837 Professional and 837 Professional and Institutional ChangesInstitutional Changes

4010A1 to 50104010A1 to 5010

Presented byPresented by

John BockJohn Bock

5010 Objectives5010 Objectives

Provide clear direction as to NPI usage Provide clear direction as to NPI usage and Provider Structureand Provider Structure

Eliminate, or at least minimize, ambiguityEliminate, or at least minimize, ambiguity Eliminate redundanciesEliminate redundancies Close 4010 LoopholesClose 4010 Loopholes Minimize need for trading partner Minimize need for trading partner

companion guidescompanion guides TR3 Development RequirementsTR3 Development Requirements

NPI and Provider StructureNPI and Provider Structure

4010A1 Implementation4010A1 Implementation Allows for a significant amount of flexibility in Allows for a significant amount of flexibility in

provider structure provider structure Results in major challenge for both providers Results in major challenge for both providers

and payersand payers

Consistent Structure – The Problem Consistent Structure – The Problem DefinedDefined

ABC Hospital System

Hospital A Hospital B

Payer A enrolls at the system level and requires the Billing Provider be ABC Hospital System.

Payer B enrolls at the hospital level and requires the Billing Provider to be the individual hospital.

Consistent Structure – The Problem Consistent Structure – The Problem Defined (Cont)Defined (Cont)

XYZ Group Practice

Site A with multiple physicians

Site B with multiple physicians

Payer A enrolls at the group level and requires the Billing Provider be XYZ Group Practice

Payer B enrolls at the Site level and requires the Billing Provider to be the individual site.

Payer C enrolls the individual physicians and requires the Billing Provider to be the physician. The Group is considered a Pay-to and must be reported as such.

Billing ProviderBilling Provider The 4010A1 versions allowed service The 4010A1 versions allowed service

bureaus and clearinghouses to be bureaus and clearinghouses to be reported in the Billing Provider Loop. This reported in the Billing Provider Loop. This is not allowed in 5010. The Billing Provider is not allowed in 5010. The Billing Provider must be a provider. must be a provider.

All payer specific secondary identifiers All payer specific secondary identifiers have been removed from the Billing have been removed from the Billing Provider loop.Provider loop.

Billing Provider (Cont)Billing Provider (Cont)

The remaining identifiers in the Billing The remaining identifiers in the Billing Provider Loop are:Provider Loop are: license numberslicense numbers tax identification numberstax identification numbers UPIN (837P only). UPIN (837P only).

The Billing Provider address must be a The Billing Provider address must be a street address.street address.

Payer Specific IdentifiersPayer Specific Identifiers

Billing Provider payer specific identifiers Billing Provider payer specific identifiers have been moved to the Payer Loop.have been moved to the Payer Loop.

The Billing Provider has also been added The Billing Provider has also been added to the COB loops to enable clear reporting to the COB loops to enable clear reporting of payer specific identifiers.of payer specific identifiers.

Payer specific qualifiers have been Payer specific qualifiers have been removed from all provider loops in favor of removed from all provider loops in favor of a standard generic qualifier (G2).a standard generic qualifier (G2).

The Billing Provider’s NPIThe Billing Provider’s NPI

In professional and dental claims, the In professional and dental claims, the Billing Provider must be an individual Billing Provider must be an individual when the provider is an unincorporated when the provider is an unincorporated entity and not eligible for an organization entity and not eligible for an organization NPI. In all other situations, the Billing NPI. In all other situations, the Billing Provider must be the organization.Provider must be the organization.

The Billing Provider’s NPI The Billing Provider’s NPI (Cont)(Cont)

If a covered healthcare provider has If a covered healthcare provider has created subparts, the Billing Provider must created subparts, the Billing Provider must always be the most granular level of always be the most granular level of enumeration. enumeration.

This is the NPI which is then sent to all This is the NPI which is then sent to all payers.payers.

Service Location and the NPIService Location and the NPI

The NPI is not allowed within the service The NPI is not allowed within the service location loops for health care providers location loops for health care providers except when the service location is not except when the service location is not part of the Billing Provider’s organization part of the Billing Provider’s organization (e.g. outside lab services, physician (e.g. outside lab services, physician hospitalist services, etc)hospitalist services, etc)

Pay-to ProviderPay-to Provider The affect of the 4010A1 Billing Provider The affect of the 4010A1 Billing Provider

definition is the Pay-to Provider can be a definition is the Pay-to Provider can be a service provider or service location. This service provider or service location. This resulted in a high level of confusion and resulted in a high level of confusion and varied implementation. In the 5010 varied implementation. In the 5010 versions, it is simply an alternate address versions, it is simply an alternate address to direct payment.to direct payment.

