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
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Agenda
•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
•
Medicare Rejections for Billing Provider IDs
•NPPES website
•Changes to McKesson/RelayHealth Carrier Report rejections
•
Washington Publishing Company website, Claim Status Codes
•
Washington Publishing Company website, Claim Status Codes
•EDI tips
•Questions
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Introduction – Administrative Notes
•DO NOT put your phone on HOLD - Very Important!
•Please hold specific rejections questions until after
presentation.
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
•
This presentation will be available on the HealthSystems
website – www.HealthSystems.net
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Alabama Medicaid 2008 reminders
•NPI numbers are required on ALL claims as of Feb 25th.
•
NPI numbers
must be
REGISTERED with Alabama
•
NPI numbers
must be
REGISTERED with Alabama
Medicaid / EDS
•
Paper claims must be submitted on the CMS1500 form.
•
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.
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Georgia Medicaid 2008 reminders
•All electronic claims for Georgia Medicaid must contain the
NPI in all provider loops. *
NPI in all provider loops. *
•At this time it is still permissible to submit the Medicaid
legacy number, however the NPI must be included. *
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
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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.
combination that is not registered at Alabama BCBS.
To correct this rejection:
To correct this rejection:
After the facility (Hospital or ASC) rejects, email AL BCBS
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).
that appears on rejected claim).
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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.
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 ID rows and information tab, and also from your referring
doctors
***if you file directly to Alabama Medicare or BCBS***
***if you file directly to Alabama Medicare or BCBS***
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Clearinghouse changes since May 23rd
•For McKesson *and* Centricity EDI clients
The
clearinghouses will suppress legacy numbers
, including
•
The
clearinghouses will suppress legacy numbers
, including
UPIN numbers.
•
This means your claims will go to the carrier as NPI only with
•
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)
BCBS)
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Review of NPI in Centricity
•NPI fields are found in:
–Doctor *(Responsible Provider)
–
Company
–
Company
–Facility
–Physicians (Referring Provider)
* parenthesis reflect CPS06 terminology
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Doctor setup – Centricity
Doctor’s NPI # here
Zip plus 4 here
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Doctor’s NPI # here
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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
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
This will sent the tax ID in a REF segment in
Loop 2310B
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Company setup - Centricity
Zip plus 4 here
Zip plus 4 here
Company NPI here
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Facility setup – Centricity
Zip plus 4 here Facility NPI # here (as needed)
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Physicians / Referring Providers
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鞨
Recent rejection for referring provider
•Rejection:
“Referring provider ID
“Referring provider ID
missing or invalid
qualifier”
The referring or PCP
physician does not have
the NPI field populated!
the NPI field populated!
Every referring physician
must have an NPI
must have an NPI
number entered.
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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
•
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.
the correct doctors, company, etc.
2008 Southeast
Centricity User
Conference - Slide 16
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NPI – additional info
•Changes to NPI setup since last year
–
Because all carriers should accept NPI, it is okay to populate the NPI
–
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
–
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.
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NPI Only – How do I do it?
–Admin – Edit - Insurance Carrier
–
Select carrier and Modify (Edit)
–
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
–
Select (check) ‘Do Not Send PIN/EMC in REF Segments
when NPI is sent in NM109
–
Go to Clearinghouses tab
–
Go to Clearinghouses tab
–Unselect (uncheck) ‘Requires PIN’
2008 Southeast
Centricity User
Conference - Slide 18
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NPI Only (for the billing and rendering provider)
Loops 2010AA and 2310B
Loops 2010AA and 2310B
•Admin-Edit-Insurance
Carrier
•Select ‘Medicare’ carrier
and Modify
•EDI tab – Modify row and
click settings
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NPI Only continued
•All Payers 2 – Put check in
‘Do Not Send PIN/EMC in
‘Do Not Send PIN/EMC in
REF Segments when NPI is
sent in NM109
•Clearinghouses – Uncheck
‘Requires PIN’
‘Requires PIN’
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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).
rejected in the future (when the edit is activated).
