Presented by Thhfle Department of Social Services & HP · HIPAA 5010 • The Department of Social...

Hospital Refresher Hospital Refresher WorkshopPresented by

h f lThe Department of Social Services

& HP

1

Training Topics

• HIPPA 5010

W b A t M i t• Web Account Maintenance

• New Connecticut Behavioral Health Partnership

• Third Party Liabilityy y

• Claim Resolution Guide

• Questions

2CT interChange MMIS

HIPAA 5010

• The Department of Social Services (DSS) is implementing the new 5010 version of the HIPAA Transaction and Code Set Standards.

• HIPAA rules mandate that by January 1, 2012, all covered entities must submit transactions in the 5010 version.

• The new 5010 version impacts all electronic transactions, including client eligibility verification, and Web and paper claim

b i isubmissions.

• DSS is staggering the implementation of the new 5010 transactions.

• HIPAA 5010 version updates can be access from the


pwww.ctdssmap.com, information page, under HIPAA.

Implementation Schedule

Transactions Implementation Dates

X12 270/271 Eligibility Verification - Batch 1/26/2011

X12 999 A k l d 1/26/2011X12 999 Acknowledgement 1/26/2011

Web Claim Submission and Web Eligibility Verification 3/9/2011

Provider Electronic Solutions (PES) TBDProvider Electronic Solutions (PES) TBD

Paper Claims Changes - Professional 4/27/2011

X12 837 Professional 4/27/2011

12 83 i i 4/2 /2011X12 837 Institutional 4/27/2011

X12 837 Dental 4/27/2011

X12 835 Remittance Advice 4/27/2011

X12 276/277 Claim Status 4/27/2011

Paper Claim Changes – Institutional 6/29/2011

Paper Claim Changes - Dental 7/27/2011


p g

X12 999 Acknowledgement

The Centers for Medicare and Medicaid Services (CMS) has mandated a transition to the new 5010 version of the ASC X12 HIPAA Transaction and Code Set Standards effective X12 HIPAA Transaction and Code Set Standards effective January 1, 2012. As a result of the Department of Social Services 5010 implementation, the 999 Acknowledgement will replace the 997 Functional Acknowledgement. g

• The new HIPAA 5010 Version of the 999 Acknowledgement can be access from the www ctdssmap com information can be access from the www.ctdssmap.com, information page, under HIPAA and clicking on the link “ASC X12N 999 Acknowledgement for Health Care Insurance Transactions.”

• The IK5 in the 999 replaces the AK5 reported in the 997 The IK5 in the 999 replaces the AK5 reported in the 997. The 999 also reports an AK9. If both display an A in the first position, the file is accepted.


Web Claim Submission

A new field titled 837 Version will indicate the claim’s HIPAA version. Claims submitted via the Web prior to March 9, 2011 will display 4010. Any and all future adjustments to these claims will retain this 4010 version Claims submitted these claims will retain this 4010 version. Claims submitted via the Web on or after March 9, 2011 will display 5010.

• All diagnosis panels will display version ICD-9 until the g p p yimplementation of ICD-10 scheduled for 2013.

• Medical Record Number has been expanded to 50 characters• Medical Record Number has been expanded to 50 characters.

• Referring Provider will be added at the header.

• Rendering Provider will be added at the header.


Web Claim Submission (Cont.)


Present on Admission (POA) Indicator

• Important Change: Present on Admission (POA) value “1” will no longer be valid.

POA Indicator POA Indicator DescriptionPOA Indicator POA Indicator Description

Y Diagnosis was present at time of inpatient admission

N Diagnosis was not present at time of inpatient admission

U Documentation insufficient to determine if the condition was present at the

time of inpatient admission.

W Clinically undetermined. Provider unable to clinically determine whether the

condition was present at the time of inpatient admission.

Blank* Unreported/Not used. Exempt from POA reporting. For a complete list of codes on the POA exempt list, see the Official Coding Guidelines for ICD-9-CM. http://www.cms.gov/HospitalAcqCond/Downloads/POA_Exempt_Diagnosis_Codes.zip

* A POA indicator left blank will only be valid when submitted ith di i d th POA ti li t

des.zip


with a diagnosis code on the POA exemption list.


Present on Admission (POA) Indicator



• New panel, Cause of Injury, will allow entry of up to twelve p , j y, y pExternal Cause of Injury diagnosis codes.

• New panel Reason for Visit will allow entry of up to three • New panel, Reason for Visit, will allow entry of up to three Patient Reason for Visit diagnosis codes.

P d l ill b d t S i l P d • Procedure panel will be renamed to Surgical Procedure.

• Medicare Allowed Amount field will be removed.









Medicare Allowed Amount field is removed.


HP Provider Electronic Solutions

• Upgrade your HP Provider Electronic Solutions software now to the current 3.76 version to ensure a smooth transition to the

i 3 77 5010 i f th ft upcoming 3.77 5010 version of the software.

• Keep alert to notifications on the Provider Electronic Solution pSoftware implementation date and future training workshops.


