Version 5010 Errata Provider Handout 5010 Bringing Clarity & Consistency To Your Electronic Transactions Benefits Transactions Impacted Changes Impacting Providers While we have highlighted the HIPAA Version 5010 Errata changes within this handout, your vendor may present these changes differently. To fully understand all changes and the business impacts, contact your PM, software vendor or clearinghouse. They can provide insight into the changes to your software and submission process. 1
HIPAA 5010 Benefits The benefits of HIPAA 5010 can be summarized at a high-level improved efficiency and overall usability of EDI transactions among providers, payers, and clearinghouses. Clarification of NPI instructions Standardization of COB information Enhanced eligibility checking Improved claim status inquiries/responses Greater detail on reimbursement advice received from payers Enhanced usability of referrals and authorizations Provides infrastructure for ICD-10 2
Transactions Impacted by 5010 Health Care Claim Dental (837D) Health Care Claim Professional (837P) Health Care Claim Institutional (837I) Health Care Claim Payment /Advice (835) Health Care Eligibility Benefit Inquiry and Response (270/271) Health Care Claim Status Request and Response (276/277) Health Care Claim Services Requests for Review and Response (278) 3
Health Care Claim Dental (837D) Billing Provider Address (Loop 2010AA N3) ZIP Code (Loops 2010AA, 2310C N4) Patient Relationship Codes (Loop 2000C PAT) Release of Information Code (Loop 2300 CLM) Prior Authorization (Loop 2300 REF) Referral Number (Loop 2300 REF) Diagnosis Code (Loop 2300 HI) Rendering Provider ID (Loop 2310B NM1) Physical location street address required; PO Box address not allowed. Full 9 digit ZIP code required for Billing Provider and Service Facility addresses. List of dependent relationship codes shortened. Providers must ensure system is updated to use only valid codes. No release situations removed; limited to only informed consent regulated by Federal Statutes or a signed statement held by the provider. Ensure software systems and internal work flow process are updated to identify these claims. Reference value in its own NEW segment. Reference value in its own NEW segment. NEW segment for the submission of diagnosis information for some specialty codes. Primary identification NPI required; tax ID does not apply. 4
Health Care Claim Dental (837D) Coordination of Benefits (COB) (Loop 2320 AMT) Service Line (Loop 2400 SVC) Date Treatment Start (Loop 2400 DTP) Date Treatment Completion (Loop 2400 DTP) Rules defined for calculating the previous payer s allowed/approved amounts. Number of AMT segments reduced to three (Payer Paid Amount, Remaining Patient Liability, and Total Non-Covered Amount) that apply to COB claims. New description field at Service Line for reporting unclassified CPT codes that were previously submitted in Claim Note (Loop 2300 NTE) segment. New segment at service line level to allow for a Treatment Start date that was previously submitted in Service Date segment. New segment at service line level to allow for a Treatment Completion date that was previously submitted in Service Date segment. While the new claim formats support submission of ICD-10 Diagnosis and Procedure codes, ICD-10 codes are not valid for use until October 1, 2013. Use of the ICD-10 codes prior to October 1, 2013 will result in a rejected claims submission. We encourage all providers to prepare for the transition to ICD-10. New report 999 Implementation Acknowledgment will replace 997 Functional Acknowledgment providing enhanced balancing of request to response and the capability to specify the error found in the request. New Level 2 report with the implementation of X12 version 5010 Errata transactions, EDI front end reports will include the delivery of 277CA Claim Acknowledgments. 5
Health Care Claim Professional (837P) Billing Provider Address (Loop 2010AA N3) ZIP Code (Loops 2010AA, 2310C N4) Patient Relationship Codes (Loop 2000C PAT) Release of Information Code (Loop 2300 CLM) Patient Signature Source Code (Loop 2300 CLM) Benefits Assignment Certification Indicator (Loop 2300 CLM08) Delay Reason Code (Loop 2300 CLM20) Prior Authorization (Loop 2300 REF) Referral Number (Loop 2300 REF) Diagnosis Code (Loop 2300 HI) Rendering Provider ID (Loop 2310B NM1) Physical location street address required; PO Box address not allowed. Full 9 digit ZIP code required for Billing Provider and Service Facility addresses. List of dependent relationship codes shortened. Providers must ensure system is updated to use only valid codes. No release situations removed; limited to only informed consent regulated by Federal Statutes or a signed statement held by the provider. Ensure software systems and internal work flow process are updated to identify these claims. Source Code P (Signature generated by an entity other than the patient...) required when a signature was executed on the patient s behalf. Evaluate data forms to ensure new criterion is identifiable and documented appropriately. New code value W added to be used when patient refuses to assign benefits. New code value 15 added for natural disaster. Reference value in its own segment. Reference value in its own segment. Number of diagnosis codes increased from 8 to 12 per claim. Primary identification NPI required; tax ID does not apply (only NPI allowed at Rendering Provider Level). 6
