July, Volume 04–Issue 03
The National Government Services E-Commerce Connection online newsletter is produced by the National Government Services e-commerce consultants for all Medicare electronic submitters serviced by National Government Services; these include their Part A fiscal intermediary, Part B carrier, and the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), as well as software vendors, billing services, and clearinghouses. Questions regarding the information contained in this newsletter should be addressed through the Electronic Data Interchange (EDI) Help Desk (or as otherwise noted). The toll-free number for the EDI Help Desk is (877) 273-4334. The E-Commerce Connection online newsletter is published by the National Government Services Corporate Communications Department. The next E-Commerce Connection issue is scheduled for October 2008. The National Government Services Web site is: www.NGSMedicare.com.
E-Commerce Connection Now Serving EDI Nationwide
Medicare Convention 2008: Where the Possibilities Meet
Announcing the New Electronic Data Interchange Interactive Voice Response System
Updated EDI Help Desk E-Mail Inquiry Form
Protected Health Information on E-mails
EDI Web Site Changes and Additions
Save the Date—Don’t Miss Out on Upcoming Medicare Training
New E-mail Address for the EDI Help Desk
New E-mail Address for the EDI Help Desk
The Transaction Acknowledge Report
The GENRPT (Claims Confirmation) or Level 1 (997) Report
Medicare Validation/Front-End Edit Report
New York PC-ACE Pro32 Professional Users
CMS-10125—External Infusion Pump DME MAC Information Form
How to Prevent Duplicate Claim Denials
Coming Soon! Claim Status Inquiry Computer-Based Training
National Provider Identifier Bypass Logic Claim Rejections
External Resources and Helpful Links
CMS Quarterly Provider Updates Listserv Changes
E-Commerce Connection Feedback Survey
E-Commerce Connection Now Serving EDI Nationwide
It is with excitement that National Government Services announces another change to the E-Commerce Connection. This electronic data interchange (EDI) online newsletter has been extended to include all of the National Government Services’ states. In the beginning of 2008, the E-Commerce Connection introduced a new look. This look matches many of our EDI brochures, computer-based training (CBTs) modules, and some of our manuals.
This July issue is the first to include updates and important information for the following lines of business and states:
— The Medicare Part A (hospital) contract for the states of California, Connecticut, Delaware, Hawaii, Illinois, Indiana, Kentucky, Maine, Massachusetts, Michigan, Nevada, New Hampshire, New York, Ohio, Vermont, Virginia, West Virginia, Wisconsin, and the U.S. Territories of American Samoa, Guam, and Northern Mariana Islands, serving over 17,500 Part A providers.
— The Medicare home health and hospice contract for the states of Alaska, Arizona, California, Connecticut, Hawaii, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Oregon, Rhode Island, Vermont, Washington, and the U.S. Territories of American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and U.S. Virgin Islands, serving over 1,900 home health and hospice providers of service.
— The Medicare Part B (medical) contract for the states of Indiana, Kentucky, New Jersey, and New York, serving over 175,000 Part B physicians and providers of service.
— The Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) contract for the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin, serving over 23,100 durable medical equipment (DME) suppliers.
National Government Services continues to look for ways to make our E-Commerce Connection user-friendly and beneficial to our EDI Customers. We would like to hear from you regarding the content, usefulness, and format of the new E-Commerce Connection.
Please submit your ideas to National Government Services in the E-Commerce Connection Feedback Survey. This survey is always available on the last page of each E-Commerce Connection.
Medicare Convention 2008: Where the Possibilities Meet
National Government Services is hosting a convention that will bring together five Medicare provider groups from Part A, Part B, durable medical equipment (DME), home health and hospice (HH&H), and federally qualified health centers (FQHC). The National Government Services Medicare Convention 2008 will be held from August 25 through August 28 at the Indiana Convention Center in Indianapolis Indiana.
Registration Information
Registration for the Medicare Convention 2008 is now available. To view the registration brochure and register online, go to: www.NGSMedicare.com/NGSMedicare/ConventionRegistration.aspx.
Online Registration Tips
1. Print a copy of the Registration brochure to refer to while completing the online registration.
2. Be sure to include your e-mail address correctly on the online registration so a confirmation can be sent.
Hotel Reservations—Go to the Medicare Convention 2008 Web page at www.NGSMedicare.com/NGSMedicare/2008Convention.html.
What to do in
Exhibitor Information
Interested in being an exhibitor? Go to the Medicare Convention 2008 Web page and scroll down to Exhibitor Registration to download a copy of the exhibitor brochure at www.NGSMedicare.com/NGSMedicare/2008Convention.html.
