Full Encounter Data (FED) Requirements

Transcription

1 Full Encounter Data (FED) Requirements FED Provider Partner Transition Project 05/24/2012 Version 10.2 SCAN FED Requirements _v10.1 Page 1 of 87

2 Revision History Date Version Description Author 10/06/ /12/ /20/ /26/ Initial Draft 2.0 Updates per review with Marc Carren and Char Beecher Katie Parks and Diana Sessions Katie Parks and Diana Sessions 10/27/ Based on CMS Industry Update 10-27, (a) updated atypical NPI values, (b) added duplicate logic section. Updates per latest guidance from CMS and 11/16/2011 SCAN Webinar with Provider Partners. Katie Parks 11/23/ Sections added/updated include the following: Section 2.6: Which Claims to Include in Full Encounter Data Submissions? Section 2.7: The 13 Months From Date of Service Requirement Section 2.9: Replacement and Void Encounters Section 2.10: Edits Applied Against 5010 Encounter Data Section 2.12: Dollar Amounts Are Required and Must Balance in v5010 Full Encounter Data Section 3.1.3: SCAN s 837 v5010 Companion Guides Section 3.2: National Provider Identification NPI Section 3.4: Billing Provider Address - 9-digit zip code Section 3.5: Billing Provider Address - Physical Address Only Section 3.10: Present on Admission Indicator Section 4: SCAN and CMS Encounter Rejections (as well as subsequent sections 4.1 and 4.2) Section 5: Appendix Katie Parks, Diana Sessions, & Char Beecher 12/15/ Added Section 4.3: Increase In Encounter Rejections Explained Char Beecher 12/21/2011, 12/29/ Added Section 2.13: Capitated Encounters in v5010 Full Encounter Data, (updated claim balancing) Char Beecher SCAN FED Requirements_v10.1 Page 2 of 87

3 Date Version Description Author Updates per latest guidance from CMS and Jan & Mar 2012 SCAN Webinars with Provider Partners. Sections added/updated include the following: Section 2.16: Top 10 CMS FED Requirements Section 2.15: CMS Minimum Encounter Data Elements Section 3.1: Overview Section 3.6: Ambulance claims Pick-Up and Drop-Off Locations 3/21/2012 4/13/ Section Minimum Data Elements for Ambulance Services Received on Paper Claims Section 3.8: Professional Claims Clinical Laboratory Improvement Amendment Number (CLIA) Char Beecher & Katie Parks Section 3.11: Diagnosis Code Pointers Section 5: Submission of Supplemental Encounter Data (as well as subsequent sections ) Section 7.1: Data Mining Findings of Encounter Data Received in 2011 Section 7.2: References Section 6: SCAN Business Rules Section 6.1: Summary 05/11/ Section 6.2: Encounter Data Note (NTE) Segments Section 6.3: Patient Loops - are not accepted by SCAN. Char Beecher Section 7.0: Contact Updates 06/06/ /27/ /22/ Updates\Additions per latest CMS guidance Section 3.6: Ambulance Claims Pick-Up and Drop-Off Locations Section 3.6.1: Summary Section 3.6.3: Institutional Pick-up Zip Code Section 3.6.4: UB / HCFA Location for Paper Claims Section 2.4: Dollar Amount are Required and Must Balance in v5010 Full Encounter Data - Updates Section 2.6: Post Adjudicated Claims are Required in Full Encounter Data Submission Section 2.7: Adjudicated Claims = COB Section 2.8: Adjudicated Encounter Examples Example 1 - Adjudicated Encounter Example 2 - Adjudicated Encounter Example 3 - True COB = Tertiary Payer Example 4 - True COB = Tertiary Payer Rendering Provider Updates Section 2.16: Top 10 CMS FED Requirements Section 8.1: Data Mining Findings of Encounter Data Received in 2011 Char Beecher Char Beecher Char Beecher SCAN FED Requirements_v10.1 Page 3 of 87

4 Date Version Description Author 06/20/ Section : Added note regarding positive dollar amounts Section 3.11: New Requirements for Home Health (HH) and Skilled Nursing Facilities (SNF) Section 3.4.1: Updated ZIP Code +4 Default Value Section 3.4.5: Corrected broken Encounter Data FAQ link Section 3.8.1: Added note regarding negative AMT monetary Section 4.2.2: 2320 AMT01 Inclusion Requirements Amounts Section 4.4: Added section to cover negative numbers Section 7: Updated contacts Char Beecher & AJ Bautista SCAN FED Requirements_v10.1 Page 4 of 87

5 Table of Contents 1 INTRODUCTION PURPOSE BACKGROUND ON FULL ENCOUNTER DATA INITIATIVE BACKGROUND ON FULL ENCOUNTER DATA FROM CMS BACKGROUND ON FULL ENCOUNTER DATA FROM SCAN S FED ORIENTATION OVERVIEW OF FED FROM SCAN S FAQ DOCUMENT CMS GUIDANCE ON FED FAQ DOCUMENTS FROM CMS AND SCAN POST ADJUDICATED CLAIMS ARE REQUIRED IN FULL ENCOUNTER DATA SUBMISSION ADJUDICATED CLAIMS = COB ADJUDICATED ENCOUNTER EXAMPLES TIMELY FILING 13 MONTHS FROM DATE OF SERVICE CHART REVIEW REQUIREMENTS REPLACEMENT AND VOID ENCOUNTER REQUIREMENTS EDITS APPLIED AGAINST 5010 ENCOUNTER DATA DUPLICATE LOGIC DOLLAR AMOUNTS ARE REQUIRED AND MUST BALANCE IN V5010 FULL ENCOUNTER DATA CAPITATED ENCOUNTERS IN V5010 FULL ENCOUNTER DATA TOP 10 CMS FED REQUIREMENTS CMS MINUMUM ENCOUNTER DATA ELEMENTS ANSI V5010 CHANGES EXPLAINED OVERVIEW NATIONAL PROVIDER IDENTIFICATION - NPI REFERRING PROVIDER NAME AND NPI BILLING PROVIDER ADDRESS 9-DIGIT ZIP CODE BILLING PROVIDER ADDRESS PHYSICAL ADDRESS ONLY AMBULANCE CLAIMS PICK-UP AND DROP-OFF LOCATIONS PROFESSIONAL CLAIMS CLINICAL LABORATORY IMPROVEMENT AMENDMENT NUMBER (CLIA) COORDINATION OF BENEFITS (COB) PRESENT ON ADMISSION INDICATOR DIAGNOSIS CODE POINTERS NEW REQUIREMENTS FOR HOME HEALTH (HH) AND SKILLED NURSING FACILITIES (SNF) SCAN AND CMS ENCOUNTER REJECTIONS OVERVIEW OF ENCOUNTER DATA REJECTS INCREASE IN ENCOUNTER REJECTIONS EXPLAINED ACCESSING THE SCAN PROVIDER PORTAL NEGATIVE AMOUNTS IN ENCOUNTER DATA SUBMISSION OF SUPPLEMENTAL ENCOUNTER DATA SCAN FED Requirements_v10.1 Page 5 of 87

6 5.1 SUMMARY DIRECT SUBMISSION CLEARINGHOUSE SUBMISSION IMPORTANT INFORMATION SENDING MULTIPLE ENCOUNTERS PER VISIT SCAN ENCOUNTER DATA BUSINESS RULES SUMMARY ENCOUNTER DATA NOTE (NTE) SEGMENTS PATIENT LOOPS ARE NOT ACCEPTED BY SCAN - ALL PATIENTS ARE SUBSCRIBERS CONTACT INFORMATION APPENDIX DATA MINING FINDINGS OF ENCOUNTER DATA RECEIVED IN REFERENCES SCAN FED Requirements_v10.1 Page 6 of 87

7 1 INTRODUCTION 1.1 Purpose The purpose of this requirements document is to aid in explaining the Full Encounter Data Requirements mandated by CMS, effective January 1, 2012, as well as illuminate changes contained within the ANSI v Professional and 837 Institutional EDI files. Throughout this document there are multiple references to CMS guidance and various helpful websites. Their locations are found in the footnotes and the Appendix section. What is an encounter? CMS Encounter Data Definition: Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form. Encounter data are also sometimes referred to as "shadow claims". 1 WikiAnswer s Encounter Claim Definition: An Encounter Claim is a claim submitted by the provider that records services rendered by the provider. Encounter claims have previously been paid by contracted pre-determined means. The purpose of the encounter claim is to provide validation that the payment previously made has been earned, or to assist in justification that a review for a higher reimbursement may be needed. 2 2 BACKGROUND ON FULL ENCOUNTER DATA INITIATIVE 2.1 Background on Full Encounter Data From CMS The implementation of encounter data is designed to improve the risk adjustment and MA payment system by providing complete and accurate data, allowing CMS to properly measure and analyze MA utilization and cost. The success of encounter data implementation and ability to correctly submit and collect data is dependent on understanding the terminology and processes concerning the CMS Full Encounter Data initiatve. The implementation schedule for encounter data will span six (6) years including preparation, industry outreach efforts, EDS testing and monitoring, and evaluating the quality of encounter data collected. 3 For the purpose of encounter data, Medicare Advantage Organizations (MAOs) and other entities must collect data from health care facilities and providers, as well as, Durable Medical Equipment (DME) suppliers. Thorough submission of encounter data in the 5010 format is critical for accurate risk adjustment model calibration. 4 1 CMS, Glossary, Encounter Data, 14 May, 2006, < 2 WikiAnswers, What is encounter claims? 2011, < 3 CMS, Encounter Data Participant Guide, EDParticipantGuide.pdf, 13 September 2011, Page 1-10, < 4 CMS, Encounter Data Participant Guide, Page 2-1, < SCAN FED Requirements_v10.1 Page 7 of 87

8 2.2 Background on Full Encounter Data From SCAN s FED Orientation Oct 29th, 2010: CMS formally announced the decision to transition to a new Encounter Data Processing System (EDPS) from the current Risk Adjustment Processing System (RAPS). EDPS Target Production Date of January 2nd, RAPS data submission will continue side-by-side during transition. Data collection changes from 5 elements to all elements of a HIPAA standard Encounter Data Processing System will only collect HIPAA compliant 5010 data. o 837 I (Institutional) o 837 P (Professional) RAPS Data Elements: o HIC Number o Diagnosis Codes o From Date of Service o Through Date of Service o Provider Type EDPS Encounter Data Elements: o All data elements from the HIPAA version ANSI v5010 format 5 SCAN, SCAN Full Encounter Data Orientation 2011, CMS Full Encounter Data Provider Partner Kick Off.pdf, 23 March 2011, Slides 3 & 7, < > SCAN FED Requirements_v10.1 Page 8 of 87

9 2.3 Overview of FED from SCAN s FAQ Document 6 Why is CMS implementing a Full Encounter Data requirement? Increased scope of encounter data collection -- more services, more data Increased accuracy of data edits for standardized provider identification, codes and reference data Increased timeliness and completeness of encounter data submission Increased efficiency in the handling of supplemental data submissions Increased efficiency in the handling of encounter data rejects An encounter extraction process which has access to all required and situational-required ANSI 5010-data elements Why is CMS mandating the Encounter submissions be changed to the 5010 format? CMS needs all encounter data to be formatted and submitted in the 5010 format in order to support: Measuring of healthcare utilization in MA organizations Calibrating of MA-specific Risk Adjustment models Calculating of disproportionate share hospital payments Why is it important for us to comply with the Full Encounter Data and 5010 requirements? The encounter data sent to CMS continues to drive the risk scores for your members; therefore, driving the capitation we pay to you. In order for us to submit your encounter data to CMS, it will have to be in the 5010 format and pass all CMS edits. CMS is also requiring Health Plans to submit encounter data for all services provided to members, not just those previously required for RAPS. If we cannot submit your encounter data, or if it is incomplete, CMS will not be able to appropriately capture the risk scores of your members. From a broader perspective, if the overall encounter data submitted is incomplete, CMS will not have an accurate picture of the range and intensity of services provided to MA members, which could lead to a reduction in reimbursement across the industry. Lastly, SCAN utilizes encounter data for other reasons such as HEDIS, 5 Star, and Medical Management purposes. Failure to submit accurate, complete data in the required format prevents us from storing and utilizing the data, which can impact member quality of care and your quality scores. 6 SCAN, Transition to Full CMS Encounter Data Submissions by 2012 Frequently Asked Questions, Revised June 8, 2011, Page 2., < > SCAN FED Requirements_v10.1 Page 9 of 87

10 2.4 CMS Guidance on FED Below are selected screen shots from the EDSlides_cameraready_ pdf publication from CMS,* titled 2011 Regional IT Technical Assistance Encounter Data. Colloquially referred to as CMS Business Requirements for FED, published to Payers on 9/14/ *Note that this is not the final guidance as we are awaiting that from CMS. 7 CMS, Encounter Data Slide Presentations, EDISlides_cameraready_ pdf, 13 September 2011, Pages SCAN FED Requirements_v10.1 Page 10 of 87

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14 2.5 FAQ Documents from CMS and SCAN SCAN has published answers to Frequently Asked Questions. This FAQ document is a SCANaccumulated, categorized, and indexed list of frequently asked questions from our Provider Partners concerning the who, what, when, where, why, and how of transitioning to Full Encounter Data. Please refer to the following URL: Additionally, CMS has published extensive answers to Frequently Asked Questions in regards to the Full Encounter Data regulations. Please refer to the following URL: er%20data%20faqs.pdf SCAN FED Requirements_v10.1 Page 14 of 87

15 2.6 Post Adjudicated Claims are Required in Full Encounter Data Submission CMS guidance has indicated that only adjudicated claims that have been payer paid or denied payment are to be sent as encounter data with 2012 dates-of-service and forward. CMS is not simply requiring a copy of the original claim, but rather CMS also wants to see the results of the claim after all adjudication processes have take place. 8 In other words, the encounter should contain the original claim detail with all payments, adjustments, and denials; a finalized claim. Per CMS, adjudicated claims are those that are approved/accepted or denied claims. CMS only seeks data on paid and denied services and it is important that the MAOs conduct as little manipulation as possible to ensure all data is collected. 9 Important Note: see section 4 Scan and CMS Encounter Rejections of this document for definitions of denied and rejected claims. Encounters to submit o All paid & denied encounters Denials are due to contractual/payment reasons Encounters that should not be submitted o Encounters with bad or incomplete data, rendering the encounter unprocessible or rejected. Example: invalid procedure or diagnosis code data o Pending (not yet paid) For purposes of this standard, a payer is the entity that pays claims or administers the insurance product, benefit, or both. For example, a payer may be an insurance company, HMO (health maintenance organization, government agency (Medicare, etc.), or an entity such as a third party administer. 2.7 Adjudicated Claims = COB In order to send an adjudicated claim as an encounter to a payer, the formatting of the encounter will look like that of a Coordination of Benefits (COB) claim, with all payer payments and adjustments displayed.. Attempting to send the encounter with billed, paid, and adjusted amounts outside of the COB TR3 requirements will cause syntax errors. Note: When more than one payer was involved in the payment of a claim, a True COB situation occurs. Formatting of the encounter will contain primary, secondary, and tertiary payers. 2.8 Adjudicated Encounter Examples The four examples demonstrated on the following four pages are all acceptable ways to submit adjudication detail. While there are multiple ways to send syntactically correct adjudicated encounters, the examples provided passed validation edits and were accepted at CMS. 8 CMS National Meeting Summary Report, < Summary_Report.pdf > 9 Encounter data Work Group Summary Notes for Third Party Submitters, < > SCAN FED Requirements_v10.1 Page 15 of 87

