8 Considerations - Choosing the Right Medical Billing Company?

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Choosing the right company is key when outsourcing your Medical Billing!

When is it time to evaluate your billing company? It's always time. As a business owner, it's necessary to balance out where your resources (time, money, and staff) are spent. There are so many hats to be worn and so little time in between seeing patients, that often the business management is pushed aside.

There are many reputable outsourced billing companies available to you. Perhaps the one you are using is one of them. But is it the right fit for the size of your business, and your overall long-term goals? Even if you are performing your billing operations in-house, you need to check-in often to ensure you are on track.

Here are a few specific areas to evaluate and review with your designated billing representative:

Billing Knowledge / Skill Set:

• Are you often advised on billing codes and procedures based upon specific insurance?
• Do you know if your billing resource continues to allow you to code for something that is never paid?

Having this information at your fingertips increases your overall collections success and reduces your write offs.

• Is the billing staff kept abreast to all applicable policy changes from insurance companies?
• Do they know when they have to add any necessary modifiers?
• Are they aware of the rates you charge per insurance company?

By assuring that your billing resource has this knowledge base, your chances of proper payment will increase significantly.

Communication:

• Does the staff communicate well with your staff and patients?

Oftentimes, your patients will grumble about “them not getting it right.” That is your clue to listen and find out what is really happening. With the very dynamic industry we are in, insurance companies are always changing the rules. It is very important that your billing staff is willing and capable of explaining these changes or reasons of confusion to your clients.

There is also a lot of opportunity for error when sending out claims to insurance companies. If your billing resource does not have all of the pertinent information, then clean claims cannot be sent, resulting in denials. The company you hire to manage your accounts is a direct representation of your practice. Make sure you are happy with that communication process.

Accounts Receivable Follow-Up:

• How often does your staff hear from your billing company for missing or additional information?

If it is not at least weekly, then your accounts are not being paid the proper attention. A weekly list of information requests such as: authorizations, chart notes, RXs, diagnoses, confirmation of basic information such as DOB, and name, etc., must be sent to your staff, and your staff must get that information back to your billing resource as soon as feasible possible. A timeframe of one week is very appropriate. Each day one claim sits in your A/R reduces its chance of payment, significantly.

• Are you aware of your billing resources policy after an insurance company denies a claim?

If those denials are being allowed to age out, and eventually just written off, that is a red flag for improvement.

Overall, you are responsible for your business. You have investigated and evaluated your billing company prior to signing up with them. But, as you grow, or even pare down the size of your business, is your billing company able to keep up, follow-up, and communicate? This is a business relationship and should be treated as such.

A monthly meeting with very extensive reports showcasing where your A/R is at, is a must. This is your money and you should be very comfortable knowing where it is at. You might be surprised to find out that they feel their hands are tied based upon the information (or lack thereof) coming from your staff over to them. It's a great opportunity to identify areas that can be improved in both your business and theirs.

Providing a great medical billing service is not only about submitting claims … It’s also about having a great service-to-client relationship. Rather than having to deal with a different representative each time you call, your practice will be handled by one dedicated claim management specialist who handles all of your office’s medical billing needs. Your Claim Management Specialist is your single point of contact.

If it is time to investigate alternatives to your current billing process, we encourage you to talk to a CareSmart Billing consultant.  In taking advantage of outsourcing your medical billing to CareSmart, a division of Home Care Software Solutions, you can count on competitive and sensible prices that not only increase your bottom line, but cut your expenses and free up your valuable time.

Email CareSmart Billing today!

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

CMS 5010 Alert -Processing Issues

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Processing Issues with New Part A Common Edit & Enhancement Module

Description of the Problem

National Government Services experienced processing issues with the new Part A Common Edit & Enhancement Module (CEM). 

What This Means to You

Providers/trading partners are experiencing a delay in return of the 277 Claims Acknowledgment Transaction for impacted claims.

Current Status of Problem

National Government Services began to experience throughput processing issues with the new 5010 Part A Common Edit Module (CEM) on December 5, 2011. This issue has resulted in a delay of claims processing through the CEM Module, which has led to delays in claims being received into the FISS system. Providers submitting 5010 electronic claims have continued to receive the 999 Functional Acknowledgement Reports (999) but there have been delays in  receiving the 5010 277 Claim Acknowledgement reports (277CA) that the CEM produces . Although the issue has not been resolved, NGS has made significant process in working through the impacted Receipt dates and working towards resolution of this issue.