•Example:
•OKLAHOMA/NEW MEXICO MEDICARE SERVICES PAGE 111
PROFESSIONAL EMC PROGRAM
PROFESSIONAL EMC PROGRAM
PRODUCTION MEDICARE-B EMC INPUT
BATCH DETAIL CONTROL LISTING
SUBMITTER ID: J0817 SUBMITTER NAME: MCKESSON
ADDRESS: 700 LOCUST ST #500
CITY: DUBUQUE
STATE/ZIP:
IA
52001
STATE/ZIP:
IA
52001
PROCESS DATE: 01/30/2008
•
EMC PROVIDER : NPI: 3225028541 PIN: BATCH STATUS : ACCEPTED
SF017252 2310B REF 2310B REF01 1G M404 INVALID VALUE INFORMATIONAL
HIC FOR ABOVE CLAIM IN ERROR: 007284231A ICN: 2208030081730
EMC PROVIDER : NPI: 3225028541
PIN: 500522423
BATCH STATUS : ACCEPTED
EMC PROVIDER : NPI: 3225028541
PIN: 500522423
BATCH STATUS : ACCEPTED
SF017252 2310B REF 2310B REF01 1C M404 INVALID VALUE INFORMATIONAL
Informational – not rejected
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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
PRODUCTION
MEDICARE
-
B EMC INPUT
BATCH DETAIL CONTROL LISTING
SUBMITTER ID: N0817 SUBMITTER NAME: MCKESSON
ADDRESS: 700 LOCUST ST #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
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
HIC FOR ABOVE CLAIM IN ERROR: 113505379A
ICN: 0000000000000
These claims are rejected – see status ‘claim deleted’.
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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
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
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
The rejection displays the NPI # of the billing provider and the number of claims affected, but
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.
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=
NPPES Website (National Plan & Provider Enumeration System)
•Use the NPPES Website to
lookup or verify NPI
lookup or verify NPI
numbers.
•
https://nppes.cms.hhs.gov/NPPES/Welcome.do
•
https://nppes.cms.hhs.gov/NPPES/Welcome.do
•Click the ‘Search NPI
Registry Link’
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鞨
NPPES website continued
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鞨
NPPES NPI search
The provider’s NPI number will display here as well as other registered
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The provider’s NPI number will display here as well as other registered
numbers (Medicare, UPIN)
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鞨
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
•
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 CHARGE PAYMENT CHECK
EFFECTIVE ADJUDICATION PAYMENT CHARGE PAYMENT CHECK
STATUS DATE PAYMENT DATE METHOD AMOUNT AMOUNT CHECK DATE NUMBER
12/06/2007 12/07/2007 300.00 0.00 12/10/2007
CLAIM LEVEL STATUS CATEGORY: F1 STATUS: 69 MODIFIER:
JAMES BEECHAM 11/15/1945 M 422637701
TRACE NUMBER:
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 CHARGE PAYMENT CHECK
STATUS DATE PAYMENT DATE METHOD AMOUNT AMOUNT CHECK DATE NUMBER
01/30/2008 170.00 0.00
01/30/2008 170.00 0.00
CLAIM LEVEL STATUS CATEGORY: A2 STATUS: 19 MODIFIER: IN
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Washington Publishing Co. website
www.wpc-edi.com
Click here
-
then click here.
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Click here
-
then click here.
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Claim status categories
Click the category matching the first
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Click the category matching the first
letter of rejection code Will expand category here
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鞨
Claim status codes
Look for
numeric
numeric
code here
Scroll
through
through
list here
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Description of status/rejection here
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鞨
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
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.
standardized reports intended to make your work easier.
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
• 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.
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Questions and Answers
Questions and Answers
Thank you for attending!
Thank you for attending!
Be sure to check out www.HealthSystems.net/events web
page for more Webinar and other events!
page for more Webinar and other events!
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