16 2.8.1 Example 1: In this balanced example, the patient responsibility (CAS adjustment) is carried at the service line. ISA*00* *00* *ZZ*CH999 *ZZ*SCANCA3800 *111123*1600*^*00501* *0*T*:~ GS*HC*CH999*SCANCA3800* *1600*82*X*005010X222A1~ ST*837*0082*005010X222A1~ BHT*0019*00* * *0400*CH~ NM1*41*2*CLEARINGHOUSE*****46*CH999~ NM1*40*2*SCANHEALTHPLAN*****46*SCANCA3800~ Header Information should always be between provider and clearinghouse (CH). See your CH s companion guide for the details. HL*1**20*1~ M1*85*2*CARE CLINIC*****XX* ~ N3*1500 MILL LANE~ N4*IRVINE*CA* ~ REF*EI* ~ The Billing Provider where services were rendered is Care Clinic. HL*2*1*22*0~ SBR*S*18*4547A******16~ S = Secondary Payer NM1*IL*1*DOE*JANE****MI* A~ N3*200 NORTH MAIN ST~ N4*LONG BEACH*CA*99999~ DMG*D8* *M~ NM1*PR*2*SCANHEALTHPLAN*****XV*SCANCA3800~ N3*KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ REF*2U*H5425~ The encounter is being sent to SCAN as secondary payer. Note: Payer information always follows the subscriber detail. CLM* *100***11:B:1*Y*A*Y*Y~ HI*BK:78099*BF:78099~ SBR*P*18*******16~ P = Primary Payer AMT*D*80~ Primary Paid Amount OI***Y***Y~ NM1*IL*1*DOE*JANE****MI* ~ NM1*PR*2*PHYSICIANS CHOICE IPA*****XV*36072~ At the claim level, the amount billed for the service was $100. Jane Doe s primary payer made a payment of $80 towards the claim. LX*1~ SV1*HC:S5170*100*UN*1***1~ Billed amount DTP*472*D8* ~ SVD*36072*80*HC:S5170**1~ Primary Paid - Required CAS*PR*3*20~ PR=Patient 3= Co-pay indicator 20 =amount DTP*573*D8* ~ Adjudication Date SE*37*0082~ GE*1*82~ IEA*1* ~ At the service level, the amount billed for procedure S5170 was $100 (must match the claim level). The primary payer made a payment of $80 towards the claim and also made an adjustment of $20 for the Jane s co-pay amount. The primary payer made the payment on May 11 th of adjudication date is required SCAN FED Requirements_v10.1 Page 16 of 87

17 2.8.2 Example 2: Because adjudicated encounters need to be submitted to SCAN, SCAN can be both the secondary and primary payer. In this instance, SCAN is both the primary and secondary payer. Patient responsibility is listed at the claim level; service line billed and paid are equal values. HL*1**20*1~ NM1*85*2*CARE CLINIC*****XX* ~ N3*1500 MILL LANE~ N4*IRVINE*CA* ~ REF*EI* ~ The Billing Provider where services were rendered is Care Clinic. HL*2*1*22*0~ SBR*S*18*4547A******16~ S = Secondary Payer NM1*IL*1*DOE*JANE****MI* A~ N3*200 NORTH MAIN ST~ N4*LONG BEACH*CA*99999~ DMG*D8* *M~ NM1*PR*2*SCANHEALTHPLAN*****XV*SCANCA3800~ N3*KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ REF*2U*H5425~ The encounter is being sent to SCAN as secondary payer. Note: Payer information always follows the subscriber detail. CLM* *100***11:B:1*Y*A*Y*Y~ HI*BK:78099*BF:78099~ SBR*P*18*******16~ P = Primary Payer CAS*PR*3*20~ PR=Patient 3= Co-pay indicator 20 =amount AMT*D*80~ Primary Paid Amount OI***Y***Y~ NM1*IL*1*DOE*JANE****MI* ~ NM1*PR*2*SCAN HEALTHPLAN*****XV*SCANCA3800~ N3*3800 KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ REF*T4*Y~ LX*1~ SV1*HC:S5170*100*UN*1***1~ DTP*472*D8* ~ SVD*SCANCA3800*100*HC:S5170**1~ DTP*573*D8* ~ Billed Amount Primary Paid Amount Adjudication Date At the claim level, the amount billed for the service was $100. Jane Doe s primary payer made a payment of $80 with an adjustment of $20 for Jane s co-pay amount. At the service level, the amount billed for procedure S5170 was $100 (must match the claim level). The primary payer made a payment of $100 ($80 paid + $20 adjusted = $100). The payment was made on May 11 th of Adjudication date is required SCAN FED Requirements_v10.1 Page 17 of 87

18 2.8.3 Example 3 - True COB Adjudicated. When a member has other insurance that was applied to the claim, SCAN will be the Secondary and the Primary or Tertiary Payer. In this example OTHER HEALTH PLAN is the Tertiary payer, no co-pay amount. NM1*85*2*CARE CLINIC*****XX* ~ N3*1500 MILL LANE~ N4*IRVINE*CA* ~ REF*EI* ~ The Billing Provider where services were rendered is Care Clinic. HL*2*1*22*0~ SBR*S*18* A******MB~ S=Secondary Payer NM1*IL*1*DOE*JANE****MI* A~ N3*200 NORTH MAIN ST~ N4*LONG BEACH*CA*99999~ DMG*D8* *M~ NM1*PR*2*SCAN HEALTHPLAN*****XV*SCANCA3800~ N3*KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ REF*2U*H5425~ The encounter is being sent to SCAN as secondary payer. Note: Payer information always follows the subscriber detail. CLM* TC11*775***21:B:1*Y*A*Y*Y~ DTP*435*D8* ~ HI*BK:51881*BF:51881~ SBR*P*18*******16~ P= Primary Payer CAS*OA*22*436.43~ OA = Other Adjustment 22 reason code AMT*D*338.57~ Primary Paid Amount OI***Y***Y~ NM1*IL*1*DOE*JANE****MI* ~ NM1*PR*2*SCAN HEALTHPLAN*****XV*SCANCA3800~ N3*KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ REF*T4*Y~ SBR*T*18*******16~ T = Tertiary AMT*D*436.43~ Other Payer Paid Amount OI***Y***Y~ NM1*IL*1*DOE*JANE****MI* ~ NM1*PR*2*OTHER HEALTH PLAN*****XV*PAYER01~ At the claim level, the total amount billed for the services was $775. Jane Doe s primary payer made a payment of $ with an adjustment of $ for care being covered by another payer per coordination of benefits. Also at the claim level, the Tertiary payer made a payment of $ The total of the payer paid amounts equals the billed amount. The claim is balanced at the claim level. LX*1~ SV1*HC:99233*211*UN*1***1~ DTP*472*D8* ~ SVD* SCANCA3800*211*HC:99233**1~ DTP*573*D8* ~ LX*2~ SV1*HC:99291*564*UN*1***1~ DTP*472*D8* ~ SVD* SCANCA3800*564*HC:99291**1~ DTP*573*D8* st Service Billed Amount Primary Payer Paid Adjudication Date 2 nd Service Billed Amount Primary Payer Paid Adjudication Date At the service line level, the total amount billed for procedures and = the total paid amount of $775 All adjustments occurred at the claim level. Sending encounters with multiple payers at the service line has caused rejections at CMS. CMS True COB example published shows the primary payer at the service line only. SCAN FED Requirements_v10.1 Page 18 of 87

19 2.8.4 Example #4 True COB Adjudicated. When a member has other insurance that was applied to the claim, SCAN will be the Secondary and the Primary or Tertiary Payer. In this example OTHER HEALTH PLAN is the Tertiary payer and the patient co-pay is $20. NM1*85*2*CARE CLINIC*****XX* ~ N3*1500 MILL LANE~ N4*IRVINE*CA* ~ REF*EI* ~ The Billing Provider where services were rendered is Care Clinic. HL*2*1*22*0~ SBR*S*18*XYZ **47****MB~ S = Secondary NM1*IL*1*DOE*JANE****MI* A~ N3*200 NORTH MAIN ST~ N4*LONG BEACH*CA*99999~ DMG*D8* *F~ NM1*PR*2*SCAN HEALTHPLAN*****XV*SCANCA3800~ N3*KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ REF*2U*H9999~ The encounter is being sent to SCAN as the secondary payer. Note: Payer information always follows the subscriber detail. CLM* A*712.00***11:B:1*Y*A*Y*Y~ HI*BK:78901~ SBR*P*18*XYZ ******16~ P = Primary Payer CAS*CO*45*12~ CO=Contractual Obligation 45= reason code CAS*PR*3*20~ PR = Patient responsibility 3= copay 20 = amount AMT*D*680~ Primary Paid Amount OI***Y***Y~ NM1*IL*1*DOE*JANE****MI* ~ N3*200 NORTH MAIN ST~ N4*LONG BEACH*CA*99999~ NM1*PR*2*SCAN HEALTHPLAN*****XV*SCANCA3800~ N3*KILROY AIRPORT WAY~ N4*LONG BEACH*CA*99999~ SBR*T*18*XYZ ******16~ T=Tertiary Payer CAS*OA*22*700~ OA = Other Adjustment 22= reason code AMT*D*12~ Tertiary Paid Amount OI***Y***Y~ NM1*IL*1*DOE*JANE****MI* ~ N3*200 NORTH MAIN ST~ N4*LONG BEACH*CA*99999~ NM1*PR*2*OTHER HEALTH PLAN*****XV*PAYER01~ N3*400 WEST MUCK ST~ N4*NORTHVIEW*CA*99999~ REF*T4*Y~ At the claim level, the amount billed for the services was $712. Jane Doe s primary payer made a payment of $680 with a contractual obligation adjustment of $12 due to charges exceeding maximum allowable and an adjustment of $20 for the Jane s co-pay. Also at the claim level is the Tertiary payer who made a payment of $12 with an adjustment for $700 for the impact of the prior payer s adjudication. The total of the payer paid amounts with adjustments balance the total billed amount for each payer loop, as required. LX*1~ SV1*HC:99212*712*UN*1***1~ DTP*472*D8* ~ SVD* SCANCA3800*712*HC:99212**1~ DTP*573*D8* ~ Service Billed Amount Primary Payer Paid Adjudication Date At the service line level, the total amount billed for procedure = the total paid amount of $712. The payment was made on April 3 rd, 11 th of Adjudication date is required. SCAN FED Requirements_v10.1 Page 19 of 87

20 2.9 Timely Filing 13 Months from Date of Service CMS is mandating that all encounters be received within 13 months of the original claims date of service. In other words, the original/first submission of a clean encounter (one that passes the front end edits and makes it to adjudication) must occur within 13 months of the date of service. Adjustment (replacement) encounters may be submitted at any time within these 13-months; however, if an adjustment (replacement) must be made after 13 months, the transaction should be sent through Chart Review data within the usual Sweep Period window. This new requirement enforces the need to stress timely filing and should compel providers to ensure clean encounters are being sent. It also becomes quite important to work the encounter data rejections in a timely manner to avoid unmanageable backlogs that will prevent encounters from being resubmitted too late. As stated in SCAN s 837 Companion Guide 10 : If SCAN receives an encounter for the first time that has passed 13 months from the date of service, SCAN will reject that encounter for being submitted outside of the CMS timely filing limit. Further, if SCAN subsequently receives a direct submission record for this same encounter, SCAN will have the ability to reject it; groups should not be using direct submission files as a way around timely filing. However, there may be reasons to override this rejection and allow this encounter to process (to be determined on a case-by-case basis). SCAN Recommendation provided during 11/16/2011 Webinar CMS Full Encounter Data - Provider Partner Transition Update : Providers are urged to submit encounters 12 months from the date of service. This will allow one extra month for SCAN to submit the encounter data to CMS to approve or reject, and if rejected, time for providers to work the error(s) and resubmit prior to the 13-month timely filing requirement. Otherwise, providers may run the risk of the encounter being ineligible for risk adjustment processing. 10 SCAN, Standard Companion Guide Transaction Information: 837P Companion Guide, Version 1.0, 30 August 2011, Page 15, < SCAN FED Requirements_v10.1 Page 20 of 87

21 2.10 Chart Review Requirements Chart Review data, which adds/deletes diagnosis codes, is allowed during the usual Sweep Period window for submission within 25 months from date of service. Chart Reviews are intended to supplement data sent on the original encounter. Chart Review data should NOT be used to submit new encounters under the CMS radar. Though the v5010 format allows for the use of the PWK segment for submission of Chart Review Data, at this time Chart Review data should be sent to SCAN using the modified ICE format. See Direct Submissions in section 5.2 of this document for more detail. When SCAN begins to accept Chart Review data in the v5010 format, as stated in the above CMS screen shots, Chart Review data will need to be identified as such utilizing the PWK segment inside the 2300 loop. Below is information from the X12 Implementation Guide for Professional Claims. 11 Loop PWK PWK01 Example Claim Information Claim Supplemental Information Segment PWK01 Data Element Value of 09 (Progress Report) SV1*HC:99211:25*12.25*UN*1*11**1:2:3**Y~ 11 ASC X12 Insurance Subcommittee, ASC X12 Standards for Electronic Data Interchange; Health Care Claim: Professional (837), Version 5, Release 1, May 2006, Pages SCAN FED Requirements_v10.1 Page 21 of 87

22 2.11 Replacement and Void Encounter Requirements CMS has updated their requirements regarding how to submit replacement and void encounters, announced during their November 17 th, 2011 Encounter Data User Group Industry Update Call. Populating the CAS segment with specific values for replacement and void encounter transactions is no longer necessary or allowed. Shown below are the Previous and the New requirements for replacement and deletion of encounters, as taken directly from CMS MS Power Point materials referenced during the November 17 th Call: 12 PREVIOUS requirements for submitting a replacement or void encounter: If value is 7 in the Claim Frequency Code (2300/CLM05-03) then Replace an Encounter. In this case, value must be CR in the Claim Adjustment Group Code (2320/CAS/01). If value is 8 in the Claim Frequency Code (2300/CLM05-03) then Void Encounter. In this case, value must be OA in the Claim Adjustment Group Code (2320/CAS/01). 12 CMS, Encounter Data Industry Update Industry Update Materials pdf, 17 Nov 2011, Slides SCAN FED Requirements_v10.1 Page 22 of 87

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24 NEW requirements for submitting a replacement or void encounter: If value is 7 in the Claim Frequency Code (2300/CLM05-03) then Replace an Encounter. If value is 8 in the Claim Frequency Code (2300/CLM05-03) then Void Encounter. SCAN FED Requirements_v10.1 Page 24 of 87

