Excellus BlueCross BlueShield

Transcription

1 Excellus BlueCross BlueShield HIPAA 5010 Claims Certification Process Guide ASC X12N/005010X223A2 Health Care Claim Institutional (837) ASC X12N/005010X222A1 Health Care Claim Professional (837) ASC X12N/005010X221A1 Health Care Claim Payment/Advice (835) ASC X12C/005010X231A1 Implementation Acknowledgement for Health Care Insurance (999) ASC X12N/005010X214 Health Care Claim Acknowledgement (277) A nonprofit independent licensee of the BlueCross BlueShield Association Effective Date: 6/1/2011 Page 1 of 9

2 Table of Contents 1.0 Revision History Background Preface Purpose of Certification Scope Testing Procedures Certification steps for Claims Certification steps for Remittances Deployment into HIPAA 5010 Production Changing Testing or Production Go Live Dates... 8 Effective Date: 6/1/2011 Page 2 of 9

3 1.0 Revision History Date Author Version Description of Activity / Sections Affected 5/9/2011 S. Welk 1.0 Initial publication 2.0 Background Insurers and health care providers must be in compliance with the Information Technology Promotion Act of 2006, a health care technology bill. This bill contains a provision mandating deadlines to make the switch to a new billing and coding system, ICD-10. In preparation for ICD-10, on January 16, 2009, Health and Human Services published a final rule that replaces the HIPAA Accredited Standards Committee (ASC) X12 Version 4010A1 with the ASC X12 Version This is a major rewrite of the existing ASC X12 Version 4010A1 with more than 850 individual changes. To stay in compliance with these mandates, insurers and health care providers MUST be using the new HIPAA 5010 version of the standards no later than January 1, After this date, Excellus BlueCross BlueShield may no longer be able to accept nor transmit HIPAA transactions in a 4010 or 4010A1 format unless the Final Rule compliance date changes. It is imperative that providers doing their own HIPAA 5010 testing or their practice management software vendor, billing service or clearinghouse who is testing for them, contact Excellus BCBS (EDI Solutions see Section 6) as early as possible to schedule certification testing. If you are uncertain whether you or your practice management software vendor, billing service or clearinghouse is responsible for the testing, please contact EDI Solutions immediately. Effective Date: 6/1/2011 Page 3 of 9

4 Deadlines Certification must begin no later than September 1, 2011, in order to complete 5010 production deployment no later than November 1, Failure could result in the provider s inability to submit electronic claims to Excellus BCBS after December 31, Preface For expediency, any reference to 4010 implies both currently HIPAA-compliant 4010 & 4010A1 transactions. References in this guide to specific transactions reflect the current errata version being tested. 4.0 Purpose of Certification Excellus BCBS has made the necessary system modifications to accept and process HIPAA 5010 formatted transactions. During 2011, trading partners will need to test with Excellus BCBS to ensure that their HIPAA 5010-formatted claim transactions can be processed and that they can receive and process HIPAA 5010 electronic remittances along with the new acknowledgement transactions. A Trading Partner is defined as any Excellus BCBS provider, billing service, or clearinghouse that transmits to- or receives electronic data from Excellus BCBS. 5.0 Scope The following transaction types will require certification testing. They are: ASCX12N/005010X223A2 Health Care Claim Institutional (837) ASCX12N/005010X223A1 Health Care Claim Professional (837) ASCX12N/005010A1 Health Care Claim Payment/Advice (835) Providers not registered to receive a HIPAA 4010 electronic remittance advice will not test the ASCX12N/ Health Care Claim Payment/Advice (835). Effective Date: 6/1/2011 Page 4 of 9

5 In addition to testing the above transaction types, you will also be asked to confirm receipt and review error files and report file outputs. They include: TRN/TA1 transmission error reports ASC X12C/005010X231A1 Implementation Acknowledgment for Health Care Insurance (999) ASC X12N/005010X214 Health Care Claim Acknowledgment (277) Payer response report files 6.0 Testing Procedures There are nine steps to HIPAA 5010 transaction certification and deployment into production. All trading partners will need to complete all of the following: 6.1 Certification steps for Claims Step1 Contact Excellus BCBS EDI Solutions department to schedule your certification testing event. Excellus BCBS EDI Solutions Department Phone: (585) or 1 (877) EDI.Solutions@excellus.com Excellus BCBS EDI Solutions department will assign an analyst to support your testing and will provide you with a unique login/password to be used in certification testing. A certification testing start date will be scheduled during this contact. You will also be asked to confirm the information we have on file and to provide contact information for this certification event. Step 2 Once the scheduled test date has arrived, use the provided login/password to connect to the Excellus BCBS domain and upload your test files as described on page 8 of the Companion Guide ( (then follow links beginning with Coding & Billing & HIPAA Resources).This web section is being changed to HIPAA 5010 & ICD-10 Resource Center Effective Date: 6/1/2011 Page 5 of 9

