Microsoft June 2008 EDI Webinar [Compatibility Mode] AW1 HS

User Manual: AW1

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EDI Rejections and EDI Changes for
‘NPI Only’ Filing
Taz Taylor

Agenda
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Introduction and Administrative Notes
Alabama Medicaid updates
Georgia Medicaid updates
Review Doctor, Company and Facility Setup for NPI
Informational messages vs. Actual Rejections
Medicare Rejections for Billing Provider IDs
NPPES website



•
•
•
•

Changes to McKesson/RelayHealth Carrier Report rejections
Washington Publishing Company website, Claim Status Codes
EDI tips
Questions

2

Introduction – Administrative Notes
• DO NOT put your phone on HOLD - Very Important!
• Please hold specific rejections questions until after
presentation.


• Feel free to ask questions, but limit them to the current
topic. Hold other questions until the end of the presentation.
• This presentation will be available on the HealthSystems
website – www.HealthSystems.net

3

Alabama Medicaid 2008 reminders
• NPI numbers are required on ALL claims as of Feb 25th.
• NPI numbers must be REGISTERED with Alabama
Medicaid / EDS
• Paper claims must be submitted on the CMS1500 form.
• Medicaid 340 form still required for Medicare/Medicaid
crossovers – form requires NPI number now.
• Zip + 4 required for billing provider and service location.


4

Georgia Medicaid 2008 reminders
• All electronic claims for Georgia Medicaid must contain the
NPI in all provider loops. *
• At this time it is still permissible to submit the Medicaid
legacy number, however the NPI must be included. *
• NPI must be registered, Zip +4 required for service facility.**
• Tax ID required, taxonomy code required in EDI claim. **


• *Source: McKesson/Relay Health support
• ** New/effective 02/01/2008

5

Alabama BCBS recent rejection
“401 - PROV LOC NOT SET UP FOR EMC”
Occurs when a claim contains a doctor and facility
combination that is not registered at Alabama BCBS.


To correct this rejection:
After the facility (Hospital or ASC) rejects, email AL BCBS
(Ask-EDI support) and request that the facility be setup for
the doctor. (the specific combination of facility and doctor
that appears on rejected claim).
6

NPI – additional info
• Changes to NPI setup since last year
– Because all carriers should accept NPI, it is okay to populate the NPI
field on the INFORMATION tab
– Many carriers are requiring ZIP +4 zip codes when claims are

submitted with NPI numbers. Add
these expanded zip codes now to
the doctor, company and facility information areas.
– ***NPI ONLY may require removing UPIN numbers from your
doctors ID rows and information tab, and also from your referring
doctors
***if you file directly to Alabama Medicare or BCBS***

Clearinghouse changes since May 23rd
• For McKesson *and* Centricity EDI clients
• The clearinghouses will suppress legacy numbers, including
UPIN numbers.
• This means your claims will go to the carrier as NPI only with
no changes to your system.
• Clearinghouses will suppress based on carrier requirements.
• HOWEVER – any changes you have made already to send
NPI only are still correct.


• Does not affect Direct submitters (AL Medicare and AL
BCBS)
8

Review of NPI in Centricity
• NPI fields are found in:
–
–
–
–

Doctor *(Responsible Provider)
Company
Facility
Physicians (Referring Provider)

* parenthesis reflect CPS06 terminology



Doctor setup – Centricity



Zip plus 4 here

Doctor’s NPI # here

10

Tricare – Needs EIN (Employer Identification Number)

Recent Tricare rejection:
“Rendering Provider Missing EIN with NPI”
To correct, in the doctor’s Tricare ID row,
add the tax ID number in the Additional ID 1
field and select qualifier ‘Employer
Identification Number’.



This will sent the tax ID in a REF segment in
Loop 2310B

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Company setup - Centricity



Zip plus 4 here

Company NPI here

12

Facility setup – Centricity



Zip plus 4 here

Facility NPI # here (as needed)

13

Physicians / Referring Providers




Recent rejection for referring provider
• Rejection:
“Referring provider ID
missing or invalid
qualifier”
The referring or PCP
physician does not have
the NPI field populated!

鞨

Every referring physician
must have an NPI
number entered.

15

NPI – What do I do?
• Obtain an NPI number for each provider
• Enter NPI numbers in correct locations in Centricity
• ** Register your NPI number(s) with your insurance
carriers**
• Submit claims with NPI numbers
• REVIEW your claim submissions for rejections


• **It is YOUR responsibility to confirm that the insurance
carrier has your NPI numbers on file and associated with
the correct doctors, company, etc.