As of today, Electronic File submissions with Receipt Dates from December 5, 2011-January 13, 2012 have been processed through the CEM and the 277CA reports have been created.  Please note that due to an EDI Gateway Outage which occurred on January 17, 2012, providers who have not picked up their earlier reports may not have access to these older reports at this time.  Please use the FISS DDE Claims Inquiry function or IVR to confirm claims are in the FISS system.

All 999 and 277CA reports generated after January 17, 2012 would be available to providers in their electronic mailboxes.

The oldest receipt date that is currently in the processing queue is January 17, 2012. If trading partners have received accepted 999 reports for any files submitted with Receipt Dates from January 17, 2012 –January 25, 2012, please do not resubmit these electronic files as this may lead to delays in processing your claims. Due to these processing throughput issues that NGS continues to experience, please remember that the 277CA may take up to 5 business days to be available. 

If a 277CA has not been received or claims are not found in the claims system for a file with a receipt date prior to January 13, 2012, please contact the EDI Help Desk via the Online Email Inquiry Form or by calling the EDI Help Desk at 873-273-4334

National Government Services, Inc.

Corporate Communications

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Home Health and Hospice - OCR Begins HIPAA Audits

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OCR Begins HIPAA Audits Under the Watchful Eye of Congress

What to Expect and How to Prepare

01.19.2012

Elizabeth H. Johnson

Jessica M. Lewis

​ In November 2011, as required by the HITECH Act, the Office for Civil Rights (OCR) began auditing selected covered entities’ compliance with the privacy and security provisions of HIPAA and its implementing regulations. In the near future, business associates will be eligible for audit selection as well.  This article describes the current enforcement climate and provides practical steps on preparing for and responding to a HIPAA compliance audit.

Is It Getting Hot in Here? HIPAA Heats Up

The commencement of these audits is one of a series of changes that are transforming the HIPAA compliance landscape.  The last two years have seen the implementation of breach notification requirements, a 60-fold increase in OCR’s fining authority, increased enforcement activity with more serious repercussions for enforcement targets, and as noted, the start of OCR’s compliance audits.  Omnibus regulations implementing the majority of the agency’s outstanding HITECH rules are anticipated shortly.

Breach notification has highlighted significant failures to secure health records, with the number of breaches reported increasing by 32% from 2010 to 2011 at an estimated cost to the health  care industry of $6.5 billion.  The severity of the problem has not gone unnoticed.  On November 9, 2011, the Senate Judiciary Committee’s Subcommittee on Privacy, Technology, and the Law convened a hearing at which its members chastised OCR for its delay in issuing final rules to implement the HITECH Act and challenged the agency to step up HIPAA enforcement activities.

Despite what appears to the regulated community as substantial enhancement of HIPAA enforcement, the Subcommittee made clear that the agency’s efforts fell far short of its expectations, pointing out that, of tens of thousands of HIPAA complaints received by OCR since 2003, the agency has levied only one formal civil monetary penalty and has settled only six other cases for monetary amounts.  (Of course, several of these actions reached penalties in the millions, a fact that did not assuage the Subcommittee.) 

The Director of OCR, Leon Rodriguez, responded to the criticism by confirming that the agency is no longer required to provide enforcement targets with an opportunity to achieve voluntary compliance, as had been the case prior to the HITECH Act.  Rodriguez stated that the agency intends to put its fining authority to good use, stating “the real frontier is in our leveraging these new, stiff penalties that we have under the HITECH statute and expanding our utilization of those penalties” to promote compliance.

The Audit Process

It is in this climate that OCR commences its first compliance audits to assess target organizations’ compliance with the HIPAA Privacy, Breach Notice, and Security Rules.  Of the 150 targets to be assessed in 2012, the first 20 have been notified of their selection.  The audits will be conducted by OCR’s contractor, KPMG LLP, which has assisted the agency in developing an audit protocol to streamline the process.  In this pilot phase, the audit program functions as follows:

• OCR will inform the covered entity that it has been selected as an audit target and will request documentation of its privacy and security compliance efforts.  The response is due within 10 business days.
• OCR will conduct a site visit over a three to ten day period, interviewing personnel and observing operations.  Covered entities are expected to receive 30 to 90 days' notice of the site visit.
• OCR will draft an audit report, describing the audit procedures, the findings, and the actions to be taken by the audit target in response to the findings.
• OCR will give the audit target approximately 10 business days to review the draft audit report and to provide written comments to OCR regarding concerns and corrective actions in response to the draft audit report.
• OCR will finalize the audit report within 30 business days after receipt of the audit target’s response.
• If “serious compliance issues” are identified, OCR may initiate a formal compliance review.  Compliance reviews can result in a formal corrective action plan and/or monetary penalties.

