New Mexico Medicaid requires Rendering Provider Tax ID

CPID# 1492 New Mexico Medicaid requires the Rendering Provider Tax ID number when the NPI only is sent. RelayHealth has identified that a lot of clients are getting claim exclusions for not submitting this information so they have added a new edit to scrub for this.

Edit: 33 0011C: Missing rendering Provider EIN with NPI in Loop 2310B, when NM108=XX, Must have ref~EI

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Medicares Quarterly Updates - holding checks

The Centers for Medicare and Medicaid Services (CMS) requires and schedules standarda quarterly updates that each Medicare contractor must load into their claim processing system. These quarterly updates take place each January, April, July and October. The July 2008 update will take place the weekend of July 5th 2008. Medicare (CMS) will create a hold edit and place it in the system on July 1st 2008, to ensure that all claims submitted to Medicare on or after July 1, 2008, with 2008 dates of services, are held in the system until the July update has been completed.

Once Medicare confirms and validate that the system updates are processing correctly, they will start releasing the medical claims from the hold edit. Due to the volume of claims, it may take Medicare a few business days to release all claims from the hold edit.

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New Mexico Medicare and Oklahoma Medicare

CPID's 1457 New Mexico Medicare and 1458 Oklahoma Medicare require the Facility information to be present on claims that contain a Facility code Value other than 12 Home. Because of these new changes RelayHealth has added a new edit to scrub for this value:

Edit 57 0037D: Missing Service Facility Information in Loop 2400, If SV105 is not 12, then Loop 2310D (Professional Service Facility) or 2420C (Professional Service Facility) must be sent.

This new edit will begin populating on July 8th 2008.


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Oklahoma Medicaid has new NPI edits

For those medical practices that use RelayHealth as a clearinghouse and bill to Oklahoma Medicaid be aware of new exclusion edits starting June 19th 2008:

Edit HU 0043C: invalid claim ref provider ID qualifier in Loop 2310A (CMS-1500), NM108 Must be sent must be equal to XX

EDIT HU 0044C: Invalid Claim pur srv id qualifier in Loop 2310C (CMS-1500), NM108 Must be sent must be equal to XX

Edit HU 0045C: Invalid Claim Service Facility ID Qualifier in Loop 2310D (CMS-1500), NM108 Must be sent must be equal to XX

Edit HU 0046C: Invalid Claim Supervising Provider ID Qualifier in Loop 2310E (CMS-1500), NM108 Must be sent must be equal to XX

Edit HU 0047D Invalid SRV Line Pur SRV ID Qualifier in Loop 2420B (CMS-1500), NM108 Must be sent must be equal to XX

Edit HU 0048D Invalid SRV line SRV Facility ID Qualifier in Loop 2420C (CMS-1500), NM108 Must be sent must be equal to XX

Edit HU 0049D Invalid SRV Line SUP Provider ID Qualifier in Loop 2420D (CMS-1500), NM108 Must be sent must be equal to XX

Edit HU0051D Invalid SRV line Referring Provider ID Qualifier in Loop 2420F (CMS-1500), NM108 Must be sent must be equal to XX


These edits are for Oklahoma Medicaid NPI requirements

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Intermountain Healthcare is now SelectHealth

If billing electronic claims through RelayHealth they are requesting that you change the payors name from CPID#4480 Intermountain Healthcare to CPID#4480 SelectHealth.

Intermountain Healthcare is also known as IHC

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PHP TennCare has special requirements for reporting NDC info

RelayHealth has been informed that CPIDs 1893 and 8585 PHP TennCare has special requirements for reporting NDC information. The payor is requiring all providers to comply with the TennCare NDC/J-code regulations. In order to accomplish this, providers must send the following information when a J-code is present on a claim:
If Loop 2400 SV1 contains a J-code, then Loop 2410 must contain an LIN segment with the LIN02 and LIN03 elements populated.
LIN02 = N4 qualifier
LIN03 = NDC Code

If Loop 2400 SV1 contains a J-code, then Loop 2410 must contain a CTP segment with the CTP03, CTP04, and CTP05 elements populated.

CTP03 = Unit Price
CTP04 = Quantity
CTP05 = Composite Unit of Measure

Note: If the CTP segment would contain the same exact information that is sent in the SV1 segment, then the CTP segment is not necessary, otherwise it is required.
Action Required: Please make the necessary changes to your system to comply with this payor requirement and to prevent claim rejections.

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National Association of Letter Carriers electronic claims

RelayHealth has been informed that all electronic claims for CPID 4531 National Association of Letter Carriers (payor ID 53011) can be consolidated under CPID 4509 Cigna Health Plans (payor ID 62308) effective immediately.

In order for providers to make a smooth transition, please be aware of the following changes:

• RelayHealth will temporarily convert CPID 4531 National Association of Letter Carriers to CPID 4509 Cigna Health Plans until May 8, 2008.
• All claims for CPID 4531 National Association of Letter Carriers can be submitted using CPID 4509 Cigna Health Plans effective immediately.
• The last date that CPID 4531 National Association of Letter Carriers will be accepted at RelayHealth is May 8, 2008.
• Effective May 9, 2008, all claims for CPID 4531 National Association of Letter Carriers must be submitted to RelayHealth using CPID 4509 Cigna Health Plans.