25 SCAN FED Requirements_v10.1 Page 25 of 87

26 2.12 Edits Applied Against 5010 Encounter Data The CMS Encounter Data Front End System (EDFES) utilizes the Commercial Off-the-Shelf (COTS) EDI Translater and the Encounter Common Edits and Enhancements Module (CEM) to validate and edit encounter data. These systems are responsible for editing data against the HIPAA compliant version of the Accredited Standards Committee (ACS) X12N Technical Report Type 3 (TR3) for ANSI v5010 and specfic CMS edits as defined in CMS' technical edits spreadsheet and Encounter Data Companion Guide. While, the adjudication edits are not well defined at this time by CMS, it has been stated that a modified version of the fee-for-service (FFS) adjudication edits will be use. 13 Detail provided during the 03/15/2012 CMS Encounter Data User Group Call: Encounters must comply with TR3, CMS CEM Edits Spreadsheet, and Encounter Data Companion Guide. Update provided during the 11/16/2011 CMS Full Encounter Data - Provider Partner Transition Update Webinar: CMS continues to point towards FFS edits as the adjudication edits performed on encounters. CMS reserves the right to turn on or off edits that they feel are not working for encounters at any time they deem applicable. The latest guidance from CMS as of the publication date of this document can be found page 2-33 of the EDI Participant Guide. Below is the information contained on that page 14 : CMS Edits Spreadsheet CMS provides X file format technical edit spreadsheets for the 837-I and 837-P. The edits included in the spreadsheet are intended to clarify the WPC instructions or add Medicare specific requirements. Table 2O provides information included on the 837-I and 837-P edits spreadsheet. TABLE 2O EDITS SPREADSHEET ATTRIBUTES Spreadsheet Attributes 837 Edit Reference Segment or Element Description Segment or Element ID Usage Requirement Minimum/Maximum Usage Loop Loop Repeat 5010 Values Accept/Reject Status Proposed 5010 Edits Acknowledgement Report Type Disposition/Error Code Miscellaneous Notes CMS, Encounter Data Participant Guide, Page SCAN FED Requirements_v10.1 Page 26 of 87

27 CMS Edits Spreadsheet In order to pass COTS EDI translator and CEM level edits and move forward to be processed, priced, and stored in the EDS, the submitted file must be populated by reconciling the WPC, CMS edit spreadsheet, and encounter data specific field population within the WPC TR3. The CMS edit spreadsheet provides a list of proposed EDS edits. However, there may be instances that the CMS edit spreadsheet differs from the EDS specific guidance (reference footnote 12 on page 20) Duplicate Logic CMS has published their final regulations for the duplicate logic that is to be applied against encounter data submissions. This information was announced during the CMS Encounter Data Industry Update on October 27, Dollar Amounts ARE Required and Must Balance in v5010 Full Encounter Data CMS has reconfirmed (during their November 17th, 2011 Encounter Data User Group Industry Update Call) that they require the Billed, Paid, and Adjusted dollar amounts populated in FED files. To clear-up any confusion regarding CMS COB requirements on encounter balancing, SCAN conducted several tests. The results of these test scenarios have confirmed our theories. We have concluded that encounters sent to CMS that do not meet the balancing requirements as set forth in the WPC X HEALTH CARE CLAIM: PROFESSIONAL TECHNICAL REPORT 3 (TR3) will be rejected. Example Test Scenario Encounter data was sent to CMS containing a claim level other payer amount paid (2320 Loop, AMT02) amount that was not equal to the other payer paid amount at the line level (2430 SVD02). This claim was rejected for being out-of-balance. A subsequent corrected encounter was submitted that included claim level adjustments to the prior payer amount paid that balanced against the line level. The corrected claim was accepted. 15 CMS, Encounter Data Industry Update Industry Update Materials pdf, 27 Oct 2011, Slide 28. SCAN FED Requirements_v10.1 Page 27 of 87

28 Encounter Rejected CLM* *223.44***11:B:1*Y*A*Y*Y~ Claim level total billed amount = $ HI*BK:185*BF:185~ SBR*P*18*******16~ AMT*D*1~ OI***Y***Y~ Claim Level primary (other) payer amount paid NM1*IL*1*XXXXXXX*XXXXXXXX****MI* A~ NM1*PR*2*SCAN HEALTHPLAN*****XV*H5425~ N3*3800 Kilroy Airport Way~ N4*Long Beach*CA* ~ REF*T4*Y~ LX*1~ SV1*HC:77421:TC*223.44*UN*1***1 Line level total service charge amount = DTP*472*D8* ~ SVD*H5425*87.69*HC:77421:TC**1~ Line level primary (other) payer paid amount CAS*PR*3*21.92~ Primary (other) payer adjustment (Patient co-payment amount) CAS*CO*45*113.83~ Primary (other) payer adjustment (45: Charge exceeds fee schedule/maximum allowable) DTP*573*D8* ~ This encounter has rejected because the primary payer amount paid at the claim level (AMT*D*1) does not equal the primary payer amount paid at the line level (SVD*H5425*87.69*) These amounts must balance. To correct this encounter the claim level payer amount paid must match the line level payer amount paid.) The following pages will display this CA Rejection The following rejection reason was received on a 277CA report from CMS from the processing of the above encounter STC*A7:672* *U*223.44******A7:286~ o Rejection Code: 672 o Rejection Reason: Other Payer's payment information is out-of-balance Rejection Code Meanings: See also, CMS TRANSMITTAL 750: 837IEdit Reference Segment or Element TA1/999 /277CA Acce pt/r eject Disposition / Error Code 5010 Edits X AMT AMT C CSCC A7: "Acknowledgement /Rejected for Invalid Information "CSC 672: "Other Payer's payment information is out of balance"csc 286: Other payer's Explanation of Benefits/payment information X CLM CLM C CSCC A7: "Acknowledgement /Rejected for Invalid Information "CSC 400: "Claim is out of Balance"CSC 672: "Payer's payment information is out of balance" 2320 AMT02 must = the sum of all 2430.SVD02 payer paid amounts (when the value in 2430.SVD01 is the same as the value in 2330B.NM109) minus the sum of all claim level adjustments (2320 CAS adjustment amounts) for the same payer. CLM02 must equal the sum of all 2320 & 2430 CAS amounts and the 2320 AMT02 (AMT01=D). SCAN FED Requirements_v10.1 Page 28 of 87

29 Encounter Balancing Explained (Reference: X ASC X12N INSURANCE SUBCOMMITTEE HEALTH CARE CLAIM: PROFESSIONAL TECHNICAL REPORT TYPE 3) In order to ensure internal claim integrity, amounts reported in the 837 MUST balance at two different levels - the claim and the service line. With the sole exception of the CAS segments at the service line level, all charge/payment dollar amounts within an encounter must be a positive amount greater than $0.00. This requirement applies to both Institutional (837I) and Professional (837P) encounters Claim Level Balancing There are two different ways the claim information must balance, they are as follows: (1) Claim Charge Amounts The total claim charge amount reported in Loop ID-2300 CLM02 must balance to the sum of all service line charge amounts reported in Loop ID-2400 SV102. CLM* *223.44***11:B:1*Y*A*Y*Y~ SV1*HC:77421:TC*223.44*UN*1***1 Example Claim Charge = Line 1 Charge = Claim Charges (2300 CLM02) = Total of all Line Charges (2400 SV102) = (2) Claim Payment Amounts Balancing of claim payment information is done payer by payer. For a given payer, the sum of all line level payment amounts (Loop ID-2430 SVD02) less any claim level adjustment amounts (Loop ID-2320 CAS adjustments) must balance to the claim level payment amount (Loop ID-2320 AMT02). AMT*D*1.00~ SVD*H5425*87.69*HC:77421:TC**1~ Example Claim Payment = 1.00 Claim Adjustment = 0 No CAS amounts at the claim level Line 1 Payment = Claim Payment (2320 AMT02) = Line 1 Payment(2430 SVD02) Claim Adjustment (2320 CAS) 1 = ( ) This claim is out-of-balance SCAN FED Requirements_v10.1 Page 29 of 87

30 Correcting the Prevously Rejected Encounter Add applicable CAS segments to 2320 Loop to report the other payer s claim adjustments CAS*PR*1*75~ CAS*CO*45*11.69~ AMT*D*1~ deductible Charges exceed maximum allowable.. SVD*H5425*87.69*HC:77421:TC**1~ Expressed as a calculation for given payer: {Loop ID-2320 AMT02 payer payment} = {sum of Loop ID SVD02 payment amounts} minus {sum of Loop ID-2320 CAS adjustment amounts}. Test Claim Payment = 1 Claim Adjustment = Line 1 Payment = Claim Payment (2320 AMT02) = Line 1 Payment (2430 SVD02) Claim Adjustment (2320 CAS) 1 = Service Line Level Balancing Line Adjudication Information (Loop ID-2430) is reported when the payer identified in Loop ID-2330B has adjudicated the claim and service line payments and/or adjustments have been applied. NM1*PR*2*SCAN HEALTHPLAN*****XV*H5425~ Line level balancing occurs independently for each individual Line Adjudication Information loop. In order to balance, the sum of the line level adjustment amounts and line level payments in each Line Adjudication Information loop must balance to the provider s charge for that line (Loop ID-2400 SV102). The Line Adjudication Information loop can repeat up to 25 times for each line item. LX*1~ SV1*HC:77421:TC*223.44*UN*1***1 DTP*472*D8* ~ SVD*H5425*87.69*HC:77421:TC**1~ CAS*PR*3*21.92~ Patient Co-pay CAS*CO*22*113.83~ Charges payable by another payer DTP*573*D8* ~ SCAN FED Requirements_v10.1 Page 30 of 87

31 The calculation for each 2430 loop is as follows: {sum of Loop ID-2430 CAS Service Line Adjustments} plus {Loop ID-2430 SVD02 Service Line Paid Amount} = {Loop ID-2400 SV102 Line Item Charge Amount} Example Line 1 Charge = Line 1 Payment = Line 1 Adjustments = Line 1 Adjustments(2430 CAS Segments) + Line 1 Payment (SVD02) = Line Item 1 Charge (SV102) = Accepted Encounter CLM* *223.44***11:B:1*Y*A*Y*Y~ Claim level total billed amount = $ HI*BK:185*BF:185~ SBR*P*18*******16~ CAS*PR*1*75~ CAS*CO*45*11.69~ AMT*D*1~ OI***Y***Y~ deductible Charges exceed maximum allowable Claim Level primary (other) payer amount paid NM1*IL*1*XXXXXXX*XXXXXXXX****MI* A~ NM1*PR*2*SCAN HEALTHPLAN*****XV*H5425~ N3*3800 Kilroy Airport Way~ N4*Long Beach*CA* ~ REF*T4*Y~ LX*1~ SV1*HC:77421:TC*223.44*UN*1***1 Line level total service charge amount = DTP*472*D8* ~ SVD*H5425*87.69*HC:77421:TC**1~ Line level primary (other) payer paid amount CAS*PR*3*21.92~ Primary (other) payer adjustment (Patient co-payment amount) CAS*CO*45*113.83~ Primary (other) payer adjustment (45: Charge exceeds fee schedule/maximum allowable) DTP*573*D8* ~ The original encounter rejected because the primary payer amount paid at the claim level (AMT*D*1) did not equal the primary payer amount paid at the line level (SVD*H5425*87.69*) These amounts must balance. In this example, adjustments were added at the claim level allowing the claim level payer amount paid to match the line level payer amount paid.) This encounter was accepted. SCAN FED Requirements_v10.1 Page 31 of 87

32 2.15 Capitated Encounters in v5010 Full Encounter Data CMS has provided guidance for capitated encounters in their September 2011 Participant Guide. While CMS continues to iterate that billed and paid amounts should be sent if known, they have indicated that they do allow encounters to be submitted with $0.00 amounts. SCAN has conducted several tests on capitated encounters, specific to the areas of patient responsibility and balancing as SCAN requires that patient responsibility amounts are sent. The results of these test scenarios have confirmed that encounters submitted to CMS that do not meet the balancing requirements, set forth in the WPC X HEALTH CARE CLAIM: PROFESSIONAL TECHNICAL REPORT 3 (TR3) and the CMS Companion Guide, will be rejected. Amount Fields 16 Amount fields on claims submitted by capitated providers do not always have the accurate pricing amount populated. For capitated or staff model arrangements submitting encounter data, 0 should be populated in amount fields, if no amount information is available, before submitting to CMS. If pricing information is available on the encounter collected, then it should be submitted as is; however, the sum of the SV1 (Professional) and SV2 (Institutional) service lines must balance to the total amount populated on Loop ID-2300, CLM02. Capitated claims submitted with 0 in the amount fields will be priced according to 100% of the Medicare allowable amount when processed through the EDS. Type Loop Segment Field Description Claim Information Professional 2300 CLM02 Institutional 2300 CLM02 Total Claim Charge Amount Total Claim Charge Amount Must balance to the sum SV1 service lines in Loop Must balance to the sum SV2 service lines in Loop Flagging Capitated Encounters 17 There are instances in which capitated and non-capitated service lines can be present on one (1) claim. If this is the case, MAOs and other entities must populate Loop ID-2400, segment CN, data element CN101 with a value of 05 to indicate the service line is from a capitated arrangement, for professional encounters only. Institutional capitated encounters must be indicated at the claim level, Loop ID-2300, data element CN101 with a value of 05. All service lines must continue to balance to the total claim amount. Type Loop Segment Field Description Claim Information 16 Participant Guide 2011 Regional Encounter Data Technical Assistance, version 2.0, rticipantguide_cameraready_ pdf 17 Participant Guide 2011 Regional Encounter Data Technical Assistance, version 2.0, < articipantguide_cameraready_ pdf SCAN FED Requirements_v10.1 Page 32 of 87

33 Professional 2300/2400 CN101 Contract Information Institutional 2300 CN101 Contract Information SV1 service lines in Loop 2400 must balance to the total claim SV2 service lines in Loop 2400 must balance to the total claim amount. Edits Suppressed due to Capitation 18 If the capitated contract code of 05 is populated in Loop 2300 or Loop ID-2400, data element CN101, indicating the encounter data submission is from a capitated or staff model arrangement, amount field edits will be suppressed Capitated Encounters - $0.00 Billed and Paid Thorough testing has revealed that all dollar amounts must balance in order to pass the CMS front-end edits. Example Test Scenario 1 Encounter data was sent to CMS containing all $0.00 amounts with the contact code at the claim level (2300, CN1*05). This encounter was accepted. A subsequent encounter was sent with claim level $0.00 amounts billed (2300, CLM02) and paid (2320 Loop, AMT02) with a payer amount paid at the line level (2430 SVD02) and contract code notation (CN1*05). This encounter was rejected for being out-of-balance. Accepted CLM* *0***31:B:1*N*C*N*Y~ CN1*05~ HI*BK:1839*BF:1839*BF:4111*BF:42731*BF:70705~ SBR*P*18*******16~ AMT*D*0.00~ OI***N***Y~.. LX*1~ SV1*HC:99307*0*UN*1***1~ DTP*472*D8* ~ SVD*H9104*0*HC:99307**1~ DTP*573*D8* ~ 18 Participant Guide 2011 Regional Encounter Data Technical Assistance, version 2.0, < articipantguide_cameraready_ pdf SCAN FED Requirements_v10.1 Page 33 of 87