Preparing for and Responding to an Audit

Preparing for an audit is critical to success given the short time frame, particularly the 10-day period in which to respond to the document request.  The following considerations should be evaluated immediately:

• Documentation: At a minimum, covered entities and business associates must have all policies and procedures required by the HIPAA Privacy, Breach Notice, and Security Rules finalized and regulator-ready.  If your privacy function “owns” privacy policies and your IT function owns security policies, bring those groups together now to develop a comprehensive list of all relevant policies so they can be produced quickly.  Consider other documentation that supports your compliance efforts.  Are your logs of disclosures and security breaches in good order? Can you readily produce documentation supporting role-based access, systems activity review, business associate contracting, training, and other matters covered by the HIPAA rules?
• Subject Matter Experts: OCR will expect you to know which individuals in your organization can speak to each aspect of HIPAA implementation.  Do you know who handles access requests? Who reviews access rights periodically to ensure they are correct? Who monitors system activity? What activities are logged in your systems? Who is responsible for getting appropriate contracts in place with your business associates? Who handles privacy complaints?  Find these people now and ask them the kinds of questions OCR might pose.
• Site Visits: If you are selected for an audit, assume there will be a site visit.  OCR has determined that all 150 audits in this pilot phase will result in an on-site audit.  Do not wait for the agency’s notice of its visit to prepare.
• Risk Analysis: The Security Rule requires that covered entities periodically conduct a comprehensive, formal risk analysis.  OCR recently released guidance on conducting such an analysis.  The results of that analysis will be among the documents the agency can (and is very likely to) request for review.  If you have not conducted a risk analysis in the last 12 months, do so now.  Upon completion, evaluate the results and determine how best to mitigate or manage each risk identified (an activity also required by the Security Rule).  Document the entire process.
• Breach Notice and Incident Response: By now, your organization should have implemented a written incident response plan that reflects the requirements of both the Breach Notice Rule and the Security Rule.  Ideally, your organization will also conduct a trial run of its response plan and adjust the procedure as needed in light of the results.
• Evaluate Compliance: Your organization is required to periodically evaluate the effectiveness of its compliance program, including evaluating the accommodations to the recent legal changes brought about by the HITECH Act and implementing regulations.
• Training:  If you have not consistently or recently trained employees, now is a good time for a refresher.  Maintain documentation evidencing that every relevant employee has been trained.
• Business Associates: If you have not identified all of your vendors that handle protected health information, now is an excellent time to do so.  Negotiate business associate agreements with all such vendors.
• Timely Response:  Make sure that the appropriate people will timely receive OCR’s written notice of its intent to audit.  Do not let the notice sit in someone’s inbox while he or she is on vacation for a week, cutting your response time in half.
• Influencing the Audit Report: The agency provides covered entities with an opportunity to respond to the draft audit report.  In our experience working with HIPAA assessors, they will be very responsive to constructive feedback, including presentation of new facts, legal arguments regarding the scope and application of the rules, and justification of your approach to implementation based on the unique position of your organization.  When you receive the draft audit report, formulate a response to any findings that you believe were unfair or inaccurate.
• Next Steps:  Once the audit is over, be sure to take any compliance steps the agency has mandated, and seriously consider taking any it has suggested.  Failure to demonstrate reasonable progress on the audit findings, particularly if brought to light by a reportable security breach, will almost certainly result in swift enforcement action by the agency.

Whether or not your organization is ever selected for an audit, the preparatory steps described above will enhance your organization’s compliance posture.  In a time when fines surpass the million-dollar mark and a security breach lurks around every corner, undertaking that work will pay dividends even if your organization avoids an audit.  Of course, if you do find yourself among the lucky first 150 audit targets, you’ll certainly be glad you took the time to prepare in advance.

Reprinted with permission.  A thank you to our friends at PoynerSpruill.