Failure to use the correct CPID for National Association of Letter Carriers claims submitted on or after May 9, 2008 will cause the claims to reject at RelayHealth.

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How to fix exclusion 90496: Medicare report number is required

Some claims are getting rejections 90496:Medicare report number is required:

RelayHealth has been made aware of an internal system issue for CPID 1414 Florida Blue Shield. As a result, some claims are rejecting on the AVAILITY ELECTRONIC BATCH report for the following reason:

Florida Blue Shield has relayed that the issue should be corrected by the end of June, 2008. At this time, any claims receiving this rejection will need to be resubmitted via paper. RelayHealth will send an update when this issue has been resolved.

Action Required: Please be aware of any claims receiving the rejection state above. Please resubmit these claims on paper until further notice.

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National Government Services and Durable Medica Equipment

RelayHealth has been made aware that National Government Services, Inc. (NGS), has been awarded the Durable Medical Equipment (DME) Common Electronic Data Interchange (CEDI) front end contract by the Centers for Medicare and Medicaid Services (CMS). With this contract, CEDI will provide a single front end solution for the submission and retrieval of electronic transactions.

RelayHealth will be converting the following CPIDs to the CEDI front end on April 30, 2008:

• CPID 7475 Medicare DME MAC Jurisdiction A
• CPID 7476 Medicare DME MAC Jurisdiction B
• CPID 7477 Medicare DME MAC Jurisdiction C
• CPID 7478 Medicare DME MAC Jurisdiction D

RelayHealth has identified the following items for you to be aware of with the CEDI front end conversion:

Payor agreements for electronic claims are required.
New providers do need to complete a new agreement.
Payor agreements for electronic remittance are required.

New providers do need to complete a new agreement.
The following payor reports will be available.
HDIG CLAIMS CONFIRMATION REPORT: this is a new report that will be received for all four payors.

The following reports will continue to be received with this front end conversion:
RECEIVED CLAIMS LISTING (#7I6002)
BP LEVEL ERROR LISTING and CL LEVEL ERROR LISTING (#7I6003)
SUBMISSION SUMMARY (#7I6004)
CMN REJECT LISTING (#716006)
RelayHealth Standardized Payor reports for the above payors will be available as soon as possible after April 30, 2008.

The following payor report will no longer be available.
REDI-LINK CLAIM ACCEPTANCE RESPONSE currently being received for CPID 7477 Medicare DME MAC Jurisdiction C, will no longer be received with the new front end conversion.

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Benefit Plan Management INC

Reminder:RelayHealth has been informed that all electronic claims for CPID 2884 - Benefit Plan Mgmt, Inc. (payor ID 37222) can be consolidated under CPID 1889 - Health Plans, Inc. (payor ID 44273) effective immediately.

In order for providers to make a smooth transition, please be aware of the following changes:
• RelayHealth will temporarily convert CPID 2884 Benefit Plan Mgmt, Inc. to CPID 1889 Health Plans, Inc. until 4/30/2008.
• All claims for CPID 2884 Benefit Plan Mgmt, Inc. can be submitted using CPID 1889 Health Plans, Inc. effective immediately.
• The last date that CPID 2884 Benefit Plan Mgmt, Inc. will be accepted at RelayHealth is 4/30/2008.
• Effective 5/1/2008, all claims for CPID 2884 Benefit Plan Mgmt, Inc. must be submitted to RelayHealth using CPID 1889 Health Plans, Inc..

Failure to use the correct CPID for Benefit Plan Mgmt, Inc. claims submitted on or after 5/1/2008 will cause the claims to reject at RelayHealth.

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Golden Rule electronic claims

RelayHealth will be changing the electronic claims routing for the following payor on 04/30/2008.

The CPID included in this new routing is:
CPID 6483 – Golden Rule – Professional
CPID 4515 – Golden Rule – Institutional

RelayHealth has identified the following items for you to be aware of with this change:
Payor agreements for electronic claims are not required. The following payor reports will be available:
- Claim Status Report
- RelayHealth Standardized Payor reports.

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AvMed Inc electronic claim exclusions

Please be advised that effective May 1, 2008, AvMed will require the NPI on all EDI standard transactions. Please note that electronic claims submitted to AvMed after April 30, 2008, without an NPI number will be rejected. In an effort to avoid issues after the May 1, 2008 effective date, please begin immediately submitting electronic claims using your NPI number.
Effective May 23, 2008, NPI only will be required, claims must not contain legacy provider numbers.
As a result, RelayHealth will add the following edits on April 30, 2008 in order to meet payor requirements for May 1, 2008:

HU 0019C:INVALID BILLING PROVIDER ID QUAL - IN LOOP 2010AA, NM108 MUST BE EQUAL TO XX
HU 0022C:INVALID CLAIM REND PRV ID QUAL - IN LOOP 2310B(PROF)/2310C(INST), NM108 MUST BE EQUAL TO XX

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Health Administrative Services changes name

If you are currently submitting claims through RelayHealth for CPID#'s 1847 & 7500 Health Administrative Services please change the payor name to Trisurant.