34 Rejected CLM* *0***31:B:1*N*C*N*Y~ HI*BK:1839*BF:1839*BF:4111*BF:42731*BF:70705~ SBR*P*18*******16~ AMT*D*0.00~ OI***N***Y~.. LX*1~ SV1*HC:99307*0*UN*1***1~ DTP*472*D8* ~ SVD*H9104*100*HC:99307**1~ CN1*05~ DTP*573*D8* ~ Capitated Encounters Balancing Patient Responsibility Amounts SCAN requires that all patient responsibility amounts are sent (i.e. co-pays, deductibles, etc.) within the encounter data. This creates a special circumstance in keeping the encounter balanced when using $0.00 billed and paid amounts in a capitated arrangement. While testing with CMS, SCAN determined that encounters sent with the patient responsibility equal to the billed amount allowed the encounter data to pass the CMS front-end edits. Example Test Scenario 2 Encounter data was sent to CMS containing $0.00 claim level billed (2300, CLM02) and paid (2320, AMT02) amounts with line level $0.00 billed (2400, SV102), $0.00 paid (2430, SVD02) with a patient co-pay (2430, CAS02) and contract code (CN1*05). This claim was rejected for being out-of-balance. A subsequent encounter was sent that with the co-pay equaling the billed amounts. This claim was accepted. Rejected CLM* *0***31:B:1*N*C*N*Y~ HI*BK:1839*BF:1839*BF:4111*BF:42731*BF:70705~ SBR*P*18*******16~ AMT*D*0.00~ OI***N***Y~.. LX*1~ SV1*HC:99307*0*UN*1***1~ DTP*472*D8* ~ CN1*05~ SVD*H9104*0*HC:99307**1~ CAS*PR*3*25~ DTP*573*D8* ~ SCAN FED Requirements_v10.1 Page 34 of 87

35 Accepted CLM* *25***31:B:1*N*C*N*Y~ HI*BK:1839*BF:1839*BF:4111*BF:42731*BF:70705~ SBR*P*18*******16~ AMT*D*0.00~ OI***N***Y~.. LX*1~ SV1*HC:99307*25*UN*1***1~ DTP*472*D8* ~ CN1*05~ SVD*H9104*0*HC:99307**1~ CAS*PR*3*25~ DTP*573*D8* ~ When sending capitated claims with patient responsibility amounts, ensure that the billed amount is equal to the patient responsibility. SCAN FED Requirements_v10.1 Page 35 of 87

36 2.16 Top 10 CMS FED Requirements During the January and March 2012 CMS Full Encounter Data - Provider Partner Transition Update Webinars, the following Top 10 Things to Work On list was shared to assist Provider Partners in preparing for Full Encounter Data. The list is in no particular order. 1. Accurate NPI s for All Providers o Validate Taxonomy codes in NPPES Notes from the January and March Webinars: Accurate NPIs apply to all provider types: rendering, billing, ordering, etc. Provider Partners must ensure systems are updated to reflect valid and accurate taxonomy codes, which are in NPPES, as this is how CMS will determine what is risk adjustable with FED. 2. ID Numbers o o o Mammography Certification Number CLIA Number NDC Notes from the March Webinar: ID numbers (such as the mammography certification number, CLIA number, and NDC) may at first be informational edits at CMS, but CMS can turn them into hard edits and begin rejecting at any point in time. Please keep in mind that CMS is looking for this data on encounters that have these situations. 3. Referring and Ordering Provider Information Notes from the March Webinar: Referring and Ordering information again requires the NPI, so ensure that you have the NPIs in your systems, ensure they are accurate, and ensure they are sent on your encounters. 4. Rendering Providers NPIs o The Rendering Provider is required when different from the Billing Provider. Notes from the January and March Webinars: Do not assign a group NPI to any individual provider or vice versa, this causes a conflict between the provider name and the provider NPI and this will result in processing issues in either the SCAN or CMS EDPS sytems. The Rendering Provider can be either an individual or group, but must be wholly one of the other with the 5010 data reflecting this. - Example of conflict: NM1*82*2*ABCXYZ PHYSICIANS******XX* ~ Individual NPI Group Qualifier Group Name SCAN FED Requirements_v10.1 Page 36 of 87

37 5. Balanced Dollars Amounts o o o o Billed Amount Patient Responsibility Paid Amounts Adjustment Amounts Notes from the March Webinar: Balanced dollar amounts are a 5010 requirement and a requirement from CMS to get the encounter into their system. - The billed amount minus patient responsibility minus paid amount minus any other adjustments all have to equal $0. - It is very important that SCAN receives the patient responsibility to be able to compute the OOP (Out-of-Pocket) Max for the member for a given year. In the past, we have not been able to compute this maximum, but this is now a hard requirement from CMS. SCAN must proactively track the OOP Max, and we must therefore rely on our delegated Provider Partners to pass that data to us in the encounters. 6. Submission of Encounter Data for all Services o Post Adjudicated Claims: passed EDI validations, went through adjudication and were paid or denied a payment. Notes from the January and March Webinars: Post Adjudicated Claims that are accurate and clean are what is required for encounter data. Submit encounter data for all services. In other words, submit all of your post adjudicated claims, which means the claim has passed EDI validations, gone through adjudication, and was paid or denied. Pass through all services to SCAN so SCAN can send all data through to CMS. 7. Ambulance Information o o Pick-up: date, time, location Drop-off: date, time location Notes from the March Webinar: Ambulance pick-up and drop-off locations are required in If only the pick-up location is captured without the drop-off, the encounter will most likely reject at CMS. 8. Physical Address for Billing Provider o PO BOX to be sent in the Pay-to-Provider Notes from the January and March Webinars: Even though CMS has dialed back the requirement of physical addresses for billing providers, we are still highly recommending, while everyone is dealing with FED, that Provider Partners clean up the billing addresses and do send a physical address rather than PO Boxes on the encounters. CMS can begin following 5010 requirements again at any point in time. It is better to be ready now. If Providers must send through a PO Box, although SCAN does not use it for anything, it can be placed in the Pay-To loops. SCAN FED Requirements_v10.1 Page 37 of 87

38 9. Zip +4 = 9 digit zip codes o o Billing Provider Servicing Facility Notes from the January and March Webinars: The billing provider and servicing facility must be a full 9-digit zip code. CMS is allowing 9998 to be appended when the full 9-digit zip code truly is not available, but they are monitoring the usage of this default and will question high volumes of it. Please do not abuse this default. 10. Rejection Handling o o SCAN Recommends working rejections weekly, at minimum Understand where rejections come from and how to resolve Clearinghouse Encounters are not sent to SCAN Rejections should be resolved by PP and Clearinghouse SCAN Encounters are not sent to CMS Rejections are reported on the SCAN Provider Portal* CMS Encounters do not make it into the CMS EDPS Rejections are reported on the SCAN Provider Portal Notes from the January and March Webinars: Keep in mind that rejection handling is received from multiple sources: Clearinghouse, SCAN, and CMS. SCAN recommends working rejections on a weekly basis at a minimum. The clearinghouses submit to SCAN multiple times a week, and SCAN submits to CMS multiple times a week. Clearinghouse errors must be worked with the clearinghouse. - If Providers are submitting to TransUnion, work closely with TransUnion on the migration from the legacy EMS system to the new MedConnect system to ensure the errors are worked in the appropriate place and manner. SCAN and CMS errors must be worked on the Encounter Data Portal. - The new Encounter Data Portal will allow Providers to fix all of the errors right in the Portal itself, and we do recommend logging into this Portal at least on a weekly basis to understand where the rejections are coming from and how to resolve them. - There will be a deployment of the new Encounter Data Portal prior to the go-live of SCAN FED submissions to CMS. If the encounter fails SCAN edits, it is not sent to CMS. If the encounter fails CMS edits (and any previous edits), the encounter is not included for risk adjustment until the error is resolved and the encounter is resubmitted. SCAN FED Requirements_v10.1 Page 38 of 87

39 2.17 CMS Minumum Encounter Data Elements CMS recently published the final minimum data elements required on Full Encounter Data in order to pass CMS Encounter Data System (EDS) translator and their CEM (Common Edits and Enhancements Module) level edits. The minimum data elements are required to properly process and price encounters. The industry may use these data elements within the v5010 format for the submission of encounters derived from paper claims (also referred to as skinny claims), member reimbursement claims, claims from foreign providers, etc. 19 CMS Encounter Data Minimum Data Elements document can be found on the CSSC Operations site, at: d_situational_edits_ pdf/$file/eds_minimum_data_elements_commonly_used_situational_edi ts_ pdf The document uses gray shading to indicate which data elements are not found on a paper claim, however, are still required elements for CMS to properly process encounters. Data elements that are not shaded are found on a paper claim (HCFA 1500 or UB-04) where an asterisk is used to indicate situationally required fields with a note that not all situationally required fields are listed in the document. Throughout, CMS points the industry to their Companion Guide for instructions on populating the minimally required fields. In addition to supplying the minimum data elements, CMS requires the encounter be identified as a skinny paper claim by utilizing the PWK segment in loop 2300 as follows: 20 Loop 2300, PWK01 = OZ Loop 2300, PWK02 = AA Most importantly, CMS has developed requirements for the ambulance transport pick-up and drop-off locations. Please refer to section 3.6 AMBULANCE CLAIMS - PICK-UP AND DROP-OFF LOCATIONS for further information on the CMS ambulance encounter requirements. 19 CMS, Encounter Data Industry Update March User Group Presentation cameraready pdf, 15 Mar 2012, Slides CMS, Encounter Data Industry Update March User Group Presentation.pdf, 29 Mar 2012, Slide 13. SCAN FED Requirements_v10.1 Page 39 of 87

40 3 ANSI V5010 CHANGES EXPLAINED The information provided in this section is compiled from multiple sources including: Centers for Medicare and Medicaid (CMS), Washington Publishing Company (WPC), National Uniform Claim Committee (NUCC), X Implementation Guides, and the American Medical Association (AMA). 3.1 Overview and RAPS vs and EDPS Previously, encounter files received in the 4010 format were not mandated to meet all of the ANSI 837 v4010 requirements. These skinny encounters were acceptable for submission due to the limited data requirements for RAPS, as identified previously in section 2.2. Moving forward with 5010 in 2012, encounter data must be submitted in the complete HIPAA compliant ANSI 837 v5010 file format with all required fields in order to comply with CMS Full Encounter Data initiative and be accepted for processing in the CMS Encounter Data Processing System (EDPS). It is extremely important that encounter data be submitted with all of the 5010 required fields to avoid being rejected at the clearinghouse, SCAN, or CMS. Encounter rejections can lead to a loss of CMS allocated healthcare funds for SCAN members, your patients; making it imperative that our Provider Partners have implemented processes for successfully managing rejections Editing for Complete and Valid 5010 File Formats SCAN recommends that providers utilize an EDI validation engine, such as Claredi 21, to validate their 5010 files in addition to testing with the clearinghouses. Testing encounter data through an EDI validation engine will allow providers to be certain they are able to submit complete and valid 5010 files in Information on the Claredi validation tool can be found at: SCAN FED Requirements_v10.1 Page 40 of 87

41 3.1.3 SCAN s 837 v5010 Companion Guides SCAN has published both the 837 Institutional and Professional Companion Guides for v5010 to the clearinghouses (TransUnion and Office Ally). It is important to note that these are SCAN s requirements for the clearinghouses. While the SCAN companion guide does contain helpful and specific CMS detail which can be used, providers must be compliant with their clearinghouse s Companion Guide in order to pass clearinghouse edits. The SCAN Companion Guides are available for download on the SCAN Healthplan website, within Provider Tools, under the Full Encounter Data link at: SCAN FED Requirements_v10.1 Page 41 of 87

42 3.2 National Provider Identification - NPI Summary The National Provider Identifier (NPI) is used to uniquely identify health care providers in standard transactions, such as health care claims. All health care providers who are HIPAA-covered entities, whether they are individuals or organizations must obtain an NPI. The NPI must be used to identify health care providers in HIPAA standard transactions. The NPI compliance date for all covered entities except small health plans was May 23, 2007; the compliance date for small health plans was May 23, Historically, there had not been a standardized representation of organization health care providers. Identification of health care provider entities had varied by trading partner. The NPI subpart concept provided an organization health care provider the ability to represent itself in a manner consistent to all trading partners Providers Not Required to Obtain an NPI Atypical Providers There are instances where a provider is not required to obtain an NPI i.e. providers who are not eligible for enumeration. These atypical providers are service providers that do not meet the definition of health care provider. Although, they are not eligible to receive an NPI, these providers perform services that are reimbursed by some health plans. 23 Examples include: adult companion, adult foster care, driver, funeral director, home delivered meals, non-emergency transportation providers, personal care attendants, and supportive living provider. 24 Update on default NPI usage provided during 11/16/2011 Webinar CMS Full Encounter Data - Provider Partner Transition Update : The NPI is used by CMS to link specialties and thus determine which encounters should be routed to the risk adjustment process. When a default NPI is used on an encounter, this automatically excludes the encounter from being counted for risk adjustment. Per SCAN s Companion Guides 25, in instances where a provider is not required to enroll for an NPI, then submitter may use a default value. When submitting the default NPI value, then submitter must send the SCAN Provider ID with a license qualifier. The below table is captured from the Institutional Companion Guide to illustrate how to submit the Billing Provider NPI where an Atypical relationship exists. 22 CMS, The National Provider Identifier What You Need to Know < 23 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page CMS, Industry Update Materials pdf, Slide SCAN, Standard Companion Guide Transaction Information: 837-I Companion Guide, Version 1.0, 30 August 2011, Page 7, < > SCAN FED Requirements_v10.1 Page 42 of 87

43 Loop Segment Data Element Comments /Value Segment or Loop Requirement Note 2010AA: Billing Provider Name NM1 NM108: Billing Provider Qualifier ID "XX" Required NPI Identifier 2010AA: Billing Provider Name NM1 NM109: Billing Provider Identifier Billing Provider NPI Required NPI is required for Provider identification for encounter data submission. If provider is not required to enroll for an NPI, then submitter may use a default value. 2010AA: Billing Provider UPIN/License Information REF REF01: Reference Identification Qualifier "0B" "1G" Situational 0B=License 1G=SCAN Provider ID or Site ID 2010AA: Billing Provider UPIN/License Information REF REF02: Reference Identification Situational If Submitter has the Billing Provider license number, and/or SCAN Provider ID, and/or SCAN Site ID, the 2010AA REF should be populated appropriately Per the CMS Encounter Data Industry Update on October 27, 2011, they have modified their requirements on the value of the default NPI for atypical providers. Below are the updated values: 26 For Institutional submissions: For Professional submissions: For DME submissions: Location 837 Professional 27 Any location on the 5010 where a provider identifier is required, the code used should be the NPI. On the following pages are the primary provider loops and segments where an NPI should be used this is not the extensive list. 26 CMS, Industry Update Materials pdf, Slide ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Pages 87-89, , , SCAN FED Requirements_v10.1 Page 43 of 87

