Medicare Fee For Service (FFS)

5010 and Testing

Purpose of Today’s Call

Discuss readiness Transactions and errata Testing requirements and

procedures Companion Guide Going into production

5010 and Affected Business Processes Claims (837 Institutional, Professional, COB, Dental,

NCPDP) Claim Status (276/277) Claim Payment (835) Enrollment (834) Premium Payment (820) Eligibility (270/271) Referrals and Prior Authorizations (278) Claims Acknowledgements (277CA) Acknowledgement for Health Care Insurance

(999)

5010 Errata

Medicare Implementation of 5010Common Edits and Enhancement Module (CEM)

Standardized Claim Editing One set of edits per line of business Consistent editing Consistent results for transaction

exchangeStandardized Error Handling TA1 Interchange Acknowledgement

High level report of the ISA-IEA Complete file failure

Medicare Implementation of 5010Common Edits and Enhancement Module (CEM) cont’d

999 Replaces the 997 transaction Communicates X12 and IG syntax violations Can result in all claims being returned

(unless 999E)

277CA (claims acknowledgement) Used to communicate the status of

individual claims (accepted or rejected) Replaces proprietary reports

Medicare Implementation of 5010Common Edits and Enhancements Module (CEM) cont’d

Receipt, Control, and Balancing System of internal checks and balances Flags out of balance situations

Claim Number Assignment Immediate assignment of DCN to accepted

claims DCN will be included in the

acknowledgments Allows faster access to status inquiry/IVR

Timeline Current contractor activities January through March 2011 – translator level 1 and 2 testing

(TA1 and 999s) April 2011: Errata testing – including translator level 1 and 2,

Common Edit Module responses (277CA) including Medicare business rules, 835 testing

April 2011 through December 31, 2011 – Testing/Migration Must be 5010 Errata ONLY by January 2012!!!

Are you preparing for 5010? Start now Ask your vendor and/or clearinghouse about

their plans and timeframes implementing 5010 Communicate and coordinate Test: internally and externally Know your vendor’s schedule Know your trading partner’s schedule Communicate within entire organization to

insure all impacts identified early

Compliance Dates

Compliance deadlines were set per public comments

CMS expects compliance deadlines to be met – no extensions

Success will depend on starting early!

Ready, Set, Go… Don’t Wait to test or go into production! Short migration period Not just a Medicare issue CMS does not anticipate any delays to

compliance date In order to receive the customer service

and support you are accustomed to from your payers, vendors and clearinghouses it is important that you test early and go into production early.

Direct Submitters Testing Procedures

25 claim minimum Testing in errata version only 100% syntax 95% Medicare business rules ISA14 highly recommended to = 1 ISA15 must = T Submitter is considered in test until

approved by contractor

Testing Continued Know your Trading Partners plan What is your Trading Partner doing to

prepare?? Get on their schedule Review with your office what you need to

do to implement 5010 Test what is applicable to you Know what needs to be changed

More testing information January 1, 2012 – Compliance Date

CMS does not anticipate extensions to this deadline. Dual submission of 4010A1 and 5010 transactions

are allowed until December 31, 2011. Test under your current submitter ID Consult with Software Vendor to confirm the 999

and 277CA will be returned in a readable format! The timeline for testing the errata version begins

now. Make sure your updates are scheduled before the compliance date.

WPS is ready to test NOW!

Testing has begun! We have already received and

reviewed tests Test results returned within 3

business days

PC-Ace Pro32 Providers may download PC-ACE Pro-32 software at

the link below to submit 5010 file formats: http://www.wpsic.com/edi/pcacepro32.shtml

This free 5010 software may be downloaded and tested now

Additional instruction regarding set up to follow and will be posed on above web site

New PC-Ace users must test and go into production with 5010 errata version after April 2011

Companion Guide To assist trading partners and their business

associates with exchanging transactions Companion Guide provides technical and

connectivity specification for the following: 837 Health Care Claim Institutional 837 Health Care Claim Professional 835 Health Care Claim Payment Advice 276/277 Status Inquiry and Response

Companion guides posted to: http://www.wpsic.com/edi/pdf/med_a_837i_companion.pdfhttp://www.wpsic.com/edi/pdf/med_b_837p_companion.pdf

Links to Edit SpreadsheetsTransaction URL Link

Professional Claim 837P

http://www.cms.gov/MFFS5010D0/Downloads/ProfessionalClaim4010A1to5010.pdf

Institutional Claim 837I

http://www.cms.gov/MFFS5010D0/Downloads/InstitutionalClaim4010A1to5010.pdf

Remittance 835 http://www.cms.gov/MFFS5010D0/Downloads/Remittance4010A1to5010.pdf

Claim Status 276/277

http://www.cms.gov/MFFS5010D0/Downloads/ClaimStatus4010A1to5010.pdf

CMS National Provider Calls CMS will be hosting a variety of national education

calls that will inform the provider community of the steps that they need to take in order to be ready for implementation. These calls will also give participants an opportunity to ask questions of CMS subject matter experts

Delivery of a series of National Provider Calls –presentations, transcripts and audio files available at http://www.cms.gov/Versions5010andD0/V50/list.as

Next call, March 30, 2011, topic: 5010 National Call –Provider Testing and Readiness

Registration for upcoming events: http://www.eventsvc.com/palmettogba/

Future EDI ACTs 2011 These teleconferences are to address your EDI

questions. No reservations are required. Who should attend? Providers, billing staff,

vendors and clearinghouses with Medicare EDI questions.

2011 calls (all times 1-2:30pm cst):Date Dial In ID

May 12, 2011 800-305-2862 23353258

July 14, 2011 800-305-2862 23353259 September 8, 2011 800-305-2862 23353260 November 10, 2011 800-305-2862 23353261

Our Message to you… Start preparing now! Work with your vendor and/or clearinghouse Know your vendor and clearinghouse schedule It is your responsibility to be compliant CMS expects compliance deadlines to be met –

no extensions If you fail to prepare, it will be your

business and cash flow that will be affected!

EDI Addresses & Numbers EDIMedicareA@WPSIC.com EDIMedicareB@WPSIC.com

Medicare Part A Legacy A Medicare J5 MAC Part A & B(multiple states) (Iowa, Kansas, Missouri, Nebraska)WPS Medicare EDI WPS Medicare EDIPO Box 1602 1717 West BroadwayOmaha, NE 68101 Madison, WI. 53713Fax: (402) 351-6188 Fax: (608) 223-3824Med A Hotline: (866) 734-6656 J5 Hotline: (866) 503-9670

Medicare Part B Legacy Medicare Part B (Illinois, Michigan, Minnesota, Wisconsin) (EFT Only)WPS Medicare Electronic Data Services WPS Medicare Electronic Data

Services 912 N Pentecost Drive 8120 Penn Ave. S., Suite 200Marion, IL 62959 Bloomington, MN 55431Fax : (618) 998-5170 Fax: (952) 885-2899Med B EDI Hotline: (877) 567-7261 Phone: (952) 885-2811

(952) 885-2881 (952) 885-2882

Resources CMS 5010 and D.0 Webpage

http://www.cms.gov/version5010andD0 Educational Resources:

http://www.cms.gov/Versions5010andD0/70_Medicare_Fee-For-Service_Stems.aspys

5010 Technical Review Type 3 guides: X12: www.X12.org Washington Publishing www.WPC-EDI.com

WPS 5010: http://www.wpsic.com/edi/5010-Readiness.shtml CMS National Provider Calls: http://

www.eventsvc.com/palmettogba/