1847 is for Professional claims (CMS-1500)
7500 is for Institutional claims (UB04)

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Medicare must verify who you are when calling

Medicare can not just talk with anyone so in order to get your question answered please call prepared to answer some questions. As of May 23, 2008 Medicare customer service will not be able to assist you until you verify the providers National Provider Identifier (NPI) (line 33A of the CMS-1500 claim form) and the Provider Transaction Access Number (PTAN) which appears on line 33B of the CMS-1500 claim form.

All providers who enrolled with Medicare before May 23, 2008 their PTAN is their legacy Medicare number. New providers enrolling in Medicare on or after May 23, 2008 will be assigned a PTAN as part of the Medicare enrollment process.

Magellan Health Services offers direct connection with RelayHealth

RelayHealth has announced a new direct connection with Magellan Health Services to be used when processing electronic medical claims and remittance. These CPID#'s become effective as of June 17th 2008.

CPID 1419 - Magellan Health Services Professional (CMS-1500)
CPID 5539 - Magellan Health Services Institutional (UB04)

With this change are new rules:

• No EDI Agreements are required to submit medical claims electronically to Magellan when using CPID# 1419 or 5539.
• EDI Agreements are required for electronic remittance advice (Electronic Explanation of Benefits)
• RelayHealth sends the 277U reports and standardized payor reports
• RelayHealth is setting up two additional payor edits for Magellan including HU 0019 in Loop 2010AA, NM108 Must be equal to XX and HU 0022 in Loop 2310B (PROF)/2310C (INST), NM108 must be equal to XX
• Professional: Payer Claim Office Number: In LOOP 2310BB N3-01 must be sent as PO Box, other format such as P O Box or P.O. Box will cause the claim to reject.
• Institutional: Payer Claim Office Number: In LOOP 2310BC N3-01 must be sent as PO Box, other format such as P O Box or P.O. Box will cause the claim to reject.

These changes become effective on June 17, 2008

*Update 9/23/08: Prior to October 15th 2008 clients must comlete a new EDI Agreement for ERA's with RelayHealth's new direct connection to Magellan.

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Oklahoma Medicaid requires Taxonomy Code

CPID 2753 through RelayHealth is to transmit electronic claims to Oklahoma Medicaid. Oklahoma Medicaid has asked RelayHealth to scrub for Taxonomy Codes on electronic claim submission.

If you are sending your Rendering Taxonomy code in Loop 2310B or Loop 2420A the insurance carrier Oklahoma Medicaid requires an additional REF segment:

REF01 must = LU
REF02 must = Rendering Provider 9 digit zip code

RelayHealth will automatically default the LU qualifier when sent in either 2310B or 2420A Rendering Providers Loop. The client is responsible for submitting the 9 digit zip code for the Rendering Provider.

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New Payer edits for LA Medicaid

Relayhealth has created two new edits to scrub for NPI information for CPID# 1475 LA Medicaid. LA Medicaid needs to validate the NPI is being sent in Loop 2010AA Billing Provider and Loop 2010AB Pay-to-Provider. The new edits are:

Edit 09 - 0348C Billing NPI not on file
Edit 09-0349C Pay-to NPI not on file

If your office submits to RelayHealth (McKesson) and receive these exclusions you should promptly follow up with LA Medicaid to resolve the NPI registration and inform RelayHealth enrollment EDI team with the valid NPI information.

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Amerigroup Corp unknown payer response code

RelayHealth has been made aware of an issue with the MEDAVANT DATA FILE report for CPID 1741 - Amerigroup Corp that has been occurring since processing date of March 28, 2008. As a result, the intermediary produced an invalid message of UNKNOWN PAYER RESPONSE CODE. The intermediary is working to correct the issue and is determining whether they will be able to reproduce corrected reports.
The actual code that is being returned with the message is correct and should be referenced to obtain claim status. Below is a listing of the codes and their correct corresponding message descriptions.

20 - Carrier acknowledges receipt of the claim
30 - Claim is pending at receiver site
40 - All services paid/claim adjudication process has been completed by carrier
50 - Claim requires special handling
51 - Missing or invalid data
56 - Invalid date of service
61 - Provider is not an electronic submitter
83 - No active coverage exists
86 - Invalid provider ID
99 - Close out
4P - Completed: Payment made according to plan provisions
4Q - Complete; payment has been denied
4Y - Adjustments
5Z - Provider not on file
7Q - Partial denial
8U - Invalid procedure
8Z - Unable to process electronically
T5 - Need rendering name, address, phone number
BF - Subscriber/Member ID not found
PB - Pending: Under final processing - no action required at this time
PG - Pending: Claim in process - no action required at this time
QA - Missing or invalid provider NPIQC - NDC missing

Action Required: Please be aware of any invalid rejections returned from the intermediary and reference the code for claim status.