ASC X12N 835 Health Care Payment/Advice Transaction

The new HIPAA 5010 Version of the 999 Acknowledgement updates can be access from the www.ctdssmap.com, information page under HIPAA and clicking on the link “ASC information page, under HIPAA and clicking on the link ASC X12N 835 Health Care Payment/Advice.”

• This references the most significant changes to the 835 transactions transactions.

– Client’s first and last name will be expanded to 35 and 60 characters respectively.

Th i d d t f th l i ill b i l d d i th 835 – The received date of the claim will be included in the 835.

– The corrected client name will be included when the name submitted on the 837 is different than the name in the li t li ibilit fil client eligibility file.

• Both provider and trading partners must identify the complete scope of changes reported in the implementation

id


guide.

HIPAA 5010 837 Institutional Electronic Claim Transaction

Effective April 27, 2011, DSS will begin accepting HIPAA 5010 X12N 837 Institutional Electronic Claim Transaction

• Existing formats (4010) will continue to be supported until a cutover date is announced, it is strongly recommended that you upgrade prior to that time.

• Important Changes

–5010 version identifier code is 005010X223A2

–Taxonomy qualifier of “PXC” will replace “ZZ”.

–POA indicator has move from the K3 Segment to HI Segment.

–The Address for all providers must be a street address, not P.O. Box. A nine digit zip code will be required.


Client Eligibility Verification

Web and 270/271 Eligibility Verification.

• The client’s address will be added to the eligibility response.response.

• The following data will no longer be provided in the eligibility response:

Medicare coverage effective date and end date– Medicare coverage effective date and end date

– HIC

– PDP name

– PDP Plan ID

– Third Party Liability (TPL) Policy Number

Policy Holder name– Policy Holder name

– TPL Coverage Type

– TPL Effective date and TPL End date


Client Eligibility Verification (Cont.)

• The eligibility response will include the program in which the individual has coverage in the Connecticut Medical Assistance Program along with the following service type codes if they are covered services for the client’s benefit plan.covered services for the client s benefit plan.

• 1 - Medical 86 - Emergency Services• 4 - DX X-Ray 88 - Pharmacyy y• 5 - DX Lab 93 - Podiatry• 33 - Chiropractic 98 - Professional (Physician) Visit-Office• 35 - Dental AD - Occupational Therapy

42 H H lth C AF S h Th• 42 - Home Health Care AF - Speech Therapy• 45 - Hospice AL - Vision (Optometry)• 47 - Hospital DM - Durable Medical Equipment• 54 - Long Term Care MH - Mental Healthg• 56 - Medically Related Transportation PT - Physical Therapy• 75 - Prosthetic Device RT - Residential Psychiatric Treatment• 82 - Family Planning UC - Urgent Care









The Automated Voice Response System (AVRS) will continue to return TPL information in the client eligibility verification response. response.

• Providers can access AVRS by dialing 1-800-842-8440 or locally to Farmington CT at (860) 269 2028 locally to Farmington, CT at (860) 269-2028.

– Select option 1 for Self Service Options, enter the AVRS ID and PIN,

– Select option 1 for Eligibility Verification.

• The provider may also contact the insurer to obtain policy The provider may also contact the insurer to obtain policy related information.


Web Account Maintenance

Clerk Account - AVRS ID and PIN



Primary Account Holder – Clerk Maintenance

• AVRS ID and PIN



Primary Account Holder - Updating Hospital’s address

• Demographic maintenance



• Cont. Provider Account Holder - Updating Hospital’s address


New Connecticut Behavioral Health Partnership

As of April 1, 2011 the Connecticut Behavioral Health Partnership (CT BHP) Value Options (VO) will authorize behavioral health services for Medicaid fee-for-services (FFS) and Medicaid Low Income Adults (MLIA).

• Prior Authorization (PA) requirements for intensive outpatient program and outpatient psychotherapy services were reinstated as of April 1, 2011.

• All psychiatric services beginning with the first visit will follow CT BHP authorization requirements for FFS and MLIA clients.

• PA requirements can be viewed on the CT BHP Web site at www.ctbhp.com, select For Provider, then click on covered services and under the authorization schedule select General and Psychiatric Hospital.



Inpatient Admissions

• All inpatient behavioral health PA requests with an admit date of 4/1/2011 and forward will be submitted to CT BHP date of 4/1/2011 and forward will be submitted to CT BHP

• Inpatient admissions for HUSKY A, HUSKY B and Charter Oak clients with the primary diagnosis of 291 0 (Alcohol Oak clients with the primary diagnosis of 291.0 (Alcohol withdrawal delirium), with a Revenue Center Code (RCC) other than 114, 116, 124, 134, 136, 144, 146, 154, 156, or 204 will be considered a non-behavioral health admission; 204 will be considered a non behavioral health admission; therefore hospitals need to contact the client’s Managed Care Organization (MCO) to handle both the PA requests and claim processing. Claims received by HP will deny Explanation of Benefit (EOB) code 2017 “Services included in MCO coverage.”