Physical Address: 301 Fayetteville Street, Suite 1900, Raleigh, NC 27601                                 

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Home Health and Hospice Providers - How are you Preparing for ICD-10?

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In a little over 18 months from now medical providers including home health and hospice agencies will be transitioning to ICD-10.  How is your agency preparing for the transition? 

During the next 18 months, Home Care Software is committed to providing you and your home health and hopice agency with the tools and resources that you need to be fully prepared.  To start, CMS launched ICD-10 National Provider Calls last year.  These calls can be reviewed in their entirety on the CMS YouTube channel. 

From CMS: 

Is your organization preparing for a smooth transition to ICD-10 on Tuesday, October 1, 2013?  ICD-10 National Provider Calls, hosted by the CMS Provider Communications Group, can help you prepare for the US healthcare industry's change from ICD-9 to ICD-10 for diagnosis and inpatient procedure coding.

Video slideshow presentations from the following National Provider Calls are available on the CMS YouTube Channel.  These video slideshows include the call slide presentation and audio with captions; each call includes presentations by CMS subject matter experts, followed by a question and answer session.

• ICD-10 Implementation Strategies and Planning – Thursday, November 17, 2011

The ICD-9-CM and ICD-10 Cooperating Parties – CMS, the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), and the Centers for Disease Control and Prevention (CDC) – discuss ICD-10 implementation strategies and planning, and the CMS Provider Billing Group discuss the Medicare FFS claims processing guidance issued in August 2011.

• ICD-10 Implementation Strategies for Physicians – Wednesday, August 3, 2011

CMS subject matter experts discuss how physician offices can prepare for the change to ICD-10 for medical diagnosis and inpatient procedure coding and provide updates on national ICD-10 implementation issues affecting all providers.

• CMS ICD-10 Conversion Activities – Wednesday, May 18, 2011

CMS subject matter experts discuss the ICD-10 conversion process currently taking place within CMS, including a case study from the Coverage and Analysis Group on their transition to ICD-10 for the lab national coverage determinations (NCDs).

Podcasts, complete audio files, and complete written transcripts for these ICD-10 National Provider Calls are also available on the CMS ICD-10 webpage at http://www.CMS.gov/ICD10/Tel10/list.asp.

Available 24/7, YouTube video presentations and podcasts make learning about the ICD-10 transition easy and convenient. Check them out today.

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Clarification Concerning HIPAA 5010 and Impacts on Crossover Claims

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Clarification Concerning HIPAA 5010 and NCPDP D.0 Cut-Over and Impacts on Crossover Claims

Wed 1/18/2012 3:03 PM

On Monday, December 5, 2011, CMS issued a Special Edition MLN Matters Article (SE1137) entitled “Additional Health Insurance Portability and Accountability Act (HIPAA) 837 5010 Transitional Changes and Further Modifications to the Coordination of Benefits Agreement (COBA) National Crossover Process.”  CMS issued this guidance for the benefit of physicians/practitioners, providers, and suppliers to help them understand why they were seeing greater instances of Medicare correspondence letters that made reference to error N22226 as the basis for why their patients’ claims could not be crossed over.

CMS has since learned that concern exists in the provider community concerning whether billing of hardcopy CMS 1500 or UB04 claims or HIPAA version 4010A1 or National Council for Prescription Drug Programs (NCPDP) version 5.1 batch claims will result in Medicare being unable to cross those claims over to COBA supplemental payers that have cut-over to exclusive receipt of crossover claims in the version 5010 837 claim formats or NCPDP D.0 batch claim formats.  This is not true.

During the 90-day Version 5010 non-enforcement period (Sunday, January 1, 2012 through Saturday, March 31, 2012), Medicare will have the systematic capability to perform up- or down-version conversion of incoming claim formats (ie. convert incoming hardcopy formats to HIPAA equivalent claim formats and convert incoming version 4010A1 claim formats to 5010 formats and vice-a-versa), in accordance with external supplemental payer specifications concerning production claims format.  This practice will discontinue, however, at the conclusion of the 90-day non-enforcement period, with the exception below.  (This action is controlled by information that the Common Working File receives concerning individual supplemental payers’ ability to accept HIPAA 5010 or NCPDP D.0 claim formats in “production” mode.)