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Medicare NPI exclusion edits

Correction: Edit should read as follows:
EDIT HU 0024C:INVALID CLAIM SRV FAC ID QUAL - IN LOOP 2310D(PROF) WHEN NM108 IS SENT IT MUST BE EQUAL TO XX

Update: RelayHealth has also implemented the following NPI edit for all Medicare Part A payors.
EDIT HU 0024C:INVALID CLAIM SRV FAC ID QUAL - IN LOOP 2310D(PROF) NM108 MUST BE EQUAL TO XX

RelayHealth will be implementing payor NPI changes on May 22, 2008 in preparation for the CMS requirements that will take effect on May 23, 2008. As part of this change, RelayHealth will be implementing the following NPI edits for all Medicare Part A and Part B payors.
The following edits apply to Medicare Part A payors:
EDIT HU 0022C:INVALID CLAIM REND PRV ID QUAL - IN LOOP 2310C(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0026C:INVALID CLAIM ATTEND PHY ID QUAL - IN LOOP 2310A(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0027C:INVALID CLAIM OPERATE PHY ID QUAL - IN LOOP 2310B(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0028D:INVALID SRV LINE REND PRV ID QUAL - IN LOOP 2420C(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0034D:INVALID SRV LINE ATTND PHY ID QUAL - IN LOOP 2420A(INST), NM108 MUST BE EQUAL TO XX
EDIT HU 0035D:INVALID SRV LINE OPER PHY ID QUAL - IN LOOP 2420B(INST), NM108 MUST BE EQUAL TO XX

The following edits apply to Medicare Part B payors:
EDIT HU 0021C:INVALID CLAIM REF PROV ID QUAL - IN LOOP 2310A(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0023C:INVALID CLAIM PUR SRV ID QUAL - IN LOOP 2310C(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0025C:INVALID CLAIM SUP PROV ID QUAL - IN LOOP 2310E(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0029D:INVALID SRV LINE PUR SRV ID QUAL - IN LOOP 2420B(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0031D:INVALID SRV LINE SUP PROV ID QUAL - IN LOOP 2420D(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0032D:INVALID ORDERING PROVIDER ID QUAL - IN LOOP 2420E(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0033D:INVALID SRV LINE REF PROV ID QUAL - IN LOOP 2420F(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0036D:INVALID PURCHASE SERVICE ID - FOR PROFESSIONAL CLAIMS, PS101 MUST BE 10 NUMERIC AND POSITION 1 MUST BE 1 OR 2 AND MUST PASS NPI CHECK DIGIT ROUTINE

Action Required: Please be aware of the Medicare Part A and Part B new edit requirements effective May 22, 2008.

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Billing NPI's may possibly require additional submitter numbers

RelayHealth would like to provide you with the following important information from Noridian Administrative Services EDISS Support regarding National Provider Identifier (NPI). Please read carefully and follow the specific instructions for your organizations.

Failure to update your Payor Assigned Submitter ID may cause payment delays.
EDI Support Services (EDISS) is issuing Submitter IDs (Payor Assigned Submitter IDs) in a one to one ratio with the Billing NPI, due to the transition from Medicare Provider Numbers to NPI in electronic claim submission. If you have one Billing NPI you will have one Submitter ID. If you have multiple Billing NPIs you will have multiple Submitter IDs. The way you enumerated determines the way Submitter IDs will be assigned. Refer to the following chart for examples:



For existing providers who have enumerated with multiple Billing NPIs for that one Medicare Billing Number: EDISS will fax you additional Submitter IDs for each billing NPI, if currently submitting claims with one Medicare Billing Number and one Submitter ID and have enumerated with multiple Billing NPIs for that one Medicare Billing Number.
The payors impacted are listed below:
CPID 1446 Nevada Medicare
CPID 1455 Alaska Medicare
CPID 1456 Arizona Medicare
CPID 1459 Oregon Medicare
CPID 1462 Washington Medicare
CPID 1469 Iowa Medicaid
CPID 1523 North Dakota Medicare
CPID 1527 Utah Medicare
CPID 2411 North Dakota Blue Shield
CPID 2453 North Dakota Medicare
CPID 2454 South Dakota Medicare
CPID 2458 Utah Medicare
CPID 2466 Wyoming Medicare
CPID 2467 Hawaii Medicare
CPID 2571 Iowa Medicaid
CPID 3521 Minnesota Medicare
CPID 3583 Wyoming Medicare
CPID 5515 Oregon Medicare
CPID 5521 Washington and Alaska Medicare
CPID 5546 Arizona Medicare
CPID 5581 Idaho Medicare
CPID 5589 South Dakota Medicare
CPID 7400 Montana Medicare
CPID 7489 Wyoming Blue Shield
Action Required: Providers must fax a copy of the Submitter IDs to RelayHealth at (916) 267-2963 to allow for set up in our system.


Submitter numbers are used to identify the client that is submitting the claims to the insurance carrier.

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Medicare claim billing

Medicare Notification:

PHYSICIAN (CLINIC) BILLING OF HCT OR HGB VALUES ON ERYTHROPOIESIS STIMULATING AGENT (ESA) CLAIMS

The following information must be submitted with each claim:

HCT or Hgb values:
For professional paper claims, test results are reported in item 19 of the Form CMS-1500 claim form. For electronic claims (837P), providers report the hemoglobin or hematocrit readings in Loop 2400 MEA segment. The specifics are MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results.

In other words, EMC claims should map the correct amounts to the correct field when billed as indicated in BR 5699.5: "Contractors shall require the most recent hematocrit or hemoglobin test results to be reported on claims submitted with HCPCS codes J0881, J0882, J0885, J0886, and Q4081. Hematocrit or hemoglobin test results are reported in the MEA03 segment Loop 2400 of the 837P or item 19 of the Form CMS-1500 claim form." (If the area above is blank, the claim will deny)

ICD-9 codes (For 4010A1 electronic format):
The ICD-9 code for the cause of the anemia must be placed in 2300 Loop, HI Segment for electronic claims (item 21, #1 for CMS 1500 forms) and a pointer of 1 in Loop 2400, SV1 segment for electronic claims (#1 in item 24E on the CMS 1500 form).