• FFS / MLIA Claims

Inpatient Admit Changes from Psychiatric to Medical– Inpatient Admit Changes from Psychiatric to Medical

– If the client is admitted with a primary behavioral health diagnosis (291-316) and then is subsequently admitted to a medical unit the hospital will need to contact CT BHP to a medical unit, the hospital will need to contact CT BHP Value Options (VO) to handle the authorization.

– Hospitals need to contact VO to end date the authorization authorization.

All other appropriate rules will be applied in processing these claims for payment.




• FFS / MLIA Claims

Inpatient Admit Changes from Medical to Psychiatric– Inpatient Admit Changes from Medical to Psychiatric

– If the client is admitted with a primary medical diagnosis and then is subsequently admitted to a psychiatric unit the initial authorization from Qualidigm psychiatric unit, the initial authorization from Qualidigm will cover the entire inpatient admission.

– Hospitals are required to call VO for transitional care management purposes management purposes.

– If the Hospital decides to split the claim for processing, the admit date on both claims must reflect the first day of the inpatient admission for the claim to be processed of the inpatient admission for the claim to be processed by HP.

All other appropriate rules will be applied in processing these claims for payment


claims for payment.

Other Insurance/Medicare Billing Instructions

Provider Manual Chapter 11 - Institutional Other Insurance / Medicare Billing Guide

• Providers can access this guide from the Connecticut Providers can access this guide from the Connecticut Medical Assistance Program Web site www.ctdssmap.com Information page, under Publications and then provider manuals.

• This guide will assist providers with submitting claims when the client has primary coverage through commercial the client has primary coverage through commercial insurance or Medicare, and secondary coverage through Connecticut Medicaid.

• The guide contains field by field instructions illustrating the correct format for completing the other insurance and/or Medicare information.


Medicare information.


Medicare Part A denial with Part B payment – Web claim submission• The following example illustrates a non-crossover Inpatient claim g p p

where Medicare Part A denied payment, but Medicare Part B made a payment of $200.00 with a coinsurance amount of $110.00 on the claim. The total prior payments must be entered as $310.00.

– Claim type: Inpatient Claimsyp p

– First TPL entry indicating Medicare Part A Not Applicable:



Medicare Part A denial with Part B payment – Web claim submission• Second TPL entry indicating Medicare Part B payment:y g p y



Medicare Covered Services

• If the eligibility verification response indicates “Medicare covered services only”, the client only has Qualified Medicare covered services only , the client only has Qualified Medicare Beneficiary (QMB) coverage.

Medicare is the primary payer and HP would be – Medicare is the primary payer and HP would be secondary. HP would only cover up to Medicare’s co-insurance and deductible under this benefit plan. The Medicare paid amount and the amount of co-insurance Medicare paid amount and the amount of co insurance and deductible paid by Medicaid will not exceed the Medicaid allowed amount.

– Charges that are denied or not covered by Medicare will not be considered for payment under the QMB program.


Claim Resolution Guide

Provider Manual Chapter 12 – Claim Resolution Guide

• This guide lists commonly posted Explanation of Benefit (EOB) codes and provides a brief explanation of the (EOB) codes and provides a brief explanation of the reason why claims were either suspended or denied.

Thi id id d il d d i i f h f • This guide provides a detailed description of the cause of each EOB and more importantly, the necessary correction to the claim, if appropriate, in order to resolve the error condition condition.

• This guide also provides tips to assist providers to where th d t t fi d dditi l i f ti t h l they need to go to find additional information to help on correcting their claims.



EOB 3004 “Inpatient Claim Requires Authorization”

• Cause

–The Inpatient claim requires prior authorization (PA) and there is no PA record on file in an approved status that has the same provider ID, client ID and approved dates of service that match the claim’s billing provider, client ID and admit date. The admit date must fall within the dates of service approved by Qualidigm.

• Resolution

–If the PA is not present and Qualidigm has indicated that they approved the PA more than two days ago contact they approved the PA more than two days ago, contact Qualidigm to determine the cause of the delay. The PA may have contained an error that Qualidigm needs to correct.



EOB 861 “NDC is missing or invalid”

• Cause

–The claim contains a drug related procedure code, but the National Drug Code (NDC) is either missing or invalid.

l• Resolution

–Enter the correct NDC associated to the drug related procedure code and resubmit the claim.

• Tip

–To determine the correct NDC associated to the drug related procedure code, go to www.ctdssmap.com →related procedure code, go to www.ctdssmap.com Provider → Drug Search, enter the procedure code then hit search.


Training Session Wrap Up

Where to go for more information www.ctdssmap.com

• Important Messages

• Provider Bulletins

HP Provider Assistance Center (PAC): Monday through HP Provider Assistance Center (PAC): Monday through Friday, 8 a.m. to 5 p.m. (EST), excluding holidays:

1 800 842 8440 (i t t t ll f ) (860) 269 2028 • 1-800-842-8440 (in-state toll free) or (860) 269-2028 (local to Farmington, CT).


Time for Questions

• Questions & Answers


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Presented by Thhfle Department of Social Services & HP · HIPAA 5010 • The Department of Social...

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