2008 Southeast
Centricity User
Conference - Slide 16

NPI – additional info
• Changes to NPI setup since last year
– Because all carriers should accept NPI, it is okay to populate the NPI
field on the INFORMATION tab
– Many carriers are requiring ZIP +4 zip codes when claims are
submitted with NPI numbers. Add these expanded zip codes now to

the doctor, company and facility information areas.
– May 23, most carriers will require claims to contain NPI ONLY. At
this time, all of your EDI claims should contain NPI numbers.
– NPI ONLY may require removing UPIN numbers from your doctors
ID rows and information tab, and also from your referring doctors.

17

NPI Only – How do I do it?
– Admin – Edit - Insurance Carrier
– Select carrier and Modify (Edit)
– Go to the EDI tab, highlight the File Creator and Modify
(Edit)
– Click the Creator Plug-In Settings button
– Go to All Payers (2) tab
– Select (check) ‘Do Not Send PIN/EMC in REF Segments
when NPI is sent in NM109
– Go to Clearinghouses tab
– Unselect (uncheck) ‘Requires PIN’


2008 Southeast
Centricity User
Conference - Slide 18

NPI Only (for the billing and rendering provider)
Loops 2010AA and 2310B
• Admin-Edit-Insurance
Carrier
• Select ‘Medicare’ carrier
and Modify
• EDI tab – Modify row and
click settings


19

NPI Only continued
• All Payers 2 – Put check in
‘Do Not Send PIN/EMC in
REF Segments when NPI is
sent in NM109
• Clearinghouses – Uncheck
‘Requires PIN’



20

Informational Message vs. Actual Rejection
• Claims submitted with a legacy Medicare number or UPIN may receive an ‘Informational’
warning. This claim is NOT rejected. The warning is to let you know that this claim will be
rejected in the future (when the edit is activated).
• Example:
•
PRODUCTION

OKLAHOMA/NEW MEXICO MEDICARE SERVICES
PROFESSIONAL EMC PROGRAM
MEDICARE-B EMC INPUT
BATCH DETAIL CONTROL LISTING
 MCKESSON
SUBMITTER ID: J0817
SUBMITTER NAME:
ADDRESS:
700 LOCUST ST #500
CITY:
DUBUQUE
STATE/ZIP:
IA 52001
PROCESS DATE: 01/30/2008

PAGE 111

•
EMC PROVIDER : NPI: 3225028541 PIN:
BATCH STATUS : ACCEPTED
SF017252
2310B REF 2310B REF01 1G
M404 INVALID VALUE
HIC FOR ABOVE CLAIM IN ERROR: 007284231A
ICN: 2208030081730
EMC PROVIDER : NPI: 3225028541 PIN: 500522423 BATCH STATUS : ACCEPTED
SF017252
2310B REF 2310B REF01 1C
M404 INVALID VALUE

INFORMATIONAL

INFORMATIONAL

Informational – not rejected

21

Informational Message vs. Actual Rejection continued
• Claims that do not have a valid NPI/Legacy combo or do not contain NPI (after March 1) are
REJECTED
• Example:
OKLAHOMA/NEW MEXICO MEDICARE SERVICES
PAGE 78
PROFESSIONAL EMC PROGRAM
PRODUCTION
MEDICARE-B EMC INPUT
BATCH DETAIL CONTROL LISTING
SUBMITTER ID: N0817
SUBMITTER NAME: MCKESSON
ADDRESS:
700 LOCUSTST #500
CITY:
DUBUQUE
STATE/ZIP:
IA 52001
PROCESS DATE: 01/24/2008
EMC PROVIDER : NPI: 1226828541 PIN: 800567423 BATCH STATUS: DELETED ENTIRE BATCH MUST BE RESUBMITTED
SF017252
2310B REF 2310B REF01 343731302 M343 NPI/PIN DISCREPANCY
CLAIM DELETED
HIC FOR ABOVE CLAIM IN ERROR: 007284031A
ICN: 0000000000000
SF016482
2310B REF 2310B REF01 343731302 M343 NPI/PIN DISCREPANCY
CLAIM DELETED
HIC FOR ABOVE CLAIM IN ERROR: 113505379A
ICN: 0000000000000
SF017008
2310B REF 2310B REF01 343731302 M343 NPI/PIN DISCREPANCY
CLAIM DELETED
HIC FOR ABOVE CLAIM IN ERROR: 113505379A
ICN: 0000000000000

These claims are rejected – see status ‘claim deleted’.