If you received an unprocessable denial, the claim can be resubmitted with the correct information.

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How to format out of country addresses for Medicare

OUT OF COUNTRY ADDRESSES & 837 4010 EMC PRE-PASS EDITING

The Electronic Media Claims (EMC) system reviews every claim for a number of pre-pass edits to ensure that claim data is valid. If a claim contains missing or incorrect information, one of two things will happen because of a pre-pass edit.

1. If an informational edit is in effect, the claim, batch, or file will process normally. The informational edit identifies the error and alerts the submitter in order to correct future claims.
2. If a delete edit is in effect, the claim, batch, or file will NOT process normally; it deletes from the claims processing system and alerts the submitter to the error.

Addresses are present in various loops in an electronic claim. For electronic claims, the state code is required and must be present and valid unless the country code is used. The state code edits set if N402 is present and is an invalid code OR if N402 = spaces AND N404 (Country Code) = spaces or a valid country code. Spaces or CAN are acceptable values. Alpha numeric zip codes are also acceptable.

Element Description
N401 City
N402 State
N403 Postal Code (Zip Code)
N404 County Code

Claims with a foreign address are subject to the mandatory electronic claims submission requirements for Medicare and are NOT an Administrative Simplification Compliance Act (ASCA) exception.

For a complete list of valid country codes, go to: http://unstats.un.org/unsd/methods/m49/m49alpha.htm


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Illinois Medicaid electronic claim exclusion codes

RelayHealth has identified claim rejections for CPID 2488 Illinois Medicaid regarding invalid NPI/Provider information being reported on claims.

The following error messages are being returned from the Intermediary with rejection information:

• ERROR MESSAGE: MEDICAID REQUIRES A 1 DIGIT PAYEE CODE
• ERROR MESSAGE: THE NATIONAL PROVIDER ID (NPI) IS REQUIRED FOR THIS PAYOR - LOOP 2010A
• ERROR MESSAGE: THE NATIONAL PROVIDER ID (NPI) IS REQUIRED FOR THIS PAYOR - LOOP 2010AB
• ERROR MESSAGE: THE NATIONAL PROVIDER ID (NPI) IS REQUIRED FOR THIS PAYOR - LOOP 2310B

To avoid continued claim rejections, there are two options for sending provider information correctly in order for claims to be paid properly at the payor:

Option 1: When Loop 2010AB Pay-to Provider IS NOT sent on a claim:
Loop 2010AA Billing Provider Loop must contain NPI
Loop 2010AA REF01 must be sent and must = 1D
Loop 2010AA REF02 must be sent and must contain the 9, 10 or 12 numeric legacy Medicaid Provider ID followed by a single space delimiter followed by the 1 digit payee code to identify the pay to provider.

Option 2: When Loop 2010AB Pay-to Provider IS sent on a claim:
Loop 2010AA should contain the same information as above
Loop 2010AB Pay-to Provider Loop must contain NPI
Loop 2010AB REF01 must be sent and must = 1D
Loop 2010AB REF02 must be sent and must = 1 digit payee code in position 1
RelayHealth will be adding the following NPI edits on June 13, 2008:

RelayHealth will be adding the following NPI edits on June 13, 2008:
EDIT HU 0019C: INVALID BILLING PROVIDER ID QUAL – IN LOOP 2010AA(PROF), NM108 MUST BE EQUAL TO XX
EDIT HU 0020C: INVALID PAY-TO PROVIDER ID QUAL – IN LOOP 2010AB, NM108 MUST BE EQUAL TO XX
EDIT HU 0022C: INVALID CLAIM REND PRV ID QUAL – IN LOOP 2310B(PROF), NM108 MUST BE EQUAL TO XX

Action Required: Please ensure you are reviewing your payor reports and make the necessary corrections for sending claims to this payor.

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Palmetto GBA insurance carrier EDI conversions

RelayHealth has received notification concerning the payors listed below that the current contracted Intermediaries will be converting to Palmetto GBA on the dates specified below.

Palmetto GBA is requiring re-enrollment for all providers. RelayHealth has made the Palmetto GBA agreements available on the Payor Agreement Library. Re-enrollment requirements are:

• Providers already approved to submit transactions through RelayHealth must complete the Palmetto GBA EDI Enrollment Form
• Providers with an agreement in Open status at RelayHealth must complete the Palmetto GBA EDI Enrollment Form
• Providers not enrolled through RelayHealth must complete current intermediary forms and the Palmetto GBA EDI Enrollment Form

The enrollment cut off date to enroll with the current Intermediary will be determined by Palmetto GBA. Once determined, Palmetto GBA will no longer allow enrollment through the current intermediary. After the enrollment cut off date, only the Palmetto GBA EDI Enrollment Forms will be accepted by RelayHealth.

