Microsoft June 2008 EDI Webinar [Compatibility Mode] AW1 HS

EDI Rejections and EDI Changes for

‘NPI Only’ Filing

Taz Taylor



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

2

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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

•

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. *

•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

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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.

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).

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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.

–***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***

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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)

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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

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

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Facility setup – Centricity

Zip plus 4 here Facility NPI # here (as needed)

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Physicians / Referring Providers

鞨

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!

Every referring physician

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.

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

•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

REF Segments when NPI is

sent in NM109

•Clearinghouses – Uncheck

‘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).

•Example:

•OKLAHOMA/NEW MEXICO MEDICARE SERVICES PAGE 111

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

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

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)

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

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:

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

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.

28

Click here

-

then click here.



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

鞨

Claim status codes

Look for

numeric

code here

Scroll

through

list here

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Description of status/rejection here

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

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.

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

Thank you for attending!

Be sure to check out www.HealthSystems.net/events web

page for more Webinar and other events!

32

Microsoft June 2008 EDI Webinar [Compatibility Mode] AW1 HS

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