John states if the provider ended up in the wrong situation it is because a payer forced them to. Do we have any idea how big this effort is? Laurie said if you were on board with what was going on in the industry then you shouldn't have a problem. Jenny stated that it is up to the provider to take this on. Laurie stated it was an issue with COB. Addition of the related surgical procedure is new. Does the anesthesiologist have this code available? For non compound drug reporting there is an issue with these, some use 25 per and some use one per. Can we get the Medicaids to do this the same way? The 5010 did not touch this and 837 group should handle. The billing provider definition on when it is permissible for the billing provider to be an individual some payers are asking for the billing to be put in the rendering is enforcing NPI unfortunately some providers did not because of health plan requirements. A couple of providers have indicated that they need to redo their enumeration. The subpart rule states that if a provider enumerates it must be the same for all payers. John Bock asked that we use 2 different terms one for enrollment and one for enumeration. RECOMMENDATION Go back to NPI Whitepapers Nancy Spector This is a golden opportunity for companies to do outreach Bruce LeGrand. If COB is where this is going to impact and providers benefit can providers be convinced by Cost Benefit Analysis The NPIOI did a lot of whitepapers and we should go back to them Gail Kocher If we put something in writing around subparts providers/payers can go back. Work with the Medicaids directly to address route causes work with NEHMI Betsy Clore.

2 Title Billing Provider Loop vs Pay to Loop Issue ID 2 The billing provider loop (2010AA) must now contain a physical address with a 9 digit zip code. The guides are silent on which physical address is to be used. Since physical addresses are now required, it may affect NPI crosswalks that have been developed. Industry may need to use the pay to loop as well in their NPI crosswalk strategies. DISCUSSION:Comment If provider enumerated by location or the zip code is not the same for the PO Box If there is no NPI attached to the Pay to there is also a problem. Can the payer ignore the Pay to Loop and use what they have on file? There are a lot of NPI's that have different location if the Pay to provider has to be sent for where you want the check sent. This is an extra step for payers must look at the NPI crosswalks. Everyone may need to recognize both addresses now. What physical address are they looking for? Laurie the physical address associated with the NPI. While we are talking about whether the payer has to look at this this may resort to contract information. There is a difference if there is not a contractual arrangement. What we have told providers is to use the physical address of the billing provider. Can we continue? John no it must be a physical address not a PO Box. If you want to know where the services were performed you must look at the 2310 Loop. They were excited to hear that the physical address was in billing because they don't get the 2310 loop. Is there an impact to paper John on UB04 there is a place for the Pay to Addresses in Form Loc 2. NUCC If you put a PO Box in Box 33 it will cause a problem when scanning. If you drop a secondary claim to paper is it okay to put a PO Box in 33? As this determination was made to get to standard reporting for COB some objections were made in order to get to the base units. Payer also required the surgery code with anesthesia modifiers. To overcome this objection the surgical cpt was added and ob units were added to handle the business process to handle these situations. The decision was developed with the ASA they commented against even though they were part of the development of the solution. Kepa would like to get a statement from WEDI to state any deviation from the guide needs to be stated in the GS08. Gail said this was taken away at the pre con and should be taken off the list for RECOMMENDATION WEDI comes up with a clarification of the address requirements for billing loop. There needs to be strict rules. At the end of the day we need to crosswalk the NPI. The 837 Sub Workgroup should do a whitepaper. Find out from payers what adjudication logic they are using with regards to addresses.

3 Title Patient/subscriber reporting Issue ID transactions were modified to sync up with the eligibility transactions. If a health plan has a unique member ID for a family member under a parent/subscriber then that patient ID must be reported in the subscriber loop with patient name. Patient loop is not used. DISCUSSION: Doesn't the payer still need to associate the patient with the insured? They may have patient level number but they may not print on the ID card. They do not need the number on the claim. They discussed this when they put in a new ID card system. Their concern was the typo and ID does not match the right identifier. They use an individual number but also have other logic for mapping. If it doesn't match they then have someone look at it. They only need the subscriber level. There are going to be changes that payer needs to make in 4010 the 837 and the 270/271 are out of synch. If they are doing the 270/271 correctly the subscriber information is not returned and it is required on the claim. There are a lot of smaller payers that do not do 270/271 RECOMMENDATION Payers must implement the 270/271 in the correct manner to ensure claim is correct. WEDI could gather information from payers on which way they do this and post on their website. Check the ID Standard to ensure it is in line with the new definitions.

4 Title New balancing requirements Issue ID 4 The 837 transactions now require that balancing must occur at the line level & claim level this includes the COB loops as well. DISCUSSION: Question: Does the 835 have to balance back to the 837? Laurie stated that the Front matter has a lot of information. The problem is when the payer splits the claim into separate claims per line item. The guide requires all lines to be reported on split claims with the adjustment reflecting. If done the right way it would solve the problem. Rules for claim spilling are in the 835 must balance back to the 837. RECOMMENDATION Payers need to generate balanced 835's for the providers to use. Providers need to have edits in their posting systems before the claim goes out the door.