Medicare Convention 2008 Benefits
—
This program has prior approval of the
— The Medicare Convention 2008 registration fee is a great value at $175 for each attendee.
— Over 100 different sessions are being offered at the convention.
— An opportunity to learn and network with multiple Medicare officials from the Centers for Medicare & Medicaid Services (CMS), staff from National Government Services, members from our provider/supplier Provider Outreach and Education Advisory Groups, and other convention attendees.
— Reduced rates near the convention at quality hotels that average $139 per night.
Medicare Convention 2008 EDI Sessions
Total Electronic Environment Session
The electronic remittance advice (ERA) coupled with electronic funds transfer (EFT) can make your office totally electronic. Learn about all the advantages that include quicker Medicare Part A, Part B or DME MAC payment information and receipt of funds.
Part A Specific Session
EDI Top Intermediary Front-end Rejections
This course is designed for providers and billing staff that have experience with the EDI Front-end edit reports. This session is designed to cover the most common EDI front-end rejections and how to correct and avoid these rejections.
Part B Specific Session
EDI Top Medicare Part B Front-end Rejections
This course is designed for providers and billing staff that have experience with the EDI front-end edit reports. This session is designed to cover the most common EDI front-end rejections and how to correct and avoid these rejections.
Professional Provider Telecommunication Network
This course is designed for Medicare Part B providers and will address the benefits of using the Professional Provider Telecommunication Network (PPTN) to view Medicare Part B claims topics. Topics for discussion include: claim status, beneficiary eligibility, PPTN connection alternatives, and resources.
DME Specific Sessions
Analysis Denials
This session will provide a complete analysis of the top ten claim submission errors, an overview of suggested protocols, and the resources available to avoid claims submission errors, and a jurisdiction to state comparison. This session will help suppliers correctly interpret their denied American National Standards Institute (ANSI) codes and identify when it is appropriate to resubmit a claim or request an appeal.
Interactive Voice Response/Claim Status Inquiry
Claim status, beneficiary eligibility, payment information and much more is available at your finger tips through Claim Status Inquiry (CSI) and the new Jurisdiction B DME MAC Interactive Voice Response (IVR) system. Take this opportunity to obtain step-by step instructions to learn all you need to know about both CSI and the IVR.
Part B and DME Specific Session
Medicare Remit Easy Print Demo
The Medicare Remit Easy Print (MREP) software is free and available to assist Part B providers and DME MAC suppliers in viewing and printing ERAs. View a live demonstration of the MREP software, obtain information on the benefits associated with ERAs and receive answers to your MREP questions.
Announcing the New Electronic Data Interchange Interactive Voice Response System
National Government Services will implement an IVR system on the EDI Help Desk, (877) 273-4334, in the third quarter of 2008. The EDI IVR application will assist electronic submitters through a speech-activated interface that responds to a user’s voice. Touch tone capability will be available in the event a user is unable to successfully speak to the IVR.
By implementing the EDI IVR, electronic submitters will have the ability to reset EDI passwords automatically without speaking to an EDI Help Desk technician. This new feature will expedite the processing of EDI password reset requests for all National Government Services electronic submitters.
National Government Services is implementing the EDI IVR to enhance the quality and timeliness of the customer service provided to electronic submitters through our EDI Help Desk. Further details and upcoming training documents will be available and announced through our Listserv and Web site at www.NGSMedicare.com.
Updated EDI Help Desk E-Mail Inquiry Form
To better serve our EDI customers, National Government Services has developed an EDI Help Desk E-Mail Inquiry Form.
This form should be used when assistance is needed with EDI issues or inquiries. The form can be completed and submitted online directly to Medicare Part A, Part B, or the Jurisdiction B DME MAC, based on the Web site accessed. Please complete all required information and select the “Submit Form” button. National Government Services will send an automated acknowledgement to the e-mail address provided stating that the inquiry was received.
All e-mail inquiries will receive a response within three business days of receipt.
To access the online form, choose from one of the following links:
Part A Providers:
www.NGSMedicare.com/NGSMedicare/PartA/resources/contactinformation/Help%20Desk.aspx
Part B Providers:
www.NGSMedicare.com/NGSMedicare/PartB/resources/contactinformation/help%20desk.aspx
DME Suppliers:
www.NGSMedicare.com/NGSMedicare/DMEMAC/Claims/EDI/HelpDeskInformation_EDIDMEMAC.aspx
Home Health and Hospice Providers:
www.NGSMedicare.com/NGSMedicare/RHHI/Claims/EDI/help%20desk.aspx
The EDI Help Desk is available to assist with resetting passwords for our specific systems. However, password guidelines can be as unique as your user ID. Most security breaches are a direct result of users selecting “bad” passwords. The selection of a “good” password is critical to ensure the security and integrity of your health care information. A “good” password is one that is difficult for others to guess and yet is easily remembered by the user. Follow the guidelines listed below when choosing a new password for your specific system.