44 Loop Segments Usage TR3 Notes Qualifier Example Loop Segments Usage TR3 Notes 2010AA Billing Provider Name NM108 - Billing Provider Identification Code Qualifier NM109 - Billing Provider Identification Code Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI. OR Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI. OR Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. If not required by this implementation guide, do not send. The Billing Provider may be an individual only when the health care provider performing services is an independent, unincorporated entity. In these cases, the Billing Provider is the individual whose social security number is used for 1099 purposes. That individual s NPI is reported in NM109, and the individual s Tax Identification Number must be reported in the REF segment of this loop. The individual s NPI must be reported when the individual provider is eligible for an NPI. See section (Providers who are Not Eligible for Enumeration). When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. XX NM1*85*2*ABC Group Practice*****XX* ~IAGRAM 2310A Referring Provider Name NM108 - Referring Provider Identification Code Qualifier NM109 - Referring Provider Identification Code Required when this claim involves a referral. If not required by this implementation guide, do not send. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID-2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. When there is only one referral on the claim, use code DN Referring Provider. When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code P3 - Primary Care Provider in the second SCAN FED Requirements_v10.1 Page 44 of 87

45 iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient s episode of care being billed/reported in this transaction. Qualifier Example Loop Segments Usage TR3 Notes Qualifier Example Loop Segments Usage TR3 Notes Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. XX NM1*DN*1*WELBY*MARCUS*W**JR*XX* ~IAGRAM 2310B Rendering Provider Name NM108 - Service Facility Location Identification Code Qualifier NM109 - Service Facility Location Identification Code Required when the Rendering Provider information is different than that carried in Loop ID-2010AA - Billing Provider. If not required by this implementation guide, do not send. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenens) was used, enter that provider s information here. XX NM1*82*1*DOE*JANE*C***XX* ~ 2310C Service Facility Location Name NM108 - Service Facility Location Identification Code Qualifier NM109 - Service Facility Location Identification Code Required when the location of health care service is different than that carried in Loop ID- 2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider s NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. The purpose of this loop is to identify specifically where the service was rendered. When reporting ambulance services, do not use this loop. Use Loop ID-2310E - Ambulance Pickup Location and Loop ID2310F Ambulance Drop-off Location. Qualifier Example Loop Segments Usage Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. XX NM1*77*2*ABC CLINIC*****XX* ~ 2310D Supervising Provider Name NM108 - Supervising Provider Identification Code Qualifier NM109 - Supervising Provider Identification Code Required when the rendering provider is supervised by a physician. If not required by this implementation guide, do not send. SCAN FED Requirements_v10.1 Page 45 of 87

46 TR3 Notes Qualifier Example Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. XX NM1*DQ*1*DOE*JOHN*B***XX* ~ Location Institutional 28 Any location on the 5010 where a provider identifier is required, the code used should be the NPI. Below are the main provider loops where an NPI should be used this is not the extensive list. Loop Segments Usage TR3 Notes Qualifier Example Loop Segments Usage TR3 Notes Qualifier 2010AA Billing Provider Name NM108 - Billing Provider Identification Code Qualifier NM109 - Billing Provider Identification Code Required for providers in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider is eligible to receive an NPI. Required for providers not in the United States or its territories on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI. Required for providers prior to the mandated NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. If not required by this implementation guide, do not send. When the individual or the organization is not a health care provider and, thus, not eligible to receive an NPI (For example, personal care services, carpenters, etc), the Billing Provider should be the legal entity. However, willing trading partners may agree upon varying definitions. Proprietary identifiers necessary for the receiver to identify the entity are to be reported in the Loop ID-2010BB REF, Billing Provider Secondary Identification segment. The TIN to be used for 1099 purposes must be reported in the REF (Tax Identification Number) segment of this loop. XX NM1*85*2*ABC HOSPITAL*****XX* ~IAGRAM 2310A Attending Provider Name NM108 - Attending Provider Identification Code Qualifier NM109 - Attending Provider Identification Code Required when the claim contains any services other than non-scheduled transportation claims. If not required by this implementation guide, do not send. The Attending is the individual who has overall responsibility for the patient s medical care and treatment reported in this claim. XX 28 ASC X12 Insurance Subcommittee, ASC X12 Standards for Electronic Data Interchange; Health Care Claim: Institutional (837), Version 5, Release 1, May 2006, Page 84-86, , , , , , SCAN FED Requirements_v10.1 Page 46 of 87

47 Example NM1*71*1*JONES*JOHN****XX* ~ Loop Segments 2310B Operating Physician Name NM108 - Operating Physician Name Identification Code Qualifier NM109 - Operating Physician Name Identification Code Usage Required when a surgical procedure code is listed on this claim. If not required by this implementation guide, do not send. TR3 Notes The Operating Physician is the individual with primary responsibility for performing the surgical procedure(s). Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Qualifier XX Example Loop Segments NM1*72*1*MEYERS*JANE****XX* ~ 2310C Other Operating Physician Name NM108 - Other Operating Physician Name Identification Code Qualifier NM109 - Other Operating Physician Name Identification Code Usage Required when another Operating Physician is involved. If not required by the implementation guide, do not send. TR3 Notes The Other Operating Physician is the individual performing a secondary surgical procedure or assisting the Operating Physician. Qualifier Example This Other Operating Physician segment can only be used when Operating Physician information (Loop ID-2310B) is also sent on this claim. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. XX NM1*ZZ*1*DOE*JOHN*A****XX* ~ Loop Segments Usage TR3 Notes Qualifier 2310D Rendering Provider Name NM108 - Rendering Provider Name Identification Code Qualifier NM109 - Rendering Provider Name Identification Code Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. Required when state or federal regulatory requirements call for a combined claim, that is, a claim that includes both facility and professional components (for example, a Medicaid clinic bill or Critical Access Hospital Claim.) If not required by this implementation guide, do not send. The Rendering Provider is the health care professional who delivers or completes a particular medical service or non-surgical procedure. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. XX SCAN FED Requirements_v10.1 Page 47 of 87

48 Example Loop Segments Usage TR3 Notes Qualifier Example Loop NM108 & NM109 Usage TR3 Notes Qualifier Example NM1*82*1*DOE*JANE*C***XX* ~ 2310F Referring Provider Name NM108 - Referring Provider Identification Code Qualifier NM109 - Referring Provider Identification Code Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. The Referring Provider is the provider who sends the patient to another provider for services. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. XX NM1*DN*1*WELBY*MARCUS*W**JR*XX* ~ 2310E Service Facility Location Name NM108 - Service Facility Location Identification Code Qualifier & NM109 - Service Facility Location Identification Code Required when the location of health care service is different than that carried in Loop ID- 2010AA (Billing Provider). If not required by this implementation guide, do not send. When an organization health care provider s NPI is provided to identify the Service Location, the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider. XX NM1*77*2*ABC CLINIC*****XX* ~ UB / HCFA Location for Paper Claims On the CMS-1450 (UB-04) claim form 29 : Billing Provider NPI is entered in box 56. Attending Provider NPI is entered in box 76. Operating Provider NPI is entered in box 77. Other Provider NPI and Qualifiers boxes 78 and 79. o Other Operating - use ZZ qualifier o Referring Provider - use DN qualifier o Rendering Provider - use 82 qualifier 29 CMS, Medicare Claims Processing Manual, Chapter 25 Completing and Processing the CMS Data Set, 01 July 2011, < > SCAN FED Requirements_v10.1 Page 48 of 87

49 On the CMS-1500 (HCFA) form 30 : Billing Provider NPI is entered in box 33a. Referring Provider NPI is entered in box 17b. Rendering Provider is entered in box 24i (qualifier 82) and 24j only when different from data Billing Provider entered in boxes 33a and 33b. Service Facility NPI (if different from billing NPI) should be entered in box 32a. 3.3 Referring Provider Name and NPI Summary 31 The Referring Provider must be a person. The only identifier allowed in the Referring Provider Name segment is the National Provider Identifier (NPI). The identifier has a usage of Situational as it is only required when the claim involves a referral Location Professional 32 Loop 2310A Referring Provider Name Segment NM1 - Referring Provider Name Usage Required when this claim involves a referral. If not required by this implementation guide, do not send. TR3 Notes 1. When reporting the provider who ordered services such as diagnostic and lab, use Loop ID- 2310A at the claim level. For ordered services such as Durable Medical Equipment, use Loop ID-2420E at the line level. 2. When there is only one referral on the claim, use code DN Referring Provider. When more than one referral exists and there is a requirement to report the additional referral, use code DN in the first iteration of this loop to indicate the referral received by the rendering provider on this claim. Use code P3 - Primary Care Provider in the second iteration of the loop to indicate the initial referral from the primary care provider or whatever provider wrote the initial referral for this patient s episode of care being billed/reported in this transaction. 3. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Qualifier DN Example NM1*DN*1*WELBY*MARCUS*W**JR*XX* ~ Segments Usage Qualifier Example NM108 - Referring Provider Identification Code Qualifier NM109 - Referring Provider Identification Code Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter. Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. If not required by this implementation guide, do not send. XX NM1*DN*1*WELBY*MARCUS*W**JR*XX* ~ 30 National Uniform Claim Committee, Page ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page D ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page SCAN FED Requirements_v10.1 Page 49 of 87

50 Location Institutional 33 Loop 2310F - Referring Provider Name Segment NM1 - Referring Provider Name Usage Required on an outpatient claim when the Referring Provider is different than the Attending Provider. If not required by this implementation guide, do not send. TR3 Notes 1. The Referring Provider is provider who sends the patient to another provider for services. 2. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Qualifier Example Segments Usage Qualifier Example DN NM1*DN*1*WELBY*MARCUS*W**JR*XX* ~ NM108 - Referring Provider Identification Code Qualifier NM109 - Referring Provider Identification Code Required for providers on or after the mandated HIPAA National Provider Identifier (NPI) implementation date when the provider has received an NPI and the NPI is available to the submitter. Required for providers prior to the mandated HIPAA NPI implementation date when the provider has received an NPI and the submitter has the capability to send it. If not required by this implementation guide, do not send. XX NM1*DN*1*WELBY*MARCUS*W**JR*XX* ~ UB / HCFA Location for Paper Claims On the CMS-1450 (UB-04) form, the Referring Provider Name and NPI are to be entered in box 78 and 79 respectively. See below screen shot of pages of CMS Medicare Claims Processing Manual, Chapter On the CMS-1500 (HCFA) form, the Referring Provider Name and NPI are to be entered in box 17 and 17b respectively. 33 ASC X12 Insurance Subcommittee, Health Care Claim: Institutional (837), Page CMS, Medicare Claims Processing Manual, Chapter 25, Page SCAN FED Requirements_v10.1 Page 50 of 87

51 See below details as taken from pages of the NUCC s Claim Form Manual v7. 35 Item Number 17 Title: Name of Referring Provider or Other Source Instructions: Enter the name (First Name, Middle Initial, Last Name) and credentials of the professional who referred, ordered, or supervised the service(s) or supply(ies) on the claim Description: The name is the referring provider, ordering provider, or supervising provider who referred, ordered, or supervised the service(s) or supply(ies) on the claim. Field Specification: This field allows for the entry of 26 characters Title 17b: NPI # Instructions 17b: Enter the NPI number of the referring, ordering, or supervising in Item Number 17b Description: The NPI number refers to the HIPAA National Provider Identifier number. Field Specifications: This field allows for the entry of a 10 digit NPI number. Example: 35 National Uniform Claim Committee, Pages SCAN FED Requirements_v10.1 Page 51 of 87

52 3.4 Billing Provider Address 9-Digit Zip Code Summary The Billing Provider s address zip code now must be reported with the 4-digit extension. When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. 36 SCAN Recommendation provided during 11/16/2011 Webinar CMS Full Encounter Data - Provider Partner Transition Update : Per CMS, the billing provider 9-digit zip code remains a requirement in FED files in 2012 because it is utilized by CMS to establish pricing. All providers are encouraged to submit a 9- digit zip code for the billing provider address. If the 9-digit zip code is not supplied, SCAN warns that the encounter will not pass CMS adjudication edits and would result in a rejection. Furthermore, the encounter will not price appropriately. Provider Partners should correct and resubmit encounters for all providers sending incomplete zip codes. For those intendeding to use the default 4-digit extension, rather than obtain the correct code, CMS does reserve the right to audit the usage of the default value of 9998 as the 4 digit extension. If CMS notices too many of the 9998 s being used, they will question providers. SCAN warns not to abuse the use of the default. Note: The previously accepted default value for the default 4-digit extension was CMS revised this default value to 9998 as of May 3, : 36 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page CMS, "Encounter Data System User Group", March_21_2013_UserGroupPresentation_cameraready_ pdf, 21 Mar 2012, Slide 17 SCAN FED Requirements_v10.1 Page 52 of 87

53 Location Professional 38 Loop 2010AA Billing Provider Name Segments N4 - Billing Provider City, State and Zip Code Postal Code N403 - Postal Code Usage Required TR3 Notes Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send. When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. Example N4*COLUMBUS*OH* ~ Location Institutional 39 Loop 2010AA Billing Provider Name Segments N4 - Billing Provider City, State and Zip Code Postal Code N403 - Postal Code Situational Required Rule TR3 Notes Required when the address is in the United States of America, including its territories, or Canada, or when a postal code exists for the country in N404. If not required by this implementation guide, do not send. When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. Example N4*COLUMBUS*OH* ~ 38 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page 92, ASC X12 Insurance Subcommittee, Health Care Claim: Institutional (837) Page 88, 89. SCAN FED Requirements_v10.1 Page 53 of 87

54 3.4.4 UB / HCFA Location for Paper Claims On the CMS-1500 (HCFA) form, the Billing Provider Zip Code is to be entered in box 33. (Enter the provider of service or supplier's billing name, address, zip code, and telephone number.) Details and screen shot below take from pages 56 and 57 of the NUCC s Claim Form Manual v7. 40 Title 33: Billing Provider Info & Ph# Instructions: Enter the provider s or supplier s billing name, address, ZIP code, and phone number. The phone number is to be entered in the area to the right of the field title. Enter the name and address information in the following format: 1 st Line Name 2 nd Line Address 3 rd Line City, State and ZIP Code Item 33 identifies the provider that is requesting to be paid for the services rendered and should always be completed. Do not use punctuation (i.e., commas, periods) or other symbols in the address (e.g., 123 N Main Street 101 instead of 123 N. Main Street, #101). Enter a space between town name and state code; do not include a comma. When entering a 9-digit ZIP code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number. Description: The billing provider's or supplier's biling name, address, zip code, and phone number refers to the billing office location and the telephone number of the provider or supplier. Field Specifications: This field allows for the entry of the following: 3 character for the area code, 9 characters for the phone number, and three lines of 29 characters each in the Billing Provider Info are. Example: 40 National Uniform Claim Committee, Pages SCAN FED Requirements_v10.1 Page 54 of 87