The payor affected are listed below:
CPID 1446 Nevada Medicare currently with contracted Noridian, converting on August 4, 2008
CPID 2467 Hawaii Medicare currently with contracted Noridian, converting on August 4, 2008
CPID 3508 California Medicare currently with contracted NGS, converting on August 18, 2008
CPID 5567 Hawaii Medicare currently with contracted NGS, converting on August 18, 2008
CPID 1436 Northern California Medicare currently contracted with NHIC, converting on September 2, 2008
CPID 1444 Southern California Medicare currently contracted with NHIC, converting on September 2, 2008

Action Required: Re-enrollment is required for both enrolled and non-enrolled providers who want to continue sending to the above payors. Please begin using the new agreements on the Payor Agreement Library to complete enrollment.

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Missouri Medicaid requires NPI and Pay to Provider Taxonomy Code in Loop 2000A

When submitting claims electronically to Missouri Medicaid regarding their NPI/Taxonomy Code requirement. If providers have one NPI and that NPI is associated to more than one legacy Medicaid provider number, providers may need to send their Billing or Pay-To provider Taxonomy Code in Loop 2000A - Billing/Pay-To Provider Specialty Loop and will also need to send their Rendering Taxonomy code in Loop 2310B - Rendering Provider Loop.

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Medciare Payment for Inpatient Hostipal Visits

PAYMENT FOR INPATIENT HOSPITAL VISITS - GENERAL (CODES 99221, 99222, 99223, 99224, 99225, 99226, 99227, 99228, 99229, 99230, 99231, 99232, 99233, 99234, 99235, 99236, 99237, 99238 & 99239)

Providers should note the payment policy for billing inpatient hospital visits provided on the same day as critical care services. See the Key Points section of this article for a complete list of the updates. CR5792 updates Chapter 12, Section 30.6.9 of the Medicare Claims Processing Manual. The updated section of this manual is attached to CR5792 and the address/link to that CR is listed in the Additional Information section of this article.

To read this article in full, please go to:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5792.pdf


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Medicare Refund Forms have been updated

Please begin using the newest version for the Medicare Refund:
http://www.wpsmedicare.com/part_b/business/vol_refund_new.shtml

This is for Medicare Part B Voluntary Refund forms.

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Medicare Provider Enrollment Telephone number

IMPORTANT NOTICE REGARDING PROVIDER ENROLLMENT HOTLINE TELEPHONE NUMBER HOURS OF OPERATION

Please note, the Provider Enrollment Hotline hours of operation are 8 a.m. - 4 p.m. CT, Monday through Friday.

The toll free numbers are as follows:
Minnesota: 1-866-564-0315
Illinois/Michigan/Wisconsin: 1-877-908-8476

Medicare NPI

MARCH 3, 2008 - Medicare fee-for-service 837P and CMS-1500 claims must include an NPI in the primary fields on the claim (i.e., the billing, pay-to, and rendering fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary fields. Failure to submit an NPI in the primary fields will result in your claim being rejected or returned as unprocessable beginning March 1, 2008. Until further notice, you may continue to include legacy identifiers only for the secondary fields.

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Medicare Holidays

IMPORTANT NOTICE REGARDING PROVIDER CUSTOMER SERVICE CLOSINGS

WPS Medicare will close for the following holidays:
March 21, 2008 (Good Friday – PM only)
May 26, 2008 (Memorial Day)
July 4, 2008 (Independence Day)
September 1, 2008 (Labor Day)

During weekends and evenings, the Interactive Voice Response (IVR) and CMS Secure Net Access Portal (C-SNAP) will continue to be available for your use to check eligibility and claim status. For more information regarding C-SNAP, please call 1-877-476-8116

To use the IVR, call:
Illinois (877) 908-9499
Michigan (877) 567-7201
Minnesota (877) 908-8470
Wisconsin (877) 567-7176

Medicare denial for secondary insurers

Medicare may allow payment for services or items when those services or items are a covered benefit and provided by a person or entity enrolled with Medicare. For a general description of services payable by Medicare, please access the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Pub. 100-04, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, Section 10.3.

Providers should submit a claim for non-billable services directly to the patient's other insurance plan, not to Medicare. If the other insurance plan requires documentation of non-coverage, providers can access the references in this article and use a copy of this document with their claim.
Providers of services may not be able to enroll with Medicare as defined in CMS IOM Pub. 100-08, Program Integrity Manual, Chapter 10, Section 6.2.1 and CMS IOM Pub. 100-04, Claims Processing, Chapter 12, Section 10.8. Those providers unable to enroll in Medicare based on their specialty and credentialing are also not able to submit claims to Medicare.

You can access the manual citations listed above at the following Web address:
http://www.cms.hhs.gov/Manuals/01_Overview.asp


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Medicare does not want staples on claims

When billing claims to Medicare please do not staple the documents. Medicare has to manually remove the staples from every document prior to scanning or working the documents. If 100,000 doctors mailed in 5 claims all with stapled paperwork attached.... well, I think you see the problem.

If you hate the thought of Medicare possibly missing a piece of paper they recommend you use paper clips.


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Medical BIlling doing their part to go Green

As a medical biller, trainer and consultant I am always working with other billing services and medical offices. Most offices are trying to identify ways to go "green". The biggest changes are sending claims electronically.

Each office I train ends up converting about 500+ claims from paper to electronic submissions. This is saving tremendous paper waste.

We also train clients to scan, email and fax documents instead of printing and mailing or printing and shredding. The more we convert clients over to a paperless office the easier it is for them to see huge savings on ink, paper, stamps, printers etc.