22

Medicare rejected claims for billing provider ID
• Medicare claims that are rejecting for billing provider ID errors do NOT display the rejected
ticket number.
• Applies to South Carolina Medicare *and* Railroad Medicare EDI claims, may apply to
other regions.
• Very important to read all of the CR report to determine error.
• Rejection appears on the CR report as displayed below:
REDI-LINK - CLAIM ACCEPTANCE RESPONSE
RESPONSE DATE: 2008/02/07 RESPONSE TYPE: INITIAL RESPONSE TIME: 07:23:26


SENDER: XMCARE
GATEWAY PRODUCTION NETWORK (GPNET)
PAYOR: C00880
MEDICARE 'B' - SOUTH CAROLINA
FORMAT: ANSI
------------------------------------------------------------------------------PROVIDER ID: 1565591448
BATCH ID: 000000 0089 STATUS: REJECTED/PROD
TOTAL CLAIMS:
5
CHARGES:
$5460.00
CLAIM REJECTS:
5
CHARGES:
$5460.00
R MSG-Y1K BILLING PROVIDER SSN OR EIN NOT ON CROSSWALK
REF-NM
------------------------------------------------------------------------------PROVIDER ID: 1256591448
BATCH ID: 000000 0090 STATUS: REJECTED/PROD
TOTAL CLAIMS:
85
CHARGES: $67857.00
CLAIM REJECTS:
85
CHARGES: $67857.00
R MSG-Y1K BILLING PROVIDER SSN OR EIN NOT ON CROSSWALK
REF-NM

The rejection displays the NPI # of the billing provider and the number of claims affected, but
DOES NOT itemize or display the ticket number of the rejected claims.
23

NPPES Website (National Plan & Provider Enumeration System)
• Use the NPPES Website to
lookup or verify NPI
numbers.
• https://nppes.cms.hhs.gov/NPPES/Welcome.do
=

• Click the ‘Search NPI
Registry Link’

24

NPPES website continued

鞨

25

NPPES NPI search

鞨

The provider’s NPI number will display here as well as other registered
numbers (Medicare, UPINU)
26

New rejection messages on CR reports
• McKesson/RelayHealth has changed claim routing for some carriers. This means that claims that
formerly went through EMDEON-WebMD are now going directly to the insurance company.
• For many of these claims, the status of the claim (rejected vs. accepted) and the rejection reason as
shown on the CR report is now a numeric code instead of a plain text explanation.
• Use the WPC-EDI website to translate these new status messages and rejections
•

Example:
TRACEY DAWN

09/01/1946

M

254568663

TRACE NUMBER:
CLAIM
CLAIM
PAYORS CLAIM NUMBER: EA34A8DSH00
PERIOD BEG PERIOD END MEDICAL RECORD NUMBER:
12/05/2007 12/05/2007
BILLING TYPE:
EFFECTIVE ADJUDICATION PAYMENT
STATUS DATE PAYMENT DATE METHOD
12/06/2007 12/07/2007
300.00

鞨

CHARGE
PAYMENT
AMOUNT
AMOUNT
0.00 12/10/2007

CLAIM LEVEL STATUS CATEGORY: F1 STATUS: 69

MODIFIER:

JAMES BEECHAM
11/15/1945 M
TRACE NUMBER:
CLAIM
CLAIM
PAYORS CLAIM NUMBER: EG34BQ1H800
PERIOD BEG PERIOD END MEDICAL RECORD NUMBER:
01/24/2008 01/24/2008
BILLING TYPE:
EFFECTIVE ADJUDICATION PAYMENT
STATUS DATE PAYMENT DATE METHOD
01/30/2008
170.00

422637701

CHARGE
PAYMENT
AMOUNT
AMOUNT
0.00

CLAIM LEVEL STATUS CATEGORY: A2 STATUS: 19

CHECK
CHECK DATE NUMBER

CHECK
CHECK DATE NUMBER

MODIFIER: IN

27

Washington Publishing Co. website
www.wpc-edi.com



Click here - then click here.
28

Claim status categories




Click the category matching the first
letter of rejection code

Will expand category here
29

Claim status codes

Look for
numeric
code here

鞨

Scroll
through
list here
Description of status/rejection here
30

EDI Tips
EDI Reports:
• McKesson/RelayHealth has made significant changes that impact your EDI
reports. Be aware of these changes and review your EDI workflow to make sure
that all rejections are being properly resolved.
• New reports from McKesson include the SR, SE, and SF reports. These are
standardized reports intended to make your work easier.
鞨

If you do not recognize or understand these reports, continue using your proven
workflow strategies of reading and acting on the CR reports.

Updated EDI Software
• A new McKesson EDI plug-in (version 7.0.515 for Centricity 04) is available that
will update the individual visits with carrier level results. Contact HealthSystems
to find out if your practice is ready for this update.

31

Questions and Answers



Thank you for attending!
Be sure to check out www.HealthSystems.net/events web
page for more Webinar and other events!

32



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