6 The file should include all transaction types as defined on page 7 of the Companion guide. These guidelines represent the minimum set of transaction types required for certification testing. You may use previously processed production files that have been converted to the HIPAA 5010 transaction format, as long as all required transaction types are included. Step 3 Excellus BCBS will accept your file and make the necessary test execution. You will receive acknowledgements and reports indicating the status of the test run, delivered to your personal Clearinghouse mailbox. The trading partner will need to review the following: TRN/TA1 reports give status on the transmission 999 implementation acknowledgements will give a status on the batch and list any errors found 277 acknowledgement report lists all transactions that have been transmitted Step 4 Step 5 Step 6 In addition, within hours, payer response reports will be available in your mailbox indicating any transactions that were rejected. Please review the rejections. If there are any errors, you will be asked to correct the problem and resubmit your files for retest (step 3-5) until all errors are eliminated. After all errors are corrected and a clean run is accomplished, Excellus BCBS will mark you as 837 certified. You must be certified before Excellus BCBS will change our production systems to accept and process formatted transactions from you. 6.2 Certification steps for Remittances Step 7a If you normally receive an Electronic Remittance Advice/835, check receipt and accuracy of remittances as follows: Payformance Corporation PaySpan Health Excellus BCBS will test independently with Payformance Corporation and be certified by them. If you are paid through Payformance Corporation PaySpan Health, you can obtain HIPAA remittances that were generated from the test claims submitted through the Excellus BCBS Clearinghouse. Effective Date: 6/1/2011 Page 6 of 9

7 At the time the provider or their vendor is certifying with Excellus BCBS, they can request of the EDI Solution analyst assisting them, to obtain the PaySpan Health remittance. Once the provider is migrated to 5010 production by Excellus BCBS, PaySpan Health HIPAA 5010 remittances are accessible through new provider portal functionality as part of PaySpan Health s newest release version 4.1. The provider or their vendor should contact PaySpan Health Provider Services at 1 (877) for information on how to modify their PaySpan Health account settings to receive the 5010 format of the 835. Remittances will be available in both 4010 & 5010 formats during 2011 on PaySpan Health via Document Archive Search, even if you have elected to default to On April 30, 2011, two weeks prior to the May 14, 2011, production release of 4.1, Provider Services will start publishing News & Alerts on PaySpan Health to promote the new provider portal functionality ( format option) as well as webinar schedules on the new content. Excellus BCBS Clearinghouse If you receive an Electronic Remittance Advice/835 directly from Excellus BCBS through your Clearinghouse mailbox: Using the same test file you submitted for testing 837s, Excellus BCBS will adjudicate the claims and produce matching 835 remittances and deliver them to the test Clearinghouse mailbox. Review the remittances received from the end-to-end test run. Notify your EDI Solutions analyst of any issues you are experiencing and they will work with you to determine root cause. Step 7b If You Receive Paper Check and Paper Remittance If you currently receive paper checks and paper remittances from Excellus BCBS, we internally test to validate accuracy as we did when you first began sending transactions to Excellus BCBS in 4010 format. 6.3 Deployment into HIPAA 5010 Production Step 8 Once you are satisfied with the 835 electronic remittances available through your Clearinghouse mailbox; please notify your Excellus BCBS EDI Solutions analyst. At that time your analyst Effective Date: 6/1/2011 Page 7 of 9

8 will work with you to schedule your go live date to switch you from 4010 to 5010 production. Step 9 Go Live As of 6 a.m. on the scheduled go live date, Excellus BCBS systems will start accepting 837 institutional 5010A2 formatted transactions, 837 professional 5010A1 transactions and will deliver A1 formatted 835 electronic remittances to your delivery location. Once you go live, Excellus BCBS will no longer accept 4010 formatted 837 transactions, and your claims will be rejected if they are in the 4010 format. If you experience any difficulties after the go live, please contact the E-Commerce department at 1 (877) Trading Partner Help Desk. 7.0 Changing Testing or Production Go Live Dates Scheduled Test Date Please notify your EDI Solutions analyst if you need to change the date. Contact us as soon as you are aware of a need to reschedule. Please attempt to keep the original test date, as rescheduling might result in a new date significantly in the future. This could result in a new production deployment date that impacts the migration of your entire 5010 deployment with all of your trading partners (clearinghouses, billing services, other payers, etc.) prior to January 1, Production Switch-Over to 5010 date Please notify your EDI Solutions analyst if you need to change the date. Your 4010 mailbox will be turned off on the production cutover date you were provided. Effective Date: 6/1/2011 Page 8 of 9

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