Pay-to Provider (Cont)Pay-to Provider (Cont)

As the Pay-to Provider is simply an As the Pay-to Provider is simply an alternate address for payment and alternate address for payment and correspondence to be directed, there are correspondence to be directed, there are no applicable identifiers. no applicable identifiers.

This loop is where lock-box or PO Box This loop is where lock-box or PO Box addresses are to be reported.addresses are to be reported.

Other ProvidersOther Providers

The NPI of individual providers is required The NPI of individual providers is required when the role of the provider can be when the role of the provider can be influenced by the Billing Provider. These influenced by the Billing Provider. These include; Attending, Rendering, include; Attending, Rendering, Supervising, Operating, Other Operating.Supervising, Operating, Other Operating.

Provider roles where the NPI is only Provider roles where the NPI is only required when known include; Referring, required when known include; Referring, Purchased Service, OrderingPurchased Service, Ordering

Other Providers (Cont)Other Providers (Cont)

Replaced the ambiguity of the mysterious Replaced the ambiguity of the mysterious “Other Provider” in the 837I with specific “Other Provider” in the 837I with specific loops for the Referring, Rendering, and loops for the Referring, Rendering, and Other Operating Provider Loops. Each Other Operating Provider Loops. Each with its own specific definition and usage with its own specific definition and usage requirements.requirements.

Added support for payer specific line level Added support for payer specific line level provider identifiers.provider identifiers.

Other Structure ChangesOther Structure Changes

Drug informationDrug information Revised loop structure to ensure only one Revised loop structure to ensure only one

way for compound drugs to be reported.way for compound drugs to be reported. Subscriber/Patient InformationSubscriber/Patient Information

Revised the rules for subscriber reporting to Revised the rules for subscriber reporting to be in sync with the eligibility transactionbe in sync with the eligibility transaction

Oxygen Therapy InformationOxygen Therapy Information The various segments needed to complete The various segments needed to complete

the CMN for Oxygen services has been the CMN for Oxygen services has been consolidated into the FRM Segment.consolidated into the FRM Segment.

Other Structure Changes (Cont)Other Structure Changes (Cont)

Payer Specific Referral and Prior Payer Specific Referral and Prior Authorization NumbersAuthorization Numbers Developed a structure that is more efficient Developed a structure that is more efficient

and robust than was done in 4010.and robust than was done in 4010. Added the Pay-to Plan loop to support the Added the Pay-to Plan loop to support the

Medicaid (and other payer) Subrugation Medicaid (and other payer) Subrugation processprocess

Other Structure Changes (Cont)Other Structure Changes (Cont)

Loop and Segment RepeatsLoop and Segment Repeats Segments and loops with repeat possibilities Segments and loops with repeat possibilities

were reviewed for appropriateness. In cases were reviewed for appropriateness. In cases where the number of repeats was deemed where the number of repeats was deemed excessive or illogical, the count was changed. excessive or illogical, the count was changed. Examples are: Examples are:• Accident Date reduced from 10 to 1Accident Date reduced from 10 to 1• Acute Manifestation Date from 5 to 1Acute Manifestation Date from 5 to 1• Line Adjustment Information (CAS) from 99 to 5Line Adjustment Information (CAS) from 99 to 5

Data Requirements ReviewData Requirements Review

Several data elements, segments and Several data elements, segments and loops were eliminated as they were loops were eliminated as they were deemed no longer necessary. These deemed no longer necessary. These include, but are not limited to:include, but are not limited to: Responsible Party InformationResponsible Party Information Credit/Debit Card InformationCredit/Debit Card Information Home Care Plan InformationHome Care Plan Information Many COB related amounts which can be Many COB related amounts which can be

calculated or derived based upon other data calculated or derived based upon other data within the claimwithin the claim

Data Requirements Review (Cont)Data Requirements Review (Cont)

