|
|
|
|
HIPAA 5010 Bulletin
ATTENTION X12 BILLING PROVIDERS
In order to prepare for HIPAA 5010, please see a few of the changes being made below. Note these change apply to claims mentioned below and changes will take effect January 1, 2012.
-
Professional Anesthesia claim(s) including electronic, paper and adjustments will now need to be billed with units as minutes instead of by 15 minute increments. This change will be effective for all claims submitted in 5010 format regardless of the date of service. This change will also be effective for all paper claims and adjustments as of 1/1/2012.
-
Professional, Institutional and Encounter claim(s) that are submitted in the HIPAA 5010 format will now only allow ONE (1) NDC per corresponding service line, when applicable. This change is also effective for paper claims processed 1/1/2012 and after.
-
Professional, Dental and Institutional claims are now subject to new claim balancing rules. They are as follows:
a – Claims MUST balance at two different levels; the claim and the service line. Claim adjustment information (CAS) can repeat 1 to 5 times at either the claim level (2320 loop) or the line level (2430 loop). This allows for adjustment group codes: contractual obligations, correction and reversals, other adjustments, payer initiated reason codes with corresponding dollar amount and quantities to explain the difference between the submitted charges and the amount paid. See the X12 TR3 guides for detailed claim balancing rules. In addition to the X12 rules, DMAP will only allow CAS data at either the header or detail for a single Other Payer. CAS data will NOT be permitted to be submitted at both the header and detail for the same Other Payer on a claim.
b – DMAP expects that TPL payments, patient responsibility and claim adjustment information (CAS) is present at the claim header level only for Inpatient and Nursing home claims. For all other claim types, this information is expected at the claim detail when an Other Payer has approved the claim. DMAP’s clearinghouse, BES, will reject any claim where the Other Payer data is not billed in the required header/detail loop.
c – For claims being billed to DMAP where there is a Medicare Advantage Plan as a primary payer, starting 1/1/2012, these claims will be considered TPL claims and will no longer be considered a Medicare Crossover claim. Based on this, when billing these claims electronically, these claims must be billed with the following Claim Filing Indicator value: ‘OF’ - Other Federal Program
-
The Claim Quantity (QTY) segment has been deleted for 5010. This segment contained the total covered days, non-covered days, coinsurance days, and lifetime reserve days.
This information will now be reported in Loop 2300 - HI Value Information segment of an Institutional Claim type.
There will be four value codes in this segment that will identify the four fields that were previously found in the Claim Quantity (QTY) segment:
80- covered days
81- non-covered days
82 – coinsurance days
83- lifetime days.
-
5010 defines the ICD-9-CM Surgical Procedure code information on the claim header to be required on Inpatient claims when a procedure was performed. Based on this, the header surgical procedure codes can no longer be sent on non-inpatient claims.
-
Accept / Reject Reports for electronic transmissions which are found on the WEB Bulletin Board System (www.mo.ebx-eds.com) will now be combined into a single report called ‘Transaction Summary by Status’ report. This transaction report will have the same naming standard as the accept / reject report with the exception that the file name extension will end with .TXN. With HIPAA 5010, A 999 Implementation Acknowledgement report will also now be returned.
For any questions / concerns regarding the information above or regarding the HIPAA 5010 Implementation, please contact Provider Relations at 800-999-3371 option 0 then option 1 or send any inquiries to DEXIX-PR-ECS@HP.COM
|
|