Note that physicians/practitioners, providers, and suppliers that have authorization under the Administrative Simplification Compliance Act (ASCA) to submit claims using a hardcopy format should know that Medicare has the systematic capability to convert keyed claims into outbound-compliant HIPAA 837 claim formats for crossover claim transmission purposes.  This is true at all times, not just during the 90-day non-enforcement period.

Flu Season is Here! While seasonal flu outbreaks can happen as early as October, flu activity usually peaks in January. Remind your patients that annual vaccination is recommended for optimal protection. Medicare pays for the seasonal flu vaccine and its administration for seniors and others with Medicare with no co-pay or deductible. Healthcare workers, who may spread the flu to high risk patients, should get vaccinated too. Don’t forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. Get the Flu Vaccine—Not the Flu.

Remember – The flu vaccine plus its administration are covered Part B benefits.  CMS has posted the 2011-2012 seasonal flu vaccine payment limits at http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp.  Note that the flu vaccine is NOT a Part D-covered drug. 

For more information on coverage and billing of the flu vaccine and its administration, as well as related educational provider resources, visit http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp and http://www.cms.gov/immunizations.

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

7 Reasons to Outsource Medical, Home Health, and Hospice Billing.

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Do you need an MBA to manage your practice or agency?  Outsourcing is a common pratice when it comes to medical billing. Most medical, home health, and hospice providers will at some point find themselves outsourcing their medical billing to an at-home specialist, a professional medical billing company, or a practice management company. Here are some of the reasons medical providers choose to outsource their billing.

1. It saves time. Medical billing is an immense task requiring billing staff to stay current on always-changing regulations and requirements. By partnering with a medical billing team, medical providers can shift their focus from staffing and training and instead fully concentrate on providing the best in care to your patients.
2. It saves resources. If you're running a small practice, your staff may not be able to focus exclusively on billing or have the necessary expertise. Practices and agencies that don't outsource often are unable to have one employee focus exclusively on billing without giving attention to other clerical duties. Partnering with a medical billing provider provides the staff who is 100% dedicated to your medical billing and will have the knowledge and experience to take care of all the medical billing issues that arise with your practice, and free your staff to concentrate on other aspects of running the practice.
3. It reduces rejected claims. A great deal of rejected claims come back simply because of errors in coding. Hiring a medical billing provider to focus exclusively on billing can cut down on errors and save you revenue in rejected claims.
4. It provides added security. It's a well-known fact that most cases of fraud come from within a company. When you outsource your medical billing, you'll have an outside eye looking at your finances and providing checks and balances that you and your staff might not have the time or ability to provide. If there are inconsistencies in your finances, a professional medical billing company will have a good chance of spotting them.
5. You'll get your money faster. Most practices with limited resources can't designate multiple employees to concentrate on billing. This means it takes longer to submit claims, follow-up can be inconsistent, and your money comes in later than it could. With a medical billing firm, your claims will be submitted more quickly and follow-up will be more consistent, all adding up to more and quicker revenue for your practice.
6. It improves your business. Many doctors say that you don't just need an M.D. to be in private practice anymore-you also need an MBA. An experienced medical billing provider do not just send out claims, they serve as a valuable business partner. A good medical billing firm will provide you with monthly, quarterly, and annual reports detailing the financial health of your practice, and can recommend ways to boost profitability as well.
7. It helps you negotiate with insurance carriers. An outsource medical billing provider can give you the detailed information you need to successfully negotiate a contract with an insurance carrier. Knowing your costs and your utilization patterns will go a long way toward giving you the upper hand in insurance contract negotiations.

Oursourcing your medical billing allows you, the medical professional, to concentrate on providing the best in care and makes sure your patients get all of your attention on their most important reason for being there: their health. 

Evaluating outsouring options?  Download our eBook:

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Home Health - 2012 Claim and Reimbursement Strategies

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With the New Year here it is essential to analyze practices and procedures to ensure your home health and/or hospice agency is receiving the maximum reimbursement.  It is vital to each organization to ensure specific best practice policies are in place to reduce denials and increase claim turn-around time.  How you handle claims within your organization has an impact on both direct and indirect costs.