On the other hand, additional data On the other hand, additional data elements were added as a result of elements were added as a result of requests submitted either directly to X12 requests submitted either directly to X12 or through DSMO change requests. or through DSMO change requests. Examples of these include;Examples of these include; Ambulance pick-up and drop-off addressesAmbulance pick-up and drop-off addresses EPSDT (837I)EPSDT (837I) Condition Codes (837P)Condition Codes (837P) Present on Admission Indicator (837I)Present on Admission Indicator (837I) Support for ICD-10 CM and ICD-10 PCSSupport for ICD-10 CM and ICD-10 PCS

Data Requirements Review (Cont)Data Requirements Review (Cont) In the name of clarity, many segments In the name of clarity, many segments

were “flattened” out. This means were “flattened” out. This means segments with multiple qualifiers and segments with multiple qualifiers and purposes were split out into their own purposes were split out into their own distinct segment representation. This distinct segment representation. This allows for clear rules to be written for each allows for clear rules to be written for each piece of information. Examples of this piece of information. Examples of this include:include: Referral/Prior Authorization NumberReferral/Prior Authorization Number Principal, Admitting, E-Code, and Patient Principal, Admitting, E-Code, and Patient

Reason for Visit Diagnosis InformationReason for Visit Diagnosis Information

Data Requirements Review (Cont)Data Requirements Review (Cont)

Situational Rules clarified and tightened.Situational Rules clarified and tightened. Rules were modified as necessary to clearly Rules were modified as necessary to clearly

state when the data is required.state when the data is required. The rules also state when the data is not to be The rules also state when the data is not to be

sent.sent. Informational notes were painstakingly Informational notes were painstakingly

separated from rule notes for clarity.separated from rule notes for clarity.

004010A1 Note Structure004010A1 Note Structure Notes: 1. In the case where the patient is the same person as the

subscriber, the property and casualty claim number is placed in Loop ID-2010BA. In the case where the patient is a different person than the subscriber, this number is placed in Loop ID-2010CA. This number should be transmitted in only one place.

2. This is a property and casualty payer-assigned claim number. It is required on property and casualty claims. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 4.2, Property and Casualty, for additional information about property and casualty claims.

3. Not required for HIPAA (The statutory definition of a health plan does not specifically include workers’ compensation programs, property and casualty programs, or disability insurance programs, and, consequently, we are not requiring them to comply with the standards.) but may be required for other uses.

005010 Note Structure005010 Note Structure

Situational Rule: Required when the services included in this claim are to be considered as part of a property and casualty claim. If not required by this implementation guide, do not send.

TR3 Notes: 1. This is a property and casualty payer-assigned claim number. Providers receive this number from the property and casualty payer during eligibility determinations or some other communication with that payer. See Section 1.4.2, Property and Casualty, for additional information about property and casualty claims.

2. This segment is not a HIPAA requirement as of this writing.

ConsistencyConsistency

Consistency efforts have long been a challenge Consistency efforts have long been a challenge in developing the Implementation Guides. in developing the Implementation Guides. Thanks to the creation of new tools and a Thanks to the creation of new tools and a database design, consistency within a single IG database design, consistency within a single IG and across all of the 5010 837 IGs is a and across all of the 5010 837 IGs is a tremendous improvement. tremendous improvement.

Significant effort was expended on the part of Significant effort was expended on the part of both X12 and the NUBC to ensure the UB04 and both X12 and the NUBC to ensure the UB04 and the 5010 837I are as in sync as possible.the 5010 837I are as in sync as possible.

Education and ExamplesEducation and Examples

““Front Matter” instruction has been added Front Matter” instruction has been added to provide direction and clarify many high to provide direction and clarify many high level concepts. These sections include:level concepts. These sections include: Extensive COB instructionExtensive COB instruction

• How to create a COB claim from a paper remitHow to create a COB claim from a paper remit• How to balance a COB claimHow to balance a COB claim• How receivers are to calculate the allowed amount How receivers are to calculate the allowed amount

of the prior payerof the prior payer AcknowledgmentsAcknowledgments

Education and Examples (Cont)Education and Examples (Cont)

Inpatient and Outpatient designationsInpatient and Outpatient designations Other definitionsOther definitions NPI Usage Within the 837NPI Usage Within the 837 Receiver direction to take an ignore, don’t Receiver direction to take an ignore, don’t

reject attitude towards situational or reject attitude towards situational or redundant data they do not useredundant data they do not use

Example transactions have been updated, Example transactions have been updated, created, and verified to be current.created, and verified to be current.

Questions?Questions?

Contact InformationContact Information

John BockJohn Bock jbock@prodigy.netjbock@prodigy.net