55 3.4.5 Additional Information 1. CMS Published Encounter Data Frequently Asked Questions #106 from 04/11/ : Q: One of the new requirements for 5010 is that all zip codes are nine (9) digits in length. Much of our address data is still in 5-digit format. Will it be permissible for plans to add four (4) zeroes to a zip code that is only five (5) digits in length for testing purposes? A: As of now, a valid nine (9) digit zip code must be populated on the 5010 in order to successfully process through the CEM edits. 2. CMS Published Quarterly Newsletter from Volume 1, Issue 4 (2011) 42 : Guidance for Submission of Nine (9) Digit ZIP Code: Due to feedback from the industry during the Regional IT Technical Assistance sessions, CMS has investigated modifications to the nine (9) digit ZIP code requirement. Encounter data must be submitted to the EDS on the 5010 Version 837-X with a valid nine (9) digit ZIP code in order to process appropriately through the Encounter Data Front-End System (EDFES). However, CMS has determined that MAOs and other entities may populate the last four (4) digits of the ZIP code with a default value of 9998 if the full nine (9) digits are unavailable. The use of this default value will allow the encounter to pass translator edits, and the 277CA edits that check the validity of the nine (9) digit ZIP code will be relaxed. CMS will monitor the use of the default ZIP code value. If the nine (9) digit ZIP code is available, MAOs and other entities are expected to submit the true data instead of the default value. 41 CMS, Encounter Data Frequently Asked Questions (FAQs), 10 May 2011, Page 16, < a%20faqs.pdf> 42 CMS, Encounter Data Quarterly Newsletter, 2011, Volume 1, Issue 4, < SCAN FED Requirements_v10.1 Page 55 of 87

56 3.5 Billing Provider Address Physical Address Only Summary The Billing Provider Address must be a street address. Other types of mailing addresses for the Billing Provider (such as a Post Office Box or a Lock Box) must be sent in the Pay-To Address Name loop. 43 SCAN Recommendation provided during 11/16/2011 Webinar CMS Full Encounter Data - Provider Partner Transition Update : Although CMS has recently relaxed the edits for the Billing Provider Address, SCAN strongly recommends that all Provider Partners continue their clean-up efforts as it relates to ensuring the Billing Provider Address contains a street address and does not contain a P.O. Box. It is well worth the effort to clean up any errors now rather than later as CMS can change their mandates at any time Location Professional 44 Loop 2010AA Billing Provider Name Segment N3 - Billing Provider Address Usage Required TR3 Notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3*123 MAIN STREET~ Location Institutional 45 Loop 2010AA Billing Provider Name Segment N3 - Billing Provider Address Usage Required TR3 Notes The Billing Provider Address must be a street address. Post Office Box or Lock Box addresses are to be sent in the Pay-To Address Loop (Loop ID-2010AB), if necessary. Example N3*123 MAIN STREET~ UB / HCFA Location for Paper Claims On the CMS-1450 (UB-04) form, the Billing Provider Address is to be entered in FL01, as shownin the screen shot below. See section above for the CMS-1500 (HCFA) detail. 43 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page D ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page ASC X12 Insurance Subcommittee, Health Care Claim: Institutional (837), Page 87. SCAN FED Requirements_v10.1 Page 56 of 87

57 3.6 Ambulance Claims Pick-Up and Drop-Off Locations Summary Ambulance suppliers who submit professional medical transportation encounters will be required to report the pick-up and drop-off locations for ambulance transport services. This information should be reported at the claim level (5010 loops 2310E and 2310F). Round-trip ambulance services should also be reported at the claim level using the CR109 segment (Loop 2300). For institutional ambulance services, the pick-up zip code must be populated in a HI segment (Loop 2300). See v5010 details below Location Professional 1. Pick-Up Location 46 Loop Segment Usage TR3 Notes Qualifier Value Example Segment TR3 Notes Example Segment Example 2310E Ambulance Pick-Up Location NM1 - Ambulance Pick-Up Location Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. PW 2 Non-Person Entity NM1*PW*2~DIAGRAM N3 - Ambulance Pick-Up Location Address If the ambulance pickup location is in an area where there are no street addresses, enter a description of where the service was rendered (for example, crossroad of State Road 34 and 45 or Exit near Mile marker 265 on Interstate 80.) N3*123 MAIN STREET~ N4 - Ambulance Pick-Up Location City, State, Zip Code N4*KANSAS CITY*MO*64108~ 2. Drop-Off Location ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Pages SCAN FED Requirements_v10.1 Page 57 of 87

58 Loop 2310F Ambulance Drop-Off Location Segment NM1 - Ambulance Drop-Off Location Usage Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. TR3 Notes Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. Qualifier 45 Value 2 Non-Person Entity Example NM1*45*2~ Segment Example Segment Example N3 - Ambulance Drop-Off Location Address N3*123 MAIN STREET~ N4 - Ambulance Drop-Off Location City, State, Zip Code N4*KANSAS CITY*MO*64108~ 3. Round Trip Services 48 Loop Segment Usage TR3 Notes Example Segment Semantic Usage Example 2300 CLAIM INFORMATION and 2400 Service Line Number CRC1 - Ambulance Transport Information Required on all claims involving ambulance transport services. If not required by this implementation guide, do not send. The CR1 segment in Loop ID-2300 applies to the entire claim unless overridden by a CR1 segment at the service line level in Loop ID-2400 with the same value in CR101. CR1*LB*140**A*DH*12****UNCONSCIOUS~ CR109 - Description CR109 is the purpose for the round trip ambulance service. Required when the ambulance service is for a round trip. If not required by this implementation guide, do not send. CR1*LB*140**D*DH*12***ROUND TRIP*UNCONSCIOUS~ Location Institutional Per CMS guidance during the May 24, 2012 Encounter Data System User Group Meeting, when billing ambulance services on an instutional encounter, the pick-up zip code must be reported. Provide the zip code for ambulance pick-up location in Loop 2300 HI (Value Information) o HI01-1 = BE (Value Qualifier) 47 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Pages , SCAN FED Requirements_v10.1 Page 58 of 87

59 Loop o o HI01-2 = A0 (Value Code) HI01-5 = Zip Code + 4, when available (Value Code Amount) First eight (8) digits of the Zip Code +4 should be populated to the left of the decimal Last digit of the Zip Code +4 should be populated to the right of the decimal Example: HI01-5 = (Zip = 23456; +4 = 9999) HI - VALUE INFORMATION Usage TR3 Notes HI01-1 HI01-2 HI01-5 Example Required when billing for ambulance or non-emergency transportation services. If not required by this implementation guide, do not send. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. BE A0 ZIP+4 HI BE:A0:: ~ UB / HCFA Location for Paper Claims The current CMS 1500 (HCFA) and CMS1450 (UB) forms do not contain specific fields for capturing the pick-up and drop-off address locations for ambulance transport services. The information must be submitted to CMS through the use of the ANSI 837 v5010 format. Provider Partners who continue to receive paper claims from their providers should begin to require ambulance transport information in a supplemental manner in order to be v5010 compliant when submitting encounters. Where this is not possible, CMS has provided a work-around for missing ambulance pick-up and drop-off locations. Please refer to section Minimum Data Elements for Ambulance Services Received on Paper Claims below for more detail Additional Information Refer to the CMS Medicare Claims Processing Manual, Chapter 15 - Ambulance Web page at for more information Minimum Data Elements for Ambulance Services Received on Paper Claims CMS has published a document to explain the minimum data elements required to properly process encounters (refer to section 2.15 above). During CMS Encounter Data Industry User Group calls held in March, 2012, CMS further clarified what these minimum data element requirements specifically mean for ambulance services. Industry feedback has prompted CMS to create a work-around for the absence of ambulance transport locations. While CMS would prefer to receive the pick-up and drop-off location addresses in full, it is understood that this information is not always available to Provider Partners who continue to receive paper claims as billed on the CMS 1500 (HCFA) form. SCAN FED Requirements_v10.1 Page 59 of 87

60 Per CMS, when submitting 5010 encounter data, the ambulance pick-up and drop-off location fields must be populated. Where the address is unknown, CMS requires the following: If available, provide the complete address for ambulance pick-up and drop-off locations. If the complete address for ambulance pick-up and drop-off locations are unavailable: a. Provide the complete address for the Rendering Provider. b. Provide the complete address for the Billing Provider if the Rendering Provider is the same as the Billing Provider. Always populate a value of AM in PWK01 and a value of AA in PWK02 to indicate ambulance pick-up and drop-off locations are not available and the Rendering or Billing Provider information has been used instead. In short, when the complete pick-up and drop-off addresses are not available, Provider Partners can utilize the Rendering Provider street address, city, state, and zip code for the pick-up and drop-off locations. When using the Rendering address detail, the PWK01 and PWK02 segments must also be populated to indicate that a replacement address was used. See 5010 examples in section above for instructions. Loop Segment Usage Segments Example 2300 CLAIM INFORMATION PWK - CLAIM SUPPLEMENTAL INFORMATION Required when there is a paper attachment following this claim. OR Required when attachments are sent electronically (PWK02 = EL) but are transmitted in another functional group (for example, 275) rather than by paper. PWK06 is then used to identify the attached electronic documentation. The number in PWK06 is carried in the TRN of the electronic attachment. OR Required when the provider deems it necessary to identify additional information that is being held at the provider s office and is available upon request by the payer (or appropriate entity), but the information is not being submitted with the claim. Use the value of AA in PWK02 to convey this specific use of the PWK segment. If not required by this implementation guide, do not send. PWK01 - Populate AM for Ambulance Certification PWK02 - Populate AA for Available on Request at Provider Site (This means that the additional information is not being sent with the claim at this time. Instead, it is available to the payer (or appropriate entity) at their request.) PWK*AM*AA~ SCAN FED Requirements_v10.1 Page 60 of 87

61 Mammography Claims Mammography Certification Number Summary 49 Medicare compensates for film and digital mammography services only if the provider is certified by the FDA to perform the type of mammogram for which payment is sought and then only for the period for which the certification is effective. Providers should enter their FDA assigned 6-digit certification number on all claims submitted for mammography services. Likewise, the mammography number should also be included on all encounters where mammography services where performed Location Professional 50 Loop 2300 Service Line Number Segment REF - Mammography Certification Number Usage Required when mammography services are rendered by a certified mammography provider. If not required by this implementation guide, do not send. Qualifier EW Example REF*EW*T554~ UB / HCFA Location for Paper Claims On the CMS-1450 (UB-04) form, the Mammography Certification Number is not applicable. On the CMS-1500 (HCFA) form, per CMS instruction,the Mammography Certification Number is to be entered in box Additional Information To search for a provider s 6-digit FDA-assigned certification number, refer to the FDA MQSA Web page at 49 CMS, MLN Matters, 15 January 2008, Page 2, < 50 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page 192. SCAN FED Requirements_v10.1 Page 61 of 87

62 3.7 Professional Claims Clinical Laboratory Improvement Amendment Number (CLIA) Summary 51 The Centers for Medicare & Medicaid Services (CMS) regulate all laboratory testing (except research) performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments of 1988 (CLIA). The objective of the CLIA program is to ensure quality laboratory testing. CLIA requires all entities that perform even one test, including waived tests on "materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of, human beings" to meet certain Federal requirements. If an entity performs tests for these purposes, it is considered under CLIA to be a laboratory and must register with the CLIA program Location Professional 52 Loop 2300 Claim Information Segment REF - Clinical Laboratory Improvement Amendment Number Usage Required for all CLIA certified facilities performing CLIA covered laboratory services. If not required by this implementation guide, do not send. TR3 Notes If a CLIA number is indicated at the line level (Loop ID-2400) in addition to the claim level (Loop ID- 2300) that would indicate an exception to the CLIA number at the claim level for that individual line. In cases where this claim contains both in-house and outsourced laboratory services, the CLIA Number for laboratory services performed by the Billing or Rendering Provider is reported in this loop. The CLIA number for laboratory services which were outsourced is reported in Loop ID Qualifier X4 Example REF*X4*12D ~ Loop Segment Usage Qualifier Example Loop Segment Usage Qualifier Example 2400 Service Line Information REF - Clinical Laboratory Improvement Amendment Number Required for all CLIA certified facilities performing CLIA covered laboratory services and the number is different than the CLIA number reported at the claim level (Loop ID-2300). If not required by this implementation guide, do not send. X4 REF*X4*12D ~ 2400 Service Line Information REF - Referring Clinical Laboratory Improvement Amendment Number Facility Identification Required for claims for any laboratory that referred tests to another laboratory covered by the CLIA Act that is billed on this line. If not required by this implementation guide, do not send. F4 REF*F4*34D ~ 51 CLIA Information as provided by CMS Centers for Medicare and Medicaid: < 52 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Pages 197, 198, 404, 405. SCAN FED Requirements_v10.1 Page 62 of 87

63 3.7.3 UB / HCFA Location for Paper Claims On the CMS-1450 (UB-04) form, the CLIA Number is not applicable. On the CMS-1500 (HCFA) form, the CLIA Number is to be entered in box 23. See below details as taken from page 33 of the NUCC s Claim Form Manual v7. 53 Item Number 23 Title: Prior Authorization Number Instructions: Enter any of the following: prior authorization number or referral number, mammography pre-certification number (per CMS, mammography number must be in box 32 see page for reference) or Clinical Laboratory Improvement Amendments (CLIA) number, as assigned by the payer for the current service. Do not enter hyphens of spaces within the number. For Workers Compensation and Other Property & Casualty Claims: Required when prior authorization, referral, concurrent review, or voluntary certification was received, Description: The Prior Authorization Number referes to the payer assigned number authorizing service(s) Field Specifications: This field allows for the entry of 29 characters Additional Information CMS published CLIA numbers: 53 National Uniform Claim Committee, Page 33. SCAN FED Requirements_v10.1 Page 63 of 87

64 3.8 Coordination of Benefits (COB) Summary 54 The Coordination of Benefits amount fields have been reduced, in large due to the HIPAA X12 Committee determining that the HIPAA American National Standard Institute (ANSI) 837 version 4010A1 institutional and professional claims transactions contained numerous redundancies in terms of AMT segments. Most notably are the elimination of the allowed and approved amounts. While there has been a reduction in COB AMT fields in v5010, CMS acknowledges that claims and enounters must balance. Use claim adjustment segments (CAS), where applicable, to ensure proper balancing when reporting COB information. The following COB amounts have been removed on the 5010: COB Allowed Amount COB Patient Responsibility Amount COB Discount Amount COB Per Day Limit Amount COB Patient Paid Amount COB Tax Amount COB Total Claim Before Taxes Amount The follow COB amount has been added on the 5010: COB Total Non-Covered Amount The follow COB amount has remained on the 5010: COB Payer Paid Amount Note: COB monetary amounts within an AMT segment, either at the claim level or the line item level, must be a positive monetary amount. A negative monetary amount will result in the encounter being rejected Location Professional 55 Loop 2320 Other Subscriber Information Segment AMT - COB Payer Paid Amount Monetary Amount Information Usage Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency.if not required by this implementation guide, do not send. Qualifier D Example AMT*D*411 Segment AMT - COB Total Non-Covered Amount Monetary Amount Information 54 ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page D ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Page 305, 306. SCAN FED Requirements_v10.1 Page 64 of 87

65 Usage Qualifier Example Required when the destination payer s cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. A8 AMT*A8* Location Institutional 56 Loop 2320 Other Subscriber Information Segment AMT - Coordination of Benefits (COB) Payer Paid Amount Monetary Amount Information Usage Required when the claim has been adjudicated by the payer identified in Loop ID-2330B of this loop. OR Required when Loop ID-2010AC is present. In this case, the claim is a post payment recovery claim submitted by a subrogated Medicaid agency. If not required by this implementation guide, do not send. Qualifier D Example AMT*D*411 Segment Usage TR3 Notes Qualifier Example AMT - Coordination of Benefits (COB) Total Non-Covered Amount Monetary Amount Information Required when the destination payer s cost avoidance policy allows providers to bypass claim submission to the otherwise prior payer identified in Loop ID-2330B. If not required by this implementation guide, do not send. When this segment is used, the amount reported in AMT02 must equal the total claim charge amount reported in CLM02. Neither the prior payer paid AMT, nor any CAS segments are used as this claim has not been adjudicated by this payer. A8 AMT*A8* UB / HCFA Location for Paper Claims The current CMS 1500 (HCFA) form does not contain specific fields for capturing COB information. The information must be submitted to CMS through the use of the ANSI v5010 format Additional Information Additional information on COB guidelines from CMS can be found in their Coordination of Benefits Agreement (COBA) Companion Guide for Health Insurance Portability and Accountability Act (HIPAA) 837 Institutional and Professional Medicare Coordination of Benefits Version 5010 (COB)/Crossover Claim Transactions. COB Companion Guide located at: 56 ASC X12 Insurance Subcommittee, Health Care Claim: Institutional (837), Page 364, 366. SCAN FED Requirements_v10.1 Page 65 of 87

66 SCAN FED Requirements_v10.1 Page 66 of 87

67 3.9 Present on Admission Indicator Summary To group diagnoses into the proper diagnosis-related group (DRG), CMS must capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. The POA indicator is required on Institutional files submitted for inpatient encounters. POA is defined by CMS as the diagnosis being present at the time the order for inpatient admission occurs. Further, conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are also considered POA.. The POA Indicatorhas been added to the Diagnosis Information (HI) segments within the v5010 Institutional Technical Report Type 3 (TR3) Location Institutional 58 The POA Indicator is a field present in all HI segments within the 2300 loop. Below is the information related to the first location the principle diagnosis. For more information on the remaining locations, please reference the ASC X12 v5010 Implementation Guide for 837I. Loop Segment Usage Data Element: HI01-9 Semantic Condition 2300 Claim Information HI - Principle Diagnosis Required to indicate a POA HI01-9 Yes/No Condition for Present on Admission C is used to identify the diagnosis onset as it relates to the diagnosis reported in C A Y indicates that the onset occurred prior to admission to the hospital; an N indicates that the onset did NOT occur prior to admission to the hospital; a U indicates that it is unknown whether the onset occurred prior to admission to the hospital or not UB / HCFA Location for Paper Claims On the CMS-1450 (UB-04) form, the Present on Admission Indicators are to be entered in FL67 and FL67a FL67g. Below is a screen shot of pages of CMS Medicare Claims Processing Manual, Chapter ASC X12 Insurance Subcommittee, Health Care Claim: Institutional (837), Pages 187 and E CMS, Medicare Claims Processing Manual, Pages SCAN FED Requirements_v10.1 Page 67 of 87

68 3.10 Diagnosis Code Pointers Summary The Diagnosis Pointer refers to the line number from the diagnosis (box 21) that relates to the reason the service(s) was performed. SCAN FED Requirements_v10.1 Page 68 of 87

69 As explained during the March 7, 2012 CMS Full Encounter Data - Provider Partner Transition Update Webinar, the CMS requirement is that each service line must have at least one diagnosis code pointer. Each diagnosis code does not need to be pointed to by a procedure. The procedure has to have at least one reason why it was performed, and thus needs to point to a diagnosis. Each procedure line has a maximum allotment of four diagnosis code pointers, so there are up to four reasons to explain the why of a procedure being performed. Only one reason, diagnosis code pointer, is required. This is a standard billing rule. Additionally, the WPC ASC X12N/005010X P TECHNICAL REPORT TYPE 3 requires only one diagnose code pointer. The remaining three pointers are situational. CMS Encounter Data Companion Guide makes no additional references to Diagnosis Code Pointers. Please refer to the latest published CMS Encounter Data Companion Guide published as of March 2012: $FIle/Feb_Release_EDCompanionGuide_837P_ pdf Locations Professional 60 : Loop 2400 Service Line Number Segment Usage Semantic TR3 Notes Example 1 SV107 1 Composite Diagnosis Code Pointer Required: A pointer to the diagnosis code in the order of importance to this service. Required to specify the service line item detail for a health care professional. Identifies the primary diagnosis code for this service line. This first pointer designates the primary diagnosis for this service line. Remaining diagnosis pointers indicate declining level of importance to service line. Acceptable values are 1 through 12, and correspond to Composite Data Elements 01 through 12 in the Health Care Diagnosis Code HI segment in the Claim Loop ID SV1*HC:99211:25*12.25*UN*1*11**1:2:3**Y~ UB / HCFA Location for Paper Claims On the CMS-1500 (HCFA) form, the Diagnosis Pointers are entered in box 24E ASC X12 Insurance Subcommittee, Health Care Claim: Professional (837), Pages National Uniform Claim Committee, 1500 Health Insurance Claim Form Reference Instruction Manual For Form Version 08/05, Version /11, July 2011, Page 39, < SCAN FED Requirements_v10.1 Page 69 of 87

70 3.11 New Requirements For Home Health (HH) and Skilled Nursing Facilities (SNF) Effective July 2013 dates of service and later, CMS will only accept Institutional Home Health encounters, as indicated in the slide below 62 : 62 CMS, "Encounter Data System User Group", Jan_24_2013_User_Group_Presentation_cameraready_ pdf, 24 Jan 2013, Slide 30. SCAN FED Requirements_v10.1 Page 70 of 87

71 Similarly, effective as of July 2013, MAOs and other entities are required to include HIPPS codes for SNF and HH encounter submissions. As a result, SNF Encounters must be submitted as Institutional encounters 63 : 63 CMS, "Encounter Data System User Group", November_15_2012_User_Group_Presentation pdf.pdf, 15 Nov 2012, Slide 28. SCAN FED Requirements_v10.1 Page 71 of 87

72 4 SCAN AND CMS ENCOUNTER REJECTIONS 4.1 Overview of Encounter Data Rejects It is SCAN s expectation with the implementation of FED, that the rejection rate of encounter data will increase in 2012, in part due to: (1) Volume of data elements now required using the ANSI 837 v5010 format (2) Encounters now subject to modified CMS Fee-For-Service edits. (Refer to section 2.10 Edits Applied Against 5010 Encounter Data for more information from CMS on FFS edits.) SCAN Recommendation provided during 11/16/2011 Webinar CMS Full Encounter Data - Provider Partner Transition Update : Providers should submit encounter data at least on a weekly basis to the clearinghouses to reduce any potential for backlogs of rejections that need to be worked and resubmitted. FAQ Q. What if a medical group can perform edits and corrections before encounters are sent to the clearinghouse? 64 A. Providers should perform edits and corrections before encounters are sent to the clearinghouse. Front end and data quality edits a medical group can perform in their system before sending encounter data to SCAN, will greatly reduce rejections from SCAN and CMS. This will reduce the volume of rejects returned to the Medical Group for remediation and of course the turnaround time for accomplishing timely encounter submissions at CMS. SCAN strongly recommends that the Medical Groups include as much CMS-acceptance-associated edits as possible during and after their transition to the 5010 format. Q. How will SCAN inform IPA/Medical Groups of encounter data rejects? 65 A. SCAN will use our existing Provider Portal for advising groups and providers of rejections. The Portal will be opened up to all SCAN s capitated providers for direct remediation of encounter rejections. SCAN may also produce other reports (like the currently in-use CMS Rejection report) in an Excel format which providers can use to send corrections back to SCAN. 64 SCAN, SCAN Full Encounter Data FAQs, Page SCAN, SCAN Full Encounter Data FAQs, Page 6. SCAN FED Requirements_v10.1 Page 72 of 87

73 4.2 Increase In Encounter Rejections Explained A rise in encounter rejections is expected as the data elements found in the ANSI 837 v5010 EDI Transaction set, required for use with the CMS Encounter Data Processing System (EDPS) in 2012, far exceed the data fields previously used by the CMS Risk Adjustment Processing System (RAPS). The sheer volume of data alone is enough to widen the margin for error. Add to that the complexities behind the fee-for-service (FFS) edits that the encounter data will be subjected to (as currently done for claims) and it is easy to expect a greater opportunity for errors, exceptions, and rejections. At a Glance RAPS Risk Adjustment Processing System Data Requirements o Health Insurance Claim (HIC) Number o ICD-9-CM Diagnosis Codes o Service from Date o Service through Date o Provider Type EDPS Encounter Data Processing System Data Requirements o Must be ANSI 837 v5010 compliant o Over a hundred fields per each encounter 5010 New Requirements CMS Rejection Reason Examples Referring/Ordering Provider Name and NPI Required Bill Provider Address 9-Digit zip code Ambulance Pick-up and Drop-off Locations Mammography Certification Number Clinical Laboratory Improvement Amendment Number (CLIA) - Professional Present on Admission Indicator (POA) - Institutional Diagnosis Code Pointers Procedure Modifiers Coordination of Benefits (COB) Billed, Paid Amounts, and Non Covered Amounts "CSCC A7: ""Acknowledgement /Rejected for Invalid Information ""CSC 562: ""Entity's National Provider Identifier (NPI)""EIC: DN Referring Provider" "CSCC A7: ""Acknowledgement/Rejected for Invalid Information ""CSC 500: ""Entity's Postal/Zip Code"" 2010AA.N403 must be a valid 9 digit zip code. " "CSCC A7: ""Acknowledgement /Rejected for Invalid Information ""CSC 503: ""Entity's Street address" CSC 266""Facility point of origin and destination - ambulance" "CSCC A7: ""Acknowledgement /Rejected for Invalid Information ""2300.REF02 must be a valid Mammography Certification Number." "CSCC A7: ""Acknowledgement /Rejected for Invalid Information ""CSC 544: ""Clinical Laboratory Improvement Amendment" CSCC A7: ""Acknowledgement /Rejected for Invalid Information ""IK403 = 7: ""Invalid Code Value" "CSCC A3: ""Acknowledgement /Returned as unprocessable claim""csc 477:""Diagnosis code pointer is missing or invalid" "CSCC A7: ""Acknowledgement /Rejected for Invalid Information ""CSC 453: ""Procedure Code Modifier(s) for Service(s) Rendered" "CSCC A7: "Acknowledgement /Rejected for Invalid Information "CSC 672: "Other Payer's payment information is out of balance"" 2320 AMT02 must = the sum of all 2430.SVD02 payer paid amounts.. minus the sum of all claim level adjustments (2320 CAS adjustment amounts) for the same payer." SCAN FED Requirements_v10.1 Page 73 of 87

74 4.2.1 What is a Rejection? Often times rejected claims are confused for being denied claims. Fortunately, there are industry definitions that will explain the differences between a rejected and a denied claim. A rejected claim is one that does not pass syntax/format edits in the front-end EDI intake. In-otherwords, a rejection is a non-clean-claim. Once a claim passes front-end EDI syntax/format edits, it is clean to pass to the adjudication system. A denied claim is one that has passed front-end EDI syntax/format edits and has made it into the adjudication system, in other words a clean claim, however, was denied payment. CMS Definitions 66 : o o o Rejected Claim: a claim that is rejected due to technical errors, including missing or erroneous required data elements. These claims are not processed and do not generate a Remittance Advice (RA). Denial: the nonpayment of a processed claim for an identified coverage or medical necessity reason. Clean Claim: a claim that does not require Medicare Contractors (Fiscal Intermediaries [FIs], Regional Home Health Intermediaries [RHHIs], Carriers, Part A/B Medicare Administrative Contractors [MACs] or Durable Medical Equipment Medicare Administrative Contractors [DME MACs]) to investigate or develop them outside of their Medicare operations on a prepayment basis. Clean Claim Examples 67 : Pass all edits (contractor and Common Working File (CWF)) and are processed electronically) Have all basic information necessary to adjudicate the claim, and all required supporting documentation Do not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) 66 Understanding Remittance Advice - A Guide for Medicare Providers, Physicians, Suppliers, and Billers, < 67 Medicare Claims Processing Manual - Chapter 1 - General Billing Requirements, < SCAN FED Requirements_v10.1 Page 74 of 87

75 4.2.2 What Encounters Should Be Submitted? CMS requires encounters to be submitted for all finalized claims that have adjudicated in the MAO or other organization s claims processing system. In a capitated arrangement this is still considered a finalized claim. o Submit Adjudicated paid & denied claims (for contractual/payment reasons) o Do Not Submit Rejected claims (bad/incomplete data) Pending claims (not yet paid) When submitting encounters, it is very important to include the AMT segment in Loop 2320 when Loop 2430 is present. Failing to include the AMT segment will result in a 999 rejection from CMS, per the slide below 68 : Rejections Areas of Importance Timely Filing Rejection handling is essential for ensuring timely filing of encounter data. CMS requires that all encounters are submitted within 13 months from the date-of-service. To meet this requirement, 68 CMS, "Encounter Data System User Group", November_29_2012_User_Group_Presentation pdf.pdf, 29 Nov 2012, Slide 14 SCAN FED Requirements_v10.1 Page 75 of 87

76 SCAN encourages all Provider Partners to submit their encounter data as soon as possible, but no later than 12 months from date-of-service to allow ample time to work potential rejections and resubmit. Encounter Submission Rate To reduce the number of rejections incurred at one time and the amount staff hours\days necessary to correct and resubmit, SCAN recommends that our Provider Partners submit encounter data to their clearinghouse on a weekly basis. Rejection Handling SCAN suggests that all Provider Partners carefully review and work their encounter rejections on a weekly basis, at minimum. It is important to understand where your rejections have occurred and the process to remediate. There are three points at which your SCAN encounter data can be rejected: at the clearinghouse, SCAN, or CMS. The point in which an encounter may be rejected is determined by the amount of edits in place by each processing center. o o o Clearinghouse Rejections: Encounters that reject at the clearinghouse are not sent to SCAN. Provider Partners are responsible for working with their clearinghouse to resolve rejections and resubmit SCAN Rejections: Encounters rejected at SCAN are not submitted to CMS Provider Partners are responsible for working with SCAN to resolve and resubmit Rejections are reported under Encounters on the Provider Portal CMS Rejections: Rejections on encounters sent by SCAN to CMS are reported via the SCAN Provider Portal Rejections are not reported to the Provider Partner directly from CMS Provider Partners are responsible for working with SCAN and CMS to resolve and resubmit SCAN FED Requirements_v10.1 Page 76 of 87

77 4.3 Accessing the SCAN Provider Portal Each Provider Partner has been given access to the SCAN Provider Portal and assigned an internal portal administrator. The portal administer is equipped to add new users to the Provider Partners account. If the portal administer is unknown or not available, please contact our Provider Portal Help Desk at: (888) for assistance with access. 1. SCAN Provider Portal: (The SCAN Provider Portal requires Internet Explorer 6.0 or higher.) 2. Provider Portal Guide The Provider Portal Guide contains detailed instructions on how to navigate through and utilize the encounter data features. Please refer to the latest publication of the Provider Portal User Guide on the Provider Portal under Portal Guide Negative Amounts in Encounter Data Recent encounter data testing with CMS has shown that CMS will not accept negative numbers in any segments aside from CAS segments (adjustment amounts). Negative number values contained in the below noted segments will result in encounter rejections from CMS. Therefore, encounters sent to SCAN with negative amounts in these identified fields will be rejected up-front, not passed to CMS, and posted to the SCAN Encounter Data Portal for correction. Please refrain from sending negative numbers in all fields listed below. 837 Professional Segments Loop Segment Element 2300 CLM AMT AMT SV SV SV SV SV AMT SVD SVD AMT Institutional Segments Loop Segment Element 2300 CLM AMT AMT SV SV AMT SVD SVD AMT Provider Portal Guide, < SCAN FED Requirements_v10.1 Page 77 of 87

78 5 SUBMISSION OF SUPPLEMENTAL ENCOUNTER DATA 5.1 Summary Medicare Advantage Organizations (MAOs) are subject to the CMS Risk Adjustment Model; a model designed for adjusting capitation payments by CMS to MAOs, either higher or lower, in response to previously predicted and paid health insurance costs. This model relies heavily on diagnosis code data for the proper evaluation and allotment of funds necessary to care for each Medicare patient. It is imperative that all diagnosis code data is submitted to SCAN. Due to various limitations, not all providers have the ability to electronically submit all diagnosis code data within one encounter transaction. SCAN has incorporated additional methods by which the providers can ensure that all diagnosis data is being sent to SCAN, as detailed below. 5.2 Direct Submission In 5010, SCAN will continue to allow Provider Partners to submit supplemental encounter data directly through the SCAN Encounter Data Portal or by encrypted . SCAN currently uses a modified ICE format for these submissions. Bear-in-mind that the direct submission format is intended to be used for sending supplemental data (ie. additional diagnosis codes, deletion of codes, etc.) for encounters already processed through the clearinghouse in the 837 v5010 format. Original\new encounter data should not be sent via Direct Submission to SCAN. 1. ICE Format- the following data is required to be identical to the original encounter to ensure roll-up of all diagnosis data into the appropriate visit: o o o o o Member ID Start DOS End DOS Rendering Provider NPI Procedure Codes (all procedure codes from the original encounter must be submitted) For additional information regarding Direct Submission enrollment, implementation, and specifications, please contact SCAN at: Encounters@scanhealthplan.com. SCAN FED Requirements_v10.1 Page 78 of 87

79 5.3 Clearinghouse Submission When necessary to submit diagnosis codes in excess of twelve per Professional encounter and twentyfive per Institutional encounter, Provider Partners may elect to submit the additional DX codes via the following clearinghouse methods: Multiple v5010 encounters (duplicate of entire encounter, with the exception of the DX Codes) Multiple iterations of the 2300 Loop (includes service loop) with one singular encounter in the v5010 format 1. Multiple v5010 encounters The following data is required to be identical to the original encounter to ensure roll-up of all diagnosis data into the appropriate visit: o o o o o Member ID Start DOS End DOS Rendering Provider NPI Procedure Code multiple 2300 Loops - same requirements as above, plus: o o Use the same PCN (CLM01 segment, 2300 Loop) Keep service line (2400 Loop) order between the 1st and 2nd iterations of the encounter the same. - 2 nd Iteration of the 2300 Loop should differ only in diagnosis codes Example: HL*1**20*1~ NM1*85*1*PAN*PETER*B***XX* ~ N3*1700 NORTH SHORE AVE*SUITE 7~ N4*NEVERLAND*CA* ~ REF*EI* ~ HL*4*1*22*0~ SBR*P*18**NEVERLAND HEALTH*****MB~ NM1*IL*1*HOOK*CAPTAIN****MI* ~ N3*100 W PACIFIC**~ N4*NEVERLAND*CA*99999~ DMG*D8* *M~ NM1*PR*2*SCAN HEALTHPLAN*****PI*018~ CLM* *326***11:B:1*Y*A*Y*Y*P~ HI*BK:25040*BF:5853*BF:25070*BF:44381*BF:25060*BF:3572*BF:25050*BF:36201*BF :40211*BF:4139*BF:41400*BF:42832~ LX*1~ SV1*HC:99215*250*UN*1***1:2:3:4~ DTP*472*RD8* ~ LX*2~ SV1*HC:94010*76*UN*1***1:2:3:4~ SCAN FED Requirements_v10.1 Page 79 of 87

80 DTP*472*RD8* ~ HL*5*1*22*0~ SBR*P*18** NEVERLAND HEALTH*****MB~ NM1*IL*1*HOOK*CAPTAIN****MI* ~ N3*100 W PACIFIC**~ N4*NEVERLAND*CA*99999~ DMG*D8* *M~ NM1*PR*2*SCAN HEALTHPLAN*****PI*018~ CLM* *326***11:B:1*Y*A*Y*Y*P~ HI*BK:29632*BF:30401*BF:5990*BF:44021*BF:72400*BF:V700*BF:49320*BF:33183~ LX*1~ SV1*HC:99215*250*UN*1***1:2:3:4~ DTP*472*RD8* ~ LX*2~ SV1*HC:94010*76*UN*1***1:2:3:4~ DTP*472*RD8* ~ SE*68*5022~ GE*1*5022~ IEA*1* ~ Notes: o o o SCAN will not reject multiple encounters for the same visit with differing diagnosis data as duplicates. The clearinghouses (TransUnion and Office Ally) have confirmed this as well. Multiple encounters are seen as encounters sent in differing files, with differing PCNs, and\or full encounters (SE to ST) instances in the same file. Multiple iterations of the 2300 Loop encounters are seen as a repeat of an encounter from the subscriber detail to the end of the service line where only the diagnosis code data differs from the first iteration of the encounter detail. 5.4 Important Information Sending Multiple Encounters Per Visit During ongoing analysis of previously processed encounter data, it was discovered that encounter service lines are not consistently containing all of the procedure codes when the encounter is submitted multiple times. Research uncovered that a percentage of the last encounter transactions contained only one procedure code while previous iterations of the encounter transactions contained more than one procedure code. Unlike diagnosis code data, procedure codes cannot be accumulated and rolled up into the final encounter/visit due to amount fields and other pointers within the 837 v5010 file. Therefore, in order to ensure all services are sent to CMS, it is important that all procedure codes are submitted on every corrected/revised encounter and not just the original encounter. For example, if procedure codes 1 and 2 are performed during a visit, then both of these procedure codes must be included on this encounter record each time the encounter is submitted to the clearinghouse. SCAN FED Requirements_v10.1 Page 80 of 87

81 6 SCAN ENCOUNTER DATA BUSINESS RULES 6.1 Summary SCAN has its own distinct business rules for processing ANSI 837 v5010 encounter data. Not all v5010 compliant data is used by SCAN or able to be processed. Where data cannot be processed, in most cases SCAN has worked with its clearinghouses to reformat the data as necessary prior to being sent to us (example. Patient Loops are not accepted by SCAN see below). However, as we continue with Full Encounter Data, there may be instances where our Providers will need to conform to specific SCAN business rules; these will be communicated. 6.2 Encounter Data Note (NTE) Segments Encounter data note (NTE) segments for both professional and institutional encounters at the claim and service level are not utilized by SCAN; these segments are stored as information only. While it is not necessary to submit these segments to SCAN, the presence of NTE segments will not negatively impact the processing your encounter data. Please be aware that NTE segments should not be used to substantiate medical treatment that is supported elsewhere within the v5010 claim data set. For example, the National Drug Code (NDC) should not be reported in a NTE segment; the NDC should be reported in the Drug Identification Loop (2410) within the LIN Segment. 6.3 Patient Loops are not accepted by SCAN - All Patients are Subscribers. Scan does not accept the usage of Patient Loops 2000C and 2010CA in encounter data. All SCAN members are considered subscribers as each SCAN member has their own unique member ID. Encounters must contain the member (your patient) detail within the Subscriber Loops 2000B and 2010BA for both Professional and Institutional encounters. In the event an encounter is sent with both Subscriber and Patient Loops and the patient, the clearinghouses will reject the encounter for invalid patient information. Encounters rejected at the clearinghouse are not submitted to SCAN. Provider Partners are responsible for reviewing clearinghouse rejections; correcting encounters and resubmitting. Example - Subscriber Loops Loop 2000B HL*2*1*22*0~ SBR*P*18**SCAN ENCOUNTERS*****HM~ Loop 2010BA NM1*IL*1*HELEN*TROY*O***MI* ~ N3*150 ATLANTIC AVE~ N4*ATLANTIS*CA* ~ DMG*D8* *F~ SCAN FED Requirements_v10.1 Page 81 of 87

82 7 CONTACT INFORMATION Please direct Full Encounter Data questions to the appropriate contacts below. Contact Name Role Telephone Marc Carren Director, Informatics and Data Interchange (562) Charlene Beecher Manager, EDI Electronic Data Interchange (562) Jahayra Barranco Manager, Encounter Data (562) Steve Vo Sr. Encounter Data Specialist (562) AJ Bautista EDI Analyst (562) SCAN FED Requirements_v10.1 Page 82 of 87

83 8 APPENDIX 8.1 Data Mining Findings of Encounter Data Received in 2011 SCAN has been performing analysis and research of RAPS encounter data received in 2011 to assist in forecasting where potential issues/rejections may arise with the implementation of Full Encounter Data in While the issues identified in this section were not areas of concern with RAPS submissions, going forward with the implementation of CMS Full Encounter Data for 2012 dates of service, these items must be addressed to ensure proper processing of encounter data at CMS. All of the items uncovered during the data mining efforts have been specifically addressed throughout this document with the exception of the last item regarding modifiers on anesthesia encounters (which warranted an informational communication via to all Provider Partners at the end of March 2012). Much of the information explained in this section has previously been shared with Provider Partners to assist those in jeopardy of negative impact caused by missing or unacceptable data. It is also purposed here to aid in preparing for Full Encounter Data mandates. Summary of data mining findings. NPI is not received on the Rendering and/or Billing Provider records as the primary identification. This was acceptable for RAPS submissions, however, the NPI is the required identification on each provider record with the implementation of Full Encounter Data in v5010 with 2012 dates of service. o The data mining results were shared with Provider Partners at the end of January o Please refer to section 3.2: National Provider Identification NPI for more information on NPI requirements. o Please see item number 1 in section 2.16: Top 10 FED Requirements for more information on NPI. SCAN FED Requirements_v10.1 Page 83 of 87

84 SCAN s first receipt date of an original encounter record is greater than twelve months from the end date of service on the claim. This was acceptable for RAPS submissions as long as the data was sent within the the given Sweeps period, however, CMS dictates with FED that original encounters must be received within thirteen months from the end date of service else that encounter is rejected and not eligible for risk adjustment processing. Therefore, SCAN has recommended that Provider Partners submit all encounters within 12 months of the date of service to allow one month for CMS to accept/reject the encounter, and if rejected, time to correct and resubmit. o The data mining results were shared with Provider Partners at the end of February o It was also discovered that many of the greater turn-around-times reflected in the data sets were received for the January 2012 Sweep. o Please refer to section 2.7: The 13 Months from Date of Service Requirement for more information on the CMS encounter timeliness requirement. Billed Amount is $0.00 or blank on Institutional encounters that have a final bill type. While this was acceptable for RAPS submissions because dollar amounts were not required, moving forward this is no longer the case. Balanced dollar amounts are required by CMS in o Data mining results regarding this topic were not specifically shared with Provider Partners as dollar amounts and balancing requirements have been communicated during Webinars at length. o Please refer to sections 2.12: Dollar Amounts are Required and Must Balance in v5010 Full Encounter Data and 2.13: Capitated Encounters in v5010 Full Encounter Data for more information on the CMS dollar amounts, balancing requirements, and capitated encounter requirements. o Please see item number 5 in section 2.16: Top 10 FED Requirements for more information on dollar amounts. The submitted Rendering or Billing Provider s name is different than the NPPES provider name matching on the NPI. This was acceptable for RAPS submissions as provider names were not required, but once CMS receives a complete 837 v5010 format for FED, it will be important that the provider information is accurate. For example, do not assign a group NPI to an individual provider name or vice versa as this causes a conflict between the provider name and the provider NPI, resulting in issues either at SCAN or CMS. o The data mining results were shared with select Provider Patners at the end of March This has also been communicated during Webinars at length. o Please see item numbers 1, 3, and specifically 4 in section 2.16: Top 10 FED Requirements for more information on provider data elements. SCAN FED Requirements_v10.1 Page 84 of 87

85 Missing or unacceptable modifiers received on anesthesia encounters. This was acceptable for RAPS submissions as modifiers were not a required data field, but CMS mandates with FED that a modifier is present to show who performed the service. o A blanket informational communication was shared with all Provider Partners at the end of March Below is a copy of this communication: Hello Valued Provider Partners During ongoing analysis of previously processed encounter data, it was discovered that many Anesthesia encounters are being submitted either without a procedure modifier or without an acceptable modifier. The CMS EDPPPS (Encounter Data Professional Processing and Pricing System) has been set to reject Anesthesia encounters without modifiers that indicate who did the service. Therefore, we would like to communicate, to all of our Provider Partners, the acceptable modifiers to avoid such rejections moving forward with 2012 date of service Full Encounter Data. Anesthesia encounters for 2012 dates of service received without one of the below noted modifiers indicating who performed the service will be rejected at CMS. Valid anesthesia modifiers. One of the following must be contained on the claim/encounter: AA (Anesthesia Services performed personally by the anesthesiologist) AD (Medical Supervision by a physician; more than 4 concurrent anesthesia procedures) QK (Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals) QX (CRNA service; with medical direction by a physician) QY (Medical direction of one certified registered nurse anesthetist by an anesthesiologist) The following three additional modifiers can also be used, but must be used in conjunction with one of the above modifiers: QS (Monitored anesthesia care service) G8 (Monitored anesthesia care (MAC) for deep complex complicated, or markedly invasive surgical procedures) G9 (Monitored anesthesia care for patient who has a history of severe cardio-pulmonary condition) If you have any questions or concerns, please do not hesitate to contact us at the CMSFED@scanhealthplan.com inbox. Thank you, SCAN Encounter Data Team SCAN FED Requirements_v10.1 Page 85 of 87

86 8.2 References Below is a listing of websites and documents for your reference. (These are also found throughout the footnotes.) 1. SCAN Provider Tools Full Encounter Data Website: 2. SCAN 837 Institutional and Professional Companion Guides: Available for download on the Provider Tools FED Website (link above). 3. SCAN Full Encounter Data FAQs: 4. CMS 2011 FED Technical Assistance EDI Participant Guide: CMS FED EDI Slides Camera Ready (FED Business Requirements) 9/13/2011: EDSlides_camerarea dy_ zip 6. CMS HIPAA Version 5010 X12 Regulations and Guidance Website: 7. CMS s Encounter Data Companion Guides: on%20guides?open&cat=cssc