Insurance carriers like Medicare, Medicaid, Blue Cross, Blue Shield, Aetna, Cigna, Humana are sending Explanation of Benefits electronically back to the medical office. This in turn saves on tons of paper and ink waste.

The Medical world is truly doing it's part to help the enviornment. Leave a message to let us know what you do in your medical office to "go green".

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Top 10 Medicare Insurance Phone Call Reasons

Top 10 Reason Codes for Wisconsin, Illinois, Michigan, and Minnesota: March 2008 (Excluding Claim Status and Eligibility Issues)

Coding Errors/Modifiers 1,674
Address/Phone/Fax/Web Address 1,465
Duplicate Claim Denials 1,318
Appeals Process/Rights 1,071
Payment Explanation/Calculation 951
Medicare Secondary Payer (MSP) 949
Contractual Obligation not Met - Claim Denials 913
Medical Necessity 815
CMS-1500 Claim Form Item 791
Provider Information 755

WPS Medicare publishes FAQs specifically developed to address Top 10 Inquiry Reasons from the previous month's reporting period. We hope the answers to the questions listed below assist you in reducing claims errors associated with these topics.

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Medicare Prolonged Services Procedure Codes 99354-99359

What You Need to Know
CR 5972, from which this article is taken, updates the sections of the Medicare Claims Processing Manual that address prolonged services codes, in order to be consistent with changes/deletions in codes and changes in typical/average time units in the American Medical Association Current Terminology Procedural Terminology (CPT) coding system.
Make sure that your billing staffs are aware of the prolonged services CPT code changes as described in Background, below.

Since Medicare Claims Processing Manual Chapter 12 (Physicians/Nonphysician Practitioners), Sections 30.6.15.1 Prolonged Services With Direct Face-to-Face Patient Contact Service (Codes 99354 - 99357) (ZZZ codes) and 30.6.15.2 (Prolonged Services Without Direct Face-to-Face Patient Contact Services (Codes 99358 - 99359) were first written, several code changes, code deletions, and typical/average time units have changed in the American Medical Association (AMA) Current Procedural Terminology (CPT) coding system.
CR 5972, from which this article is taken, updates these sections that address prolonged services codes, in order to be consistent with the AMA CPT coding changes.
These manual changes:
(In keeping with current Medicare payment policy for physician presence and supporting documentation) define Prolonged Services and explain the required evaluation and management (E&M) companion codes;
Correct and update the tables for threshold times (reproduced below) to reflect code changes and current typical/average time units associated with the CPT levels of care in code families; and
In a new Subsection (30.6.15.1 (H)), explain how to report physician visits for counseling and/or coordination of care when the visit is based on time and when the counseling and/or coordination service is prolonged.

A summary of these manual changes follow.
Prolonged Services Definitions
In the office or other outpatient setting, Medicare will pay for prolonged physician services (CPT code 99354) (with direct face-to-face patient contact that requires one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. The time for usual service refers to the typical/average time units associated with the companion E&M service as noted in the CPT code. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services with CPT code 99355.

In the inpatient setting, Medicare will pay for prolonged physician services (code 99356) (with direct face-to-face patient contact which require one hour beyond the usual service), when billed on the same day by the same physician or qualified NPP as the companion evaluation and management codes. You should report each additional 30 minutes of direct face-to-face patient contact following the first hour of prolonged services may be reported by CPT code 99357.

Note: You should not separately report prolonged service of less than 30 minutes total duration on a given date, because the work involved is included in the total work of the evaluation & management (E&M) codes.
You may use code 99355 or 99357 to report each additional 30 minutes beyond the first hour of prolonged services, based on the place of service. These codes may be used to report the final 15 – 30 minutes of prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.

Required Companion Codes
Please remember that prolonged services codes 99354 – 99357 are not paid unless they are accompanied by the companion codes as described here.
The companion E&M codes for 99354 are:
Office or Other Outpatient visit codes (99201 - 99205, 99212 – 99215),
Office or Other Outpatient Consultation codes (99241 – 99245),
Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337),
Home Services codes (99341 - 99345, 99347 – 99350);
The companion E&M codes for 99355 are 99354 and one of its required E&M codes.
The companion E&M codes for 99356 are the Initial Hospital Care and Subsequent Hospital Care codes (99221 - 99223, 99231 – 99233), the Inpatient Consultation codes (99251 – 99255); Nursing Facility Services codes (99304 -99318).
The companion codes for 99357 are 99356 and one of its required E&M codes.

Requirement for Physician Presence
You may count only the duration of direct face-to-face contact with the patient (whether the service was continuous or not) beyond the typical/average time of the visit code billed, to determine whether prolonged services can be billed and to determine the prolonged services codes that are allowable.
You cannot bill as prolonged services:
In the office setting, time spent by office staff with the patient, or time the patient remains unaccompanied in the office; or
In the hospital setting, time spent reviewing charts or discussing the patient with house medical staff and not with direct face-to-face contact with the

patient or waiting for test results, for changes in the patient’s condition, for end of a therapy, or for use of facilities.
Documentation
Unless you have been selected for medical review, you do not need to send the medical record documentation with the bill for prolonged services. Documentation, however, is required to be in the medical record about the duration and content of the medically necessary evaluation and management service and prolonged services that you bill.
You must appropriately and sufficiently document in the medical record that you personally furnished the direct face-to-face time with the patient specified in the CPT code definitions. Make sure that you document the start and end times of the visit, along with the date of service.
Use of the Codes
You can only bill the prolonged services codes if the total duration of all physician or qualified NPP direct face-to-face service (including the visit) equals or exceeds the threshold time for the evaluation and management service the physician or qualified NPP provided (typical/average time associated with the CPT E/M code plus 30 minutes).
Threshold Times for Codes 99354 and 99355