5 Title Issue ID 5 Anesthesia reporting (minutes) 837 transactions require that anesthesia units be reported as minutes using the MJ qualifier.

6 Title Compound drug reporting Issue ID 6 Current 4010A1 allows compound drug to be reported in 2 different ways which requires providers to maintain a listing of health plan requirements. Version 5010 allows compound drugs to be reported only 1 way. Reporting of individual drugs within a compound is done in a 1 to 1 relationship with a HCPCS code for all claims for example: a HCPCS would repeat multiple times when multiple NDCs are reported as part of the compound

7 Title CLP02 claim status code Issue ID 7 The claim status codes notes were modified which will result in health plans using the codes consistently. DISCUSSION:Comment The Claim Status Code you cannot send a denial code of 4 if you process the claim unless you cannot identify the patient. They would reject back to submitter before it hit adjudication so not a problem. In 4010 there were some CAS codes that were not advised and have now been removed in 5010 programming change if you were using them.

8 Title Remark code usage Issue ID 8 Remark codes are considered optional by some payers. The use of certain reason codes now require a remark code be used when further explanation must be given to support the reason for denial. DISCUSSION:Comment The remark code usage was considered optional by a lot of payers in 5010 you must use remark code if needed to clarify. If you are a payer who did not implement RRCs then you must send for some of the CAS requires one. There is additional language MUST. For example ' 96' non covered service must have a remark to explain why not covered. Payers are not using remark codes, but clearinghouses and providers may be dropping them. They need to stop doing this.

9 Title Recoupment process Issue ID 9 Payers get to dictate which recoupment process that they will use which makes it difficult for providers since they must maintain multiple methods. Although payers need to be aware of state regulations which could force them to use a specified method.

10 Title EFT Issue ID 10 EFT is not mandated under HIPAA. Until EFT is implemented, providers do not see a benefit to implement the 835 transaction without it because of the difficulties with trying to match multiple checks with multiple 835s.

11 Title Reporting of service type codes Issue ID 11 No description provided

12 Title Alternate search logic Issue ID 12 The 5010 guides have implemented alternate search logic options which may be difficult for some health plans to implement.

13 Title Reporting of patient specific identification Issue ID 13 The claim transactions were modified at the patient level to match the eligibility transaction. If a patient has their own identification number, then the patient must be reported in the subscriber loop and the patient loop is not used.

14 Title Use of specific category codes Issue ID 14

15 Title Use of status code composite elements Issue ID 15

16 Title Adoption of transaction Issue ID 16 In order to get the full benefit of HIPAA named transactions the industry needs to adopt all the named transactions which includes the "not" so used transactions like eligibility & claim status.

17 Title Standard companion guides Issue ID 17 WEDI & X12 have entered into an agreement to address this issue. It would be very beneficial for the industry if everyone would utilize a similar companion guide.

18 Title Use of other non published standards Issue ID 18 With the implementation of 5010, it was identified that it may be beneficial to look at other non named HIPAA transactions to see if there would be any benefit to look at them know. For example, claims attachment, 1st report of injury, subrogation etc.

19 Title Standardized acknowledgements Issue ID 19 CMS has announced that they will be implementing TA1, 999 & 277CA acknowledgments for their 5010 implementation. It would benefit the entire healthcare industry if all entities implemented as well.

20 Title Enforcement (compliance) Issue ID 20 With 4010 enforcement of the named transactions has been an issue due to the concern with retaliation of one entity when they report a trading partner as not implementing HIPAA. It is possible to report an issue anonymously but then it is very difficult to follow up on these types of complaints.

21 Title Level One Compliance Start now Issue ID 21 Although not required under 5010 it is strongly recommended to meet the level 1 compliance by 1/2011. How can we get the industry to adopt a good recommendation to the industry to implement.

22 Title Engage trading partners now Issue ID 22 The number of trading partners that all entities engage with, communication, collaboration & cooperation needs to begin now to ensure a successful implementation.

23 Title Need for readiness tracking tools Issue ID 23 One of the lessons learned from 4010 implementation was that a tracking tool would have been a great resource tool to have available to determine which trading partners are ready, their implementation plans etc. Many trading partners struggle to try and find out how was where in their timeline implementation & whether or not they would even be ready.

24 Title Affect of state laws Issue ID 24 State laws are having an impact on federal. What can WEDI do to help facilitate these issues?

25 Title Development of test case scenarios Issue ID 25 It was discussed that it would be very beneficial to have WEDI help develop test case scenarios to help facilitate the testing process.

26 Title Impact of Medicare changing their EDI front end Issue ID 26 CMS announced that they are changing how 5010 implementation will be significantly different from the current 4010 process. With these changes, will the industry have difficulty adopting the new transaction codes as well as a new workflow process at the same time?

27 Title Impact of Medicaid implementation on the industry Issue ID 27 WEDI need to communicate with CMS to ensure that the Medicaid agencies implement 5010 timely & correctly.

28 Title Influencing upper management to make 5010 a Issue ID 28 It was requested that WEDI create information to help the industry understand the important of starting 5010 implementation now.