Most efficient claim strategies:

• Ensure agency bills out RAP claims daily
• Respond to any Medical Record request as soon as possible
• Confirm claim file delivery with each submission
• Perform a clinical audit government paid charts prior to billing
• Review each line on Explanation of Benefits for payer errors
• Correct denied claims and send out as soon as possible
• Improve work load and flow of claims review process internally based on complexity of claims

Proper management of insurance claims is required to effectively supervise the whole process, to detect fraudulent activities and to enhance the faith and confidence of policy holders in the working of the company.  A critical part of the claims management process is the ability to monitor and improve the business activity associated with processes.

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Medicare HIPAA 5010 Compliance - Processing Issues

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National Government Services

During the week of December 5-9, 2011, National Government Services experienced processing issues with the new Part A Common Edit Module (CEM) which has resulted in a backlog of claims to be processed through the CEM.                            

What This Means to You

Providers/trading partners are experiencing a delay in return of the 277 Claims Acknowledgment Transaction for impacted claims. Trading partners should not resubmit any files sent during this timeframe, as this will result in duplicate claims. This is a reminder to providers that claim files receiving a corresponding file acknowledgment (999) may not be processed the same day. We ask that you continue to confirm that the file was accepted per the 999, and await the 277 Claims Acknowledgment which may take more than one business day. We would reassure providers that claims continue to be controlled once successfully received through the EDI gateway.                                      

Current Status of Problem

12/16/2011: National Government Services has been working very closely with the Part A Standard System Maintainer and CMS to resolve the CEM processing issues. As a result of this collaborative effort we have implemented some system adjustments that have improved our processing time. While we have made some progress, we continue to work with the System Maintainer and CMS to return our processing timeframe to the same day service level.

12/12/2011: National Government Services will continue to work directly with the Centers for Medicare & Medicaid Services (CMS) and the shared system maintainer until the identified issues are resolved. All files will process with the original receipt date. Please watch the Latest Production Alerts section of our Web site and E-mail Updates for additional information regarding this issue.

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Home Health Billing - Medicare Claim Status Information

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Original source:  Palmetto GBA

Palmetto GBA has made Medicare claim status' inquiries easier to understand for your home health or hospice agency.  The claims go thru several processes prior to completed.  The process determines the claim status or provider action required.  It is encouraged to moniter the status of claims for possible errors or payment.

All claims submitted on the UB-04 claim form are processed in the Fiscal Intermediary Shared System (FISS). You may view the status and location (S/LOC) of the claims using the Online Provider Services (OPS) or Direct Data Entry (DDE) systems. Palmetto encourages monitoring the status and location of claims.

The six statuses in the FISS system include:

'S' Status (Suspended)
The claim is still in process and no provider intervention can be made.

• All incoming claims first go to the 'S' status
• Claims cycling in the Common Working File (CWF)
• Claims chosen for medical review

When a claim is in 'S' status, providers should wait for the claim to move to a completed status. Providers should not send another claim, and should monitor how long a claim is in this status. If a claim is in the same 'S' status and location for a period of longer than 30 days, providers may call the designated Provider Contact Center (PCC) to request that the claim be released and processed.

'P' Status (Paid/Processed)
The claim is completely processed and is either fully or partially paid.

'D' Status (Denied)
The claim is completely processed and denied by Medical Review.

• Providers can not adjust or cancel the claim
• The provider can submit an appeal/redetermination

'R' Status (Rejected)
The claim is completely processed and was rejected.

• Look at the reason code on the rejected claim and resubmit a new claim with corrections noted from the reason code narrative, if applicable
• Adjust the claim if it posted to the CWF and make the necessary corrections. Providers can determine if the claim was posted to the CWF by viewing the TPE-TO-TPE field in the system. If this field contains an 'X', the finalized claim was not posted to CWF.

'T' Status (Return to Provider)
The claim has been returned to the provider (RTPd) for correction.

• Review the reason code on the claim, make the necessary corrections and resubmit the claim
• Do not submit a new claim

'I' Status (Inactive)
The Medicare Administrative Contractor (MAC) has either inactivated or specially processed your claim.

• RTPs more than 60 days old and suppressed claims are moved to an 'I B9997' status for three years then purged
• A new claim may be submitted

Some of the most common status and locations

P B9996 Payment Floor

P B9997 Paid/Processed Claim

P B7501 Post-Pay Review

P B7505 Post-Pay Review

R B9997 Claims Processing Rejection

• Provider must either resubmit the claim or adjust it. See the job aid titled 'Determining Whether to Resubmit, Adjust or Appeal a Medicare Claim'.