Threshold Times for Codes 99354 and 99355 (Office or Other Outpatient Setting)
If the total direct face-to-face time equals or exceeds the threshold time for code 99354, but is less than the threshold time for code 99355, you should bill the E&M visit code and code 99354. No more than one unit of 99354 is acceptable.
If the total direct face-to-face time equals or exceeds the threshold time for code 99355 by no more than 29 minutes, you should bill the visit code 99354 and one unit of code 99355. One additional unit of code 99355 is billed for each additional increment of 30 minutes extended duration.
Table 1 displays threshold times that your carriers and A/B MACs use to determine if the prolonged services codes 99354 and/or 99355 can be billed with the office or other outpatient settings, including outpatient consultation services and domiciliary, rest home, or custodial care services and home services codes. The AMA CPT coding-derived changes are highlighted and noted in bolded italics.

For the full document read this: http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5972.pdf

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Medicare Diagnostic Laborartory Services billed

CERT ALERT: MD ORDERS REQUIRED FOR LABORATORY SERVICES

WPS Medicare has identified a recent increase in the number of errors attributed to lack of physician orders for diagnostic laboratory services billed. CMS guidelines define an order as below:

Order
An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
* A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
* A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
* An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.

If you receive a request for medical records from the CERT contractor or your local Medicare contractor, it is critical that the physician orders for all laboratory services be included. Without the orders, the services will be determined to be medically unnecessary and payment for these services will be rescinded.

For more information, go to:
http://www.cms.hhs.gov/Transmittals/Downloads/R80BP.pdf

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Medicare supporting documentation

When documenting patient charts please make sure you take these into consideration:

1. Documentation needs to support the service billed, the level of service and the medical necessity of the service
2. Documentation needs to be clear, concise, complete and LEGIBLE
3. If someone else where to evaluate the document they should be able to come to identify the same service performed and the reason why.

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Medicare Nursing Facility Service Codes 99304-99318

NURSING FACILITY SERVICES (CODES 99304 - 99318) (CMS MLN Matters)

CR 5986, from which this article is taken, updates the Medicare Claims Processing Manual, Chapter 12, (Physicians/Non-physician Practitioners), Section 30.6.13 (Nursing Facility Services (Codes 99304 - 99318) Subsection F (Use of the Prolonged Services Codes and Other Time-Related Services) by noting that the typical/average time units for Evaluation and Management (E/M) visit codes in the Nursing Facility Services code family are reestablished and applicable, as of January 1, 2008.

Effective for services on or after July 1, 2008, you may bill Medicare for medically necessary prolonged services for E/M visits (codes 99356 and 99357) in a SNF or NF with Nursing Facility Services codes (99304 – 99306, 99307 – 99310 and 99318). Additionally, you may use these prolonged services codes (99356 and 99357) with Nursing Facility Services in the code range (99304 – 99306, 99307 – 99310, and 99318) to bill for counseling and/or coordination of care services that are based on time.

For more information, see this article in its entirety at:
http://www.cms.hhs.gov/MLNMAttersArticles/downloads/MM5968.pdf


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Medicare billing for NDC drug code for CMS claims

Take action by reading this Medicare notification for NDC:

MEDICARE SHARED SYSTEMS MODIFICATIONS NECESSARY TO ACCEPT AND CROSSOVER TO MEDICAID NATIONAL DRUG CODES (NDC) AND CORRESPONDING QUANTITIES SUBMITTED ON CMS-1500 PAPER CLAIMS (CMS MLN Matters)

Provider Action Needed
STOP – Impact to You - The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 5835 that notifies physicians and suppliers who use Claim Form CMS-1500 (those providers who qualify for a waiver from the Administrative Simplification Compliance Act (ASCA)) that changes are being made to Medicare systems to conform with instructions for submitting NDC drug code and quantity information on Form CMS-1500.

Please read this article in its entirety on the CMS Website at http://www.cms.hhs.gov/MLNMAttersArticles/downloads/MM5835.pdf

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Medicare and physicians called to active duty in Armed Forces

for those doctors that are getting called to Active Duty take a few minutes to review Medicares documentation:

EXCEPTION TO 60-DAY LIMIT ON SUBSTITUTE PHYSICIAN BILLING ARRANGEMENTS FOR PHYSICIANS CALLED TO ACTIVE DUTY IN THE ARMED FORCES RESERVES (CMS MLN Matters)

What You Need to Know
CR 5985, from which this article is taken, announces a 6-month extension of the exception to the 60-day limit on substitute physician billing for physicians called to active duty in the Armed Forces. This means that a physician who is called to active duty may continue to bill for substitute physician services furnished from January 1, 2008 through June 30 2008, which may be beyond the 60-day limit.
Make sure that your billing staffs are aware of this change.

Please read this article in its entirety on the CMS Website at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5985.pdf

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