System State Password Guidelines
Batch Submission CA, DE, NY, WI, • Total of 8 characters, must include
upper and lower case letters, special
characters (@, #, $) and numbers
• Is case sensitive
• Cannot use a previously used
password within the past 12 months
• Changes every 90 days
Batch Submission IL, IN, KY, MA, ME, • Total of 8 alphanumeric characters
NH, OH, • Must be lower case
• Cannot use a previously used
password within the past 12 months
• No special characters (i.e., @, #, $)
• Changes every 30 days
FISS/DDE CA, MA, ME, NH, • Total of 8 alphanumeric character
(EDS data center) WI, DME MAC • Is not case sensitive
• Cannot repeat a letter or number more
than once
• Cannot use a previously used
password within the past 12 months
• No special characters (i.e.,: @, #, $)
• Changes every 30 days
FISS/DDE/PPTN IL, IN, KY, OH • Total of 8 characters, must include
upper and lower case letters, special
characters (@, #, $), and numbers
• Is case sensitive
• Cannot use a previously used
password within the past 12 months
• Changes every 30 days
FISS/DDE NY • Total of 8 characters, must include
upper and lower case letters, special
characters (@, #, $), and numbers
• Is case sensitive
• Cannot use a previously used
password within the past 12 months
• Changes every 30 days
The EDI department is pleased to give providers two ways of contacting National Government Services—via telephone or by e-mail. When contacting the EDI Help Desk by telephone, immediate response is given to inquiries regarding claim rejections, password resets, file repostings, and report explanations. Our e-mail inquiry mailbox can be used for the same inquiries. However, our response time is within three business days from receipt. To ensure that we have the proper information to assist you thoroughly and quickly, review the following guidelines prior to contacting us.
Telephone Inquiries
Be prepared to give the following information:
— Your name
— Facility name
— State location, and
— PTAN
For electronic claims or electronic remittance advice inquiries, be prepared to give the following information:
— Your submitter ID
— Date of the claim submission
— Report name or remittance advice file name (if applicable), and
— Rejection code or patient name (if applicable)
For Medicare-based software (PC-ACE Pro32, PC Print, Express Plus, etc.), be prepared to give the following information:
— The software version, and
— The error message (if applicable)
Note: The EDI Help Desk does not support third party billing software. Inquires regarding software not provided by Medicare (example: PC-ACE Pro32, PC Print, Express Plus) must be directed to the software vendor.
For password resets, be prepared to give the following information:
— Your user ID
— Your Authentication Number or PIN (used as security verification)
— The system that you are trying to access, and
— Any errors you may be receiving
E-mail Inquiries
For e-mail inquiries, be prepared to give the following information:
— Your name
— Facility name, and
— PTAN
For electronic claims or electronic remittance advice inquiries, be prepared to give the following information:
— Your submitter ID
— Date of claim submission
— The report name or electronic remittance advice file name (if applicable), and
— The rejection code (if applicable)
For Medicare-based software (PC-ACE Pro32, PC Print, Express Plus, etc.), be prepared to give the following information:
— The software version, and
— The error message (if applicable)
For password resets, be prepared to give the following information:
— Your user ID
— Your authentication number or PIN (used as security verification)
— The system that you are trying to access, and
— Any errors you may be receiving
When contacting National Government Services via e-mail, be sure to use the e-mail inquiry form located on the Contact Information page of your Resources category on the www.NGSMedicare.com Web site. This form will require you to complete all the necessary information needed for EDI to assist you. We are committed to providing you with the best service possible. By supplying us with as much information as possible, we will ensure that your inquiry is answered timely and accurately.
Protected Health Information on E-mails
Sending protected health information (PHI) via e-mail is a Health Insurance Portability and Accountability Act (HIPAA) violation. Never send PHI via e-mail. PHI can consist of a patient’s name, date of birth, Health Insurance Claim number (HICN), or Social Security Number (SSN), date of service and/or diagnosis, as well as a user’s password for the National Government Services systems. Any e-mail containing PHI will be immediately deleted.
Information such as a submitter ID, Provider Transaction Access Number (PTAN) or National Provider Identifier (NPI) number, report name or error code is not considered PHI sensitive information. When you communicate via e-mail, you should include this type of information to help us assist you quickly and safely.