Health Care Claim Professional (837P) Ambulance Pick Up / Drop Off Locations (Loop 2310E, 2310F) Coordination of Benefits (COB) (Loop 2320 AMT) Service Line (Loop 2400 SV1) Anesthesia Services (Loop 2400 SV103) Drug Identification (Loop 2410 LIN) Oxygen Therapy (Loop 2440 FRM) New loops to submit ambulance address information. (Pick-up and Drop Off location, address only, not trip ticket.) Rules defined for calculating the previous payer s allowed/approved amounts. Number of AMT segments reduced to three (Payer Paid Amount, Remaining Patient Liability, and Total Non- Covered Amount) that apply to COB claims. NEW description field at Service Line for reporting unclassified CPT codes that were previously submitted in Claim Note (Loop 2300 NTE) segment. Time recognized in minutes only; units not allowed. Number of loops reduced from 25 to 1 to facilitate consistent reporting of compound drugs. Use only one NDC per service line. NEW Segment consolidates information needed to complete the Certificate of Medical Necessity (CMN) that was previously submitted in Home Oxygen Therapy segment. While the new claim formats support submission of ICD-10 Diagnosis and Procedure codes, ICD-10 codes are not valid for use until October 1, 2013. Use of the ICD-10 codes prior to October 1, 2013 will result in a rejected claims submission. We encourage all providers to prepare for the transition to ICD-10. New Level 1 report 999 Implementation Acknowledgment will replace 997 Functional Acknowledgment providing enhanced balancing of request to response and the capability to specify the error found in the request. New Level 2 report with the implementation of X12 version 5010 Errata transactions, EDI front end reports will include the delivery of 277CA Claim Acknowledgments. 7
Health Care Claim Institutional (837I) Billing Provider Address (Loop 2010AA N3) ZIP Code (Loops 2010AA, 2310C N4) Patient Relationship Codes (Loop 2000C PAT) Release of Information Code (Loop 2300 CLM) Benefits Assignment Certification Indicator (Loop 2300 CLM08) Delay Reason Code (Loop 2300 CLM20) Prior Authorization (Loop 2300 REF) Referral Number (Loop 2300 REF) Present on Admission (Loop 2300 HI) Principal, Admitting, Patient Reason for Visit, and External Cause of Injury Diagnosis Code (Loop 2300 HI) Physical location street address required; PO Box address not allowed. Full 9 digit ZIP code required for Billing Provider and Service Facility addresses. List of dependent relationship codes shortened. Providers must ensure system is updated to use only valid codes. No release situations removed; limited to only informed consent regulated by Federal Statutes or a signed statement held by the provider. Ensure software systems and internal work flow process are updated to identify these claims. New code value W added to be used when patient refuses to assign benefits. New code value 15 added for natural disaster. Reference value in its own NEW segment. Reference value in its own NEW segment. Segment allows for submission of indicator that was previously submitted in File Information segment. (Values removed N No, U Unknown, Y Yes, W No Application) are no longer applicable). Values previously sent in K3 segment are now in HI segment (HI01-9-HI12-09). Values now referenced in separate distinct NEW segments. 8
Health Care Claim Institutional (837I) Claim Quantity (Loop 2300 QTY ) Attending Provider ID (Loop 2310A NM1) Coordination of Benefits (COB) (Loop 2320 AMT) Service Line (Loop 2400 SV2) Drug Identification (Loop 2410 LIN) QTY no longer used; information is submitted in Value Codes. Primary identification NPI required; tax ID does not apply. Rules defined for calculating the previous payer s allowed/approved amounts. Number of AMT segments reduced to three (Payer Paid Amount, Remaining Patient Liability, and Total Non- Covered Amount) that apply to COB claims. NEW description field at Service Line for reporting unclassified CPT codes that were previously submitted in Claim Note (Loop 2300 NTE) segment. Number of loops reduced from 25 to 1 to facilitate consistent reporting of compound drugs. Use only one NDC per service line. Definitions for inpatient and outpatient services now align with the National Uniform Billing Committee standards, per the UB04 Data Specification Manual. Ensure that you have access to reference guides UB04 Data Specification Manual and Technical Report Type 3 (TR3). While the new claim formats support submission of ICD-10 Diagnosis and Procedure codes, ICD-10 codes are not valid for use until October 1, 2013. Use of the ICD-10 codes prior to October 1, 2013 will result in a rejected claims submission. We encourage all providers to prepare for the transition to ICD-10. New report 999 Implementation Acknowledgment will replace 997 Functional Acknowledgment providing enhanced balancing of request to response and the capability to specify the error found in the request. New Level 2 report with the implementation of X12 version 5010 Errata transactions, EDI front end reports will include the delivery of 277CA Claim Acknowledgments. 9