DB9997 Medical Review Denial

T B9900 Daily Return to Provider (RTP) Claim

The claim is not yet accessible for the provider to correct.

T B9997 RTP Claim

• The claim may be accessed and corrected through the Claim and Attachments Corrections Menu (Main Menu Option 03) in DDE.

Understanding exactly where claims are located in the system is the key to determining what action, if any, can be taken to submit claims on the UB-04 claim form for corrections.

Copyright © 2011 Home Care Software Solutions.  All rights reserved.

Medicare Fee-For-Service Policy Regarding 90 Day Discretionary Enforcement Period for Non-Compliant HIPAA Covered Entities

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From CMS this morning.

Medicare Fee-For-Service (FFS) Policy Regarding 90 Day Discretionary Enforcement Period for Non-Compliant HIPAA Covered Entities 

CMS announced on Thu Nov 17, that it would not initiate enforcement action with respect to any HIPAA covered entity that is non-compliant with the ASC X12 Version 5010 (Version 5010), NCPDP Telecom D.0 (NCPDP D.0), and NCPDP Medicaid Subrogation 3.0 (NCPDP 3.0) standards until 90 days after the Sun Jan 1, 2012 compliance date.  Notwithstanding CMS’ discretionary application of its enforcement authority, the compliance date for use of these new standards remains Sun Jan 1, 2012.

The announcement can be found at http://www.CMS.gov/ICD10/02b_Latest_News.asp.

What The 90 Day Enforcement Discretionary Period Means For Medicare Fee-For-Service:

Medicare FFS has experienced significant increases in 5010 production transactions during the last few months.  However, there are many submitters that have tested but not taken the step to move into production for 5010 and D.0.  In addition, there are many submitters that have not yet initiated testing with their Medicare Administrative Contractor (MAC).  Therefore, to ensure that progress continues to be made, Medicare FFS is planning to take the following steps for submitters and receivers of Medicare Part B and Durable Medical Equipment (DME) transactions.  Submitters and receivers of Medicare Part A transactions will follow the same action plan starting 30 days after Part B and DME:

• In December 2011, submitters/receivers that have tested and been approved for 5010/D.0 will be notified that they have 30 days to cutover to the 5010/D.0 versions.
• Submitters/receivers that have not yet tested will be notified in December 2011 that they must submit their transition plan and timeline to their MAC in 30 days.
• MACs will notify the submitters/receivers; submitters/receivers have the responsibility to notify the providers they service.

For more information on ASCX12Version 5010, NCPDP D.0, and NCPDP 3.0; please visit www.CMS.gov/Versions5010andD0.

­­­­­­­­­­­­­­

It’s a Busy Time of Year. Make each office visit an opportunity to talk with your patients about the importance of getting the seasonal flu vaccination and a one-time pneumococcal vaccination. Remember, Medicare pays for these vaccinations for all beneficiaries with no co-pay or deductible. The seasonal flu and invasive pneumococcal disease kill thousands of people in the United States each year, most of them 65 years of age and older. The Centers for Disease Control and Prevention (CDC) also recommends that healthcare workers and caregivers be vaccinated against the seasonal flu. Protect your patients. Protect your family. Protect yourself. Get the Flu Vaccine—Not the Flu.

Remember – The flu vaccine plus its administration are covered Part B benefits.  CMS has posted the 2011-2012 seasonal flu vaccine payment limits at http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp.  Note that the flu vaccine is NOT a Part D-covered drug. 

For more information on coverage and billing of the flu vaccine and its administration, as well as related educational provider resources, visit http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp and http://www.cms.gov/immunizations.

Note:  If you have problems accessing any hyperlink in this message, please copy and paste the URL into your Internet browser. 

If you know someone who would like to subscribe to a Medicare Fee-For-Service (FFS) provider listserv, go to (http://www.cms.gov/prospmedicarefeesvcpmtgen/downloads/Provider_Listservs.pdf). 

If you would like to unsubscribe from a specific provider listserv, please go to (https://list.nih.gov/cgi-bin/wa.exe?INDEX) to unsubscribe or to leave the appropriate listserv.

Please DO NOT respond to this email. This email is a service of CMS and routed through an electronic mail server to communicate Medicare policy and operational changes and/or updates. Responses to this email are not routed to CMS personnel. Inquiries may be sent by going to (http://www.cms.gov/ContactCMS).   Thank you.

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