EDI Web Site Changes and Additions
On Wednesday, April 30, 2008, National Government Services launched a new Web site at www.NGSMedicare.com. The new National Government Services Web site offers:
— ease of navigation;
— personalized portal pages;
— searchable frequently asked questions; and
— an events calendar.
A Web site tutorial is conveniently located on the home page. This tutorial offers search tips, navigation instructions, and highlights of the new key features of the new site. You are encouraged to take advantage of this free online educational tutorial on your initial visit to the new site! So join us as National Government Services embarks on this new journey on the World Wide Web. We believe that this will be a positive change for the provider community. You will like what you see!
Save the Date—Don’t Miss Out on Upcoming Medicare Training
National Government Services’ Provider Outreach and Education team presents training opportunities for all providers and suppliers. Join our Listserv or go to the Events Calendar on our Web site at www.NGSMedicare.com. When you are viewing the Events Calendar, select your Provider Type and select “go”. Both available and completed training events can be viewed, and there is direct access to the online registration page from the calendar view!
Part A EDI Updates
The following updates apply to all National Government Services Medicare Part A providers.
New E-mail Address for the EDI Help Desk
The National Government Services e-mail address for the Medicare Part A EDI Help Desk was changed effective Monday, May 5, 2008, due to a security breach. The new Medicare Part A e-mail address is: NGS_EDI_PartA@Wellpoint.com.
The following updates apply to all National Government Services Medicare Part B providers.
New E-mail Address for the EDI Help Desk
The National Government Services e-mail address for the Medicare Part B EDI Help Desk was changed effective Monday, May 5, 2008, due to a security breach. The new e-mail address is: NGS_EDI_PartB@Wellpoint.com.
The Transaction Acknowledgement Report
This is the first report the provider can receive for their claim submissions. The Transaction Acknowledgement (TRN) report is a receipt that National Government Services has received the initial download of your electronic claim file. The TRN report is available immediately after sending your claim file.
The first piece of important information is the Time Stamp. This will give you the date and time you sent the claim file. Example: 200805010809511 means that the file was sent on May 1, 2008, at approximately 9:51.
The second piece of important information is the statement “1 envelope processed out of 1 identified.” If you see 0 envelopes processed, you know that we did not receive this file. There will be an error message on this page such as File Format not recognized. You may have clicked on the incorrect claim file name. You must correct your information and resend your claim file.
If billing through a clearinghouse or billing service, you must obtain these reports from your vendor.
The GENRPT (Claims Confirmation) or Level 1 (997) Report
This report is the second report you can receive for your claim submissions. It is available up to one hour after downloading your claim file. Double click to open this report. View, print, or save the file to your desktop.
This report lists the date and time the claim file was sent, all claims with errors, and all claims rejected and accepted. On the last page, there is a listing of the patient account name/number, date of service, amount billed, and Health Insurance Claim number (HICN) for the patient.
Claims that are listed as rejected must be corrected in your billing software and resent. If your claims have been rejected, an error message will be indicated in the beginning of the file level errors list. Under the description, there is a reason for the file rejection, e.g., duplicate file found-file not processed.
Claims that have passed this validation will continue onto the Medicare validation process. In 24–48 hours, a Medicare validation/front-end edit report will be available.
If billing through a clearinghouse or billing service, you must obtain these reports from your vendor.
Medicare Validation/Front-End Edit Report
The Medicare validation/front-end edit report is one of the most important electronic reports. This report tells you if your claims have been deleted, have errors, or have passed to the Medicare processing system.
— Claims that have passed to the Medicare processing system will be issued an internal control/claim number (ICN). This will assist you in tracking your claims. These claims will be processed on the 14-day payment floor.
— Claims that have errors have not rejected; they are subject to informational edits. This means that National Government Services is not currently deleting the claims. However, these claims may reject if the claim’s information on the report has not been corrected.
— Claims that have been deleted must be reactivated in your software program, corrected and resent.
This report is available 24–48 hours after downloading your electronic claim file. You must dial in through your communication’s software to receive this report. Once downloaded you may print or save the report to your desktop.
If billing through a clearinghouse or billing service, you must obtain these reports from your vendor.
For a listing of the error messages, go to www.NGSMedicare.com/NGSMedicare/PartB/Claims/EDI/Manuals/manuals.aspx.
Steps for Billing Electronically
Many of our current electronic submitters are not aware of the steps involved when you bill electronically. Often the claim file is sent and the submitter contacts the IVR system or the Customer Care Department to see if the claim files have been received. This puts an unnecessary burden on our customer service lines.