Health Care Claim Payment/Advice (835) Payer Technical Contact (Loop 1000A PER) Payer Web Site (Loop 1000A PER) Claim Status Codes (Loop 2100 CLP) Claim Frequency Code (Loop 2100 CLP) Claim Adjustment Group Code (Loops 2100, 2110 CAS) Other Subscriber Name (Loop 2100 NM1) Rendering Provider Identification (Loop 2100 REF) Rendering Provider Information (Loop 2110 REF) NEW segment to report the EDI Solutions Help Desk contact phone number. NEW segment associated to Healthcare Policy Identification segment; to report website containing appeal, complaint, medical or other policies related to ITS payments. List of claim status codes updated. Usage of claim status code 4 clarified, Usage of this code would apply if the Patient/Subscriber is not recognized, and the claim was not forwarded to another payer. Usage clarified; reported on professional and dental claim payments when received on original claim. List of claim adjustment group codes updated. Reversed claim records report group code from originally processed claim. Group code CR Correction and Reversal does not apply. NEW segment for reporting corrected priority payer and name or identification of other subscriber when known. List of reference identification qualifiers updated. List of reference identification qualifiers updated. 10
Health Care Claim Payment/Advice (835) Statement From or To Date (Loop 2100 DTM) Coverage Expiration Date (Loop 2100 DTM) Claim Received Date (Loop 2100 DTM) Service Payment Information (Loop 2110 SVC) Line Item Control Number (Loop 2110 REF) Healthcare Policy Identification (Loop 2110 REF) Split Claims (Loop 2100 MOA, MIA) Peer segment split into distinct segments to provide more explicit usage instructions. Peer segment split into distinct segments to provide more explicit usage instructions. Peer segment split into distinct segments to provide more explicit usage instructions. List of product and service qualifiers updated. Peer segment split into distinct segments to provide more explicit usage instructions. NEW segment for reporting published and enumerated policy used for claim adjudication. Associated to Payer Website segment. Identification of split claims by reporting Remittance Advice Remark Code MA15 (Alert: Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported). 11
Health Care Eligibility Benefit Inquiry and Response (270/271) 270 Alternate Member Search Search patients by Member ID, Last Name, or Date of Birth. 271 Patient Account # Returned when received on the 270 Inquiry. Other Coverage Info Modified Responses Member Group # Primary Care Provider Patient Liability Patient Liability -same In-and Out-of-Network Out of Pocket Format Change Past/Future Date Request Service Types Authorization Indication Identifies primary and secondary insurance when available. Service Type 30 (Health Plan Benefit Coverage). Returned when printed on Member ID card or Group number received on 270 Inquiry. Returned when applicable. Return of EB12 (plan network indicator) of w when benefit applies to in and out-of-network EB03 (Service Type Code) returns all service types that contain the identification information in the Loop 2110C, 2110D on same line. Returned in the same format as patient responsibility New rejection code; AAA 62 (Date of Service Not Within Allowable Inquiry Period) when date cannot be supported. Benefits available for two new service types MH Mental Health, UC Urgent Care. Indicating if service types need authorization for some, all, or no procedures for the service type. New report 999 Implementation Acknowledgment will replace 997 Functional Acknowledgment providing enhanced balancing of request to response and the capability to specify the error found in the request. 12
Health Care Claim Status Request and Response (276/277) 276 Patient Gender No longer required in the request. Units of Service Additional Claim Level Information Billing / Rendering Provider Number Quantity (units of service) now a required element. Patient Account Number, Clearinghouse Control Number, Pharmacy Identifier are available. Billing or Rendering Provider Numbers can now be submitted. 277 Pharmacy Claims New status field. Date of Birth Additional Claim Level Information No longer provided in the response. Patient Account Number, Clearinghouse Control Number, Pharmacy Identifier. Further clarification of finalized claims at the header and line levels. New report 999 Implementation Acknowledgment will replace 997 Functional Acknowledgment providing enhanced balancing of request to response and the capability to specify the error found in the request. 13
Health Care Services Review Request and Response (278-13/11) 5010 has modified the structure of the 278 to align with the claims structure: institutional, professional and dental Specific request category code has been added for medical services reservations to expand usage of service type code. Patient Condition Indicator segment has been expanded to multiple segments that will handle Ambulance, Chiropractic, DME, Oxygen Information, Functional Limitation, Permitted Activities and Mental Status. While the new claim formats support submission of ICD-10 Diagnosis and Procedure codes, ICD-10 codes are not valid for use until October 1, 2013. Use of the ICD-10 codes prior to October 1, 2013 will result in a rejected claims submission. We encourage all providers to prepare for the transition to ICD-10. New report 999 Implementation Acknowledgment will replace 997 Functional Acknowledgment providing enhanced balancing of request to response and the capability to specify the error found in the request. Blue Cross and Blue Shield of Georgia, Inc., is an independent licensee of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. 14