Follow these steps to determine if the claim files have been received:
— Once the electronic claim file is sent to National Government Services, the TRN report will immediately be received. This report lets you know that National Government Services has received the claim file.
— Up to an hour after transmitting the claim file, the GENRPT (claims confirmation) report can be downloaded. This report indicates that the claims have been accepted or rejected. The last page will list the patient account number, date of service, HICN, and the total charges of claims that have been submitted.
— 24–48 hours after transmitting the electronic claim file, the Medicare validation/front-end edit report will be received. This validation report will list the claims that have been accepted and rejected, and the reason for the rejection. Claims that have been accepted in the Medicare system are issued an internal control/claim (ICN) number.
— These claims will be processed on the 14-day payment floor.
Note: If billing through a clearinghouse or billing service, you must obtain these reports from your vendor.
The following updates apply to all Jurisdiction B DME MAC suppliers.
When to Call the Common Electronic Data Interchange Versus the Durable Medical Equipment Medicare Administrative Contractor
The Common Electronic Data Interchange (CEDI) provides a single front-end solution for the submission and retrieval of electronic transactions. The CEDI and DME MAC EDI functions and support available are listed below.
CEDI Functions
— Receives all incoming DME MAC electronic claims (X12 837 and NCPDP)
— Returns all electronic front end reports
— Returns 835 electronic remittance advices (ERA)
— Receives all DME MAC 276 claim status requests and returns the 277 claim status responses.
CEDI Support
The CEDI Help Desk is available from 9:00 a.m.–9:00 p.m. ET, Monday–Friday, and can be reached by telephone and e-mail.
Telephone: (866) 311-9184
E-mail: NGS.CEDIHelpdesk@wellpoint.com
The CEDI Help Desk will provide support for electronic transactions exchanged with CEDI including claims, reports, ERAs, and 276/277 transactions.
To stay informed of all CEDI updates, visit the CEDI Web site at www.NGSCEDI.com and sign up for the CEDI Listserv by selecting the Listserv Registration link. You will be prompted to submit your e-mail address and name to subscribe. This Listserv is for all entities participating with CEDI whether you are a third-party billing agency or a supplier performing your own EDI transmissions.
DME MAC EDI Functions
The DME MAC Jurisdictions will continue to provide support for the following EDI functions.
1. Claim Status Inquiry (CSI)
— Enrollment or setup status
— Logon or user ID
— Password resets
— Education
2. Electronic funds transfer
— Setup status
— Questions regarding payments or banking information
3. Status of claims in the DME MAC claims processing system for Jurisdictions A, B, C and/or D
4. Questions regarding the adjudication of claims
5. Questions regarding the content of an electronic remittance advice (ERA)
— Amount paid on a claim
— Deductible or co-payments applied
— Denied claims
DME MAC EDI Support
Use the following contact information to receive support from the DME MACs for the functions described above:
Jurisdiction A—NHIC, Corp.
Telephone: (866) 419-9458
Jurisdiction B—National Government Services
DME MAC EDI Help Desk (CSI and EFT enrollment assistance)
E-mail: NGS.EDI.DMAC@anthem.com
Telephone: (877) 273-4334
Customer Care (status/adjudication of claims, content of an ERA)
IVR Telephone: (877) 299-7900
Jurisdiction C—Cigna Government Services
www.cignagovernmentservices.com
Telephone: (866) 270-4909
Jurisdiction D—Noridian
Telephone: (866) 243-7272
The CEDI has been rejecting claims with a B108 error code message on the CEDI GENRPT (claims confirmation) report when the Provider Transaction Access Number (PTAN) or national provider identifier (NPI) are not linked to the trading partner (submitter) ID. Effective May 23, 2008, the B108 Error Code Message is set as a warning edit and will no longer reject the claims at CEDI. Claims accepted by CEDI will be forwarded to the appropriate DME MAC where front end edits will continue to be performed. These edits will validate that the supplier is authorized for EDI transactions and perform NPI validation.
CEDI edit B108 will be turned on in the future. At that time, claims that do not have a PTAN and NPI match with the trading partner (submitter) ID will be rejected by CEDI and not forwarded to the DME MACs. It is important that electronic trading partners complete the steps below to correct the B108 warning message and avoid future claim rejections.
DME MAC electronic trading partners that received the B108 rejection from CEDI prior to May 23, 2008, can now resubmit those claims. When the claims are resubmitted, the electronic trading partner will see the B108 warning edit—but the claims will not be rejected by CEDI. As stated above, claims accepted by CEDI will be forwarded to the appropriate DME MAC where front end edits will continue to be performed. These edits will validate that the supplier is authorized for EDI transactions and perform NPI validation.
All DME MAC electronic trading partners that receive the B108 warning edit should complete the following steps. (If a Supplier Authorization Form has previously been submitted to CEDI for the Submitter ID and supplier PTAN/NPI receiving the B108 warning message, please do not complete the steps below.)
1. The supplier must complete the supplier authorization form by clicking on the following link: www.NGScedi.com/forms/formsindex.htm
2. Once complete, click on the submit button at the bottom of the form
3. Print the form
4. Sign the form on the last page where it indicates “Authorized DME Supplier Signature”
5. List the title of the signer and the date signed
6.
Fax the form to CEDI at
7. Retain a copy for your records
Note: The supplier authorization form cannot be signed by a third party. This form must be signed by the supplier.
The CEDI Enrollment team is processing all enrollment requests in the order they are received and will respond once your setup is complete.
CMS-10125—External Infusion Pump DME MAC Information Form
The length of need is not listed or required on the paper copy of the CMS-10125 External Infusion Pump Durable Medical Equipment Information Form (DIF).
Electronic Claim Submitters: The length of need is required on the Health Insurance Portability and Accountability Act-compliant electronic claim in the “Durable Medical Equipment Certification Quantity” field. (Loop 2400, segment CR3, element 03)*
If the electronic claim is transmitted without the length of need on the CMS-10125, it may cause the entire claim file to reject on the electronic front end. All electronic submitters should submit a “99” as the length of need in the electronic format on the DIF CMS-10125 including those transmitted by Express Plus users.
* Suppliers should contact their software vendor if they cannot locate this field in their software.
Questions and requests for additional information should be directed to the DME MAC EDI Help Desk at (877) 273-4334, or via e-mail at NGS.EDI.DMAC@anthem.com.
Paper Claim Submitters: Although the length of need is not listed or required on the paper copy of the CMS-10125 External Infusion Pump DIF, the National Government Services Jurisdiction B DME MAC claims processors will populate the length of need with a “99”.
How to Prevent Duplicate Claim Denials
The Provider Outreach and Education (POE) team continues to monitor the submission of duplicate claims. The POE team is reviewing the duplicate claim denials to identify billers, clearinghouses, providers, and suppliers who have an impact on the volumes of duplicate claim (CO-18) denials issued quarterly.
To access Information on the Jurisdiction B DME MAC duplicate claim denials including background information, steps to take to prevent duplicate claim denials, and resources for checking duplicate claims, click on the link below or paste the following into your Internet browser:
www.NGSMedicare.com/NGSMedicare/DMEMAC/Claims/Toolkit/IndexToolkitDMEMAC.aspx
Coming Soon! Claim Status Inquiry Computer-Based Training
The Claim Status Inquiry (CSI) computer-based training (CBT) course is designed to explain the benefits of using claim status inquiry to locate paper and electronically submitted claims in the Jurisdiction B DME MAC claims processing system. Claim status inquiry gives participating and nonparticipating suppliers the ability to view the status of all paid, denied, and pended claims whether assigned or nonassigned via your computer. Beneficiary eligibility information is also available through claim status inquiry.
CSI is available from 6:00 a.m.–6:00 p.m. ET, Monday–Friday, and sometimes on Saturday.
National Provider Identifier Bypass Logic Claim Rejections
Effective October 29, 2007, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) lifted the NPI bypass logic and began validating NPI/PTAN pairs submitted against the crosswalk file.
Paper claims that include nonmatching NPIs and PTANs were suspended in the claims processing system. Those claims were released and many rejected with a CO-16, N280 remark and reason code. The denial message read, “Missing/incomplete/invalid pay-to provider primary identifier.” National Government Services is now returning those claims with a letter to the supplier stating there is no NPI/PTAN match.
Electronic claims are rejecting on the front end due to the lifting of the crosswalk when the NPI cannot be successfully matched to the PTAN.
Issue 1
Some suppliers completed their NPI application listing an Individual (or, type 1) entity code. However, the National Supplier Clearinghouse (NSC) has the supplier setup as an organization (or, type 2) entity code. Most durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers and pharmacies are considered to be an entity type 2, unless they are a sole proprietor/sole proprietorship. Sole proprietorships obtain NPIs as entity type 1 (Individuals).
For clarification on choosing an entity type, refer to page five of the NPI application at www.cms.hhs.gov/cmsforms/downloads/CMS10114.pdf.
Keep in mind that a sole proprietorship can virtually be any type of provider/supplier. The Centers for Medicare & Medicaid Services (CMS) posted two frequently asked questions (FAQs) concerning sole proprietor and NPIs (FAQ #6594 and #5967) and issued two NPI fact sheets in July 2007—one “For Health Care Providers Who are Sole Proprietors” and one “For Health Care Providers Who are Organizations.” These documents are available from the CMS NPI Web site at: www.cms.hhs.gov/NationalProvIdentStand/
Suppliers who chose the incorrect entity type code when they applied for an NPI must complete new NPI applications with the National Plan and Provider Enumeration System (NPPES). The NPI associated with the incorrect entity type code should be deactivated. (It is not possible for a supplier or other health care provider to simply change the entity type code associated with an NPI.)
Note: The Jurisdiction B DME MAC will be notified by the Medicare NPI crosswalk of the change in approximately seven working days. The supplier must resubmit the electronic claim(s) using the new NPI.
Issue 2
The information listed in NPPES for some suppliers is not accurate:
— Verify that all the information is accurate including the name, address, and Employer Identification Number (EIN)
— Verify that your PTAN is listed in the Medicare NSC field in the “Other Provider Identifier” record in NPPES.
— Verify that the “Entity Type” is correct. An organization has an Entity type 2; an Individual, to include a sole proprietorship, has an Entity type 1.
Note: If the “entity type” is not correct, the supplier must obtain an NPI for the correct entity type and deactivate the existing NPI.
Suppliers can update their information via NPPES at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart, or by contacting the Enumerator toll free at (800) 465-3203 to obtain a paper NPI application/update form.
If a supplier uses a clearinghouse, billing service, or other third party to submit electronic claims, the supplier should contact the third party to determine if there have been informational messages or warnings on remittances or error notices. If claims are rejecting, it is likely that NPPES and/or the Medicare enrollment record at the NSC must be updated.
Issue 3
Some suppliers are reporting the referring/ordering physician NPI and PTANs in Items 33a (NPI) and 33b (PTAN). Do not report the referring/ordering physician information in Items 33a and 33b. Your supplier NPI is reported in 33a and your supplier PTAN identifier is reported in 33b. Suppliers report the ordering/referring physician NPI in Item 17b and the referring physician’s PTAN in Item 17a only.
Submission of the National Provider Identifier for Express Plus Users
Effective May 23, 2008, all DME MAC Medicare claims must include only the NPI. To ensure that only the NPI is submitted on claims sent on or after May 23, 2008, Express Plus users must complete the instructions listed below.
To remove the PTAN from the Express Plus software:
1. Go to the file maintenance menu
2. Click on Provider Maintenance
3. Make sure the supplier’s NPI number is listed under the field titled, “NPI”
4. Remove the PTAN listed under the field titled, “Supplier Number:”
Express Plus users should complete these instructions and transmit a few claims to make sure there are no issues with their NPI number. If the claims are accepted, the Express Plus users should continue submitting claims as usual.
External Resources and Helpful Links
The CMS Online Manual System
A Web-based manual system for Medicare contractors, providers, and state agencies brochure has been updated and is now available to order print copies or to download as a portable document format (PDF) file. This brochure explains how to navigate the Centers for Medicare & Medicaid Services (CMS) online manual system. To view the PDF file, go to www.cms.hhs.gov/MLNProducts/downloads/on-linebrochure.pdf. Print copies may be ordered by visiting the Medicare Learning Network product ordering page at www.cms.hhs.gov/MLNProducts/ on the CMS Web site.
CMS Quarterly Provider Updates Listserv Changes
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National Government Services has added a new section to the E-Commerce Connection online newsletter titled, “Ask the EDI Help Desk.” In this section, providers, and suppliers can view questions received by our electronic submitters, along with the answers provided by the National Government Services EDI Help Desk.
All questions will be published anonymously. Send us your questions today at
www.NGSMedicare.com/NGSMedicare/survey/ASKEDI_Enroll.cfm
Below are the questions for this quarter.
Medicare Part B
Question: How do you correct edit M385?
Answer: Refer to Loop 2430, the CAS segment. The M385 error code occurs if any line level CAS segment contains an invalid adjustment reason code.
For additional information, go to www.wpc-edi.com and select the Adjustment Reason Codes list to verify that a current, valid adjustment reason code is being entered on the claim.
Medicare Part A, Part B, and DME MAC
Question: How can I receive your E-Commerce Connection news letter?
Answer: The E-Commerce Connection newsletter is available on the National Government Services Web site at www.NGSMedicare.com under News and Publications and/or Claims – Electronic Data Interchange (EDI).
Unique vocabulary in the world of electronic claim submission is the norm. Listed below are the definitions of several terms and acronyms you may often see and hear.
ANSI American National Standards Institute—ANSI is the HIPAA standard format for electronic claims.
ASCA Administrative Simplification Compliance Act—ASCA is a law that allows providers that meet particular requirements an extension to comply with HIPAA transactions and code sets requirements.
ASYNC Asynchronous—A physical transfer of data to or from a device that occurs without a regular or predictable time relationship following the execution of an O/I request. Opposite from Synchronous data transfer.
CEDI Common Electronic Data Interchange—The CEDI (Common Electronic Data Interchange) provides a single electronic front end solution for all DME MAC suppliers. CEDI will work closely with DME MAC software vendors, billing services, clearinghouses, and trading partners (electronic submitters) on all electronic front end needs. Once implemented, all DME MAC electronic claims (ANSI and NCPDP) and 276 transactions will be collected by CEDI. CEDI will also return all DME MAC electronic front end reports, remittance advices and the 277 response transaction.
CMS Centers for Medicare & Medicaid Services—The CMS is a federal agency within the United States Department of Health and Human Services that regulates Medicare, Medicaid, and other health care programs.
CSI Claim Status Inquiry—CSI is the online resource for DME MAC suppliers to access beneficiary eligibility information, current claim status, pricing information, provider summary data, etc.
CWF Common Working File—The CWF contains information on more than 40 million Medicare enrollees. Hosted on an IBM mainframe, it uses million-plus lines of code to process more than 800 million Medicare claims each year. Not surprisingly, CWF touches many people and organizations. For example, it receives eligibility data from the Social Security Administration via electronic feeds. Medicare contractors use it to obtain information on beneficiaries, such as their entitlements, utilization, and specific claims history. As the final point of claims adjudication for Medicare fee-for-service transactions, CWF processes claims and returns a response within 24 hours of receipt, transmitting data electronically to payers such as National Government Services. CWF also performs prepayment editing and validation on each claim, and compares Part A and Part B claims data to eliminate improper payments.
DDE Direct Data Entry System—DDE is a process that allows remote users online connectivity to the fiscal intermediary standard system (FISS), or mainframe, used by National Government Services to:
— Enter UB-92 claims
— Correct electronic claims that were submitted by batch mode (EDI-SmartTransfer)
— Correct claims originally submitted on paper
— Track all claims through the processing system
— View the check number, date, and amount of your last 3 payments
— View a variety of files for inquiry purposes, example: diagnosis codes, revenue codes, and ANSI reason codes
— Access the Common Working File (CWF) to find information on beneficiary entitlement, eligibility, and other insurance information.
EDI Electronic Data Interchange—EDI describes the electronic exchange of business documents using standard formats.
EFT Electronic Funds Transfer—The deposit of the Medicare payments directly into a bank account.
ERA Electronic Remittance Advice—The ERA lists health care claims billed and the payment status of those claims. The report is created by the payer and delivered to the provider.
FISS Fiscal Intermediary Standard System—The Medicare processing system that processes Medicare Part A claims.
FTP File Transfer Protocol—FTP is a common way to move files between computers over the Internet. Anonymous FTP gives users access (without an ID and password) to areas on a remote system that contain public files.
HIPAA Health Insurance Portability and Accountability Act—This is the act that defines provisions on health insurance reform, administrative simplification, privacy and security.
IG Implementation Guide—The IG defines standardized data requirements and content for ANSI transactions. Each ANSI transaction has its own IG.
MCS Multi-Carrier System—The Medicare processing system that processes Medicare Part B claims.
MREP Medicare Remit East Print—The MREP software is available for free to Medicare providers and suppliers, to be used to access and print remittance advice information, including special reports, from the HIPAA 835.
NPI National Provider Identifier—The NPI is a unique identification number for an individual or entity that provides health care services and supplies.
NSC National Supplier Clearinghouse—Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) providers must enroll in the Medicare program through the NSC. The Medicare enrollment application (Form CMS-855S) must be completed to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries. The NSC processes the enrollment application and verifies the information provided.
OSCAR Online Survey Certification and Reporting System—This is the legacy Medicare Part A provider number. As of May 23, 2008 this number can no longer be submitted on incoming claims.
PC-ACE Pro32 PC-ACE Pro32—The National Government Services free/low-cost billing software. Providers can use PC-ACE Pro32 to create HIPAA-compliant electronic health care claims, view and print ERAs, and create health care claim status inquiries.
PHI Protected Health Information—Entities in the health care industry use PHI or confidential member information to perform critical, daily business functions. PHI includes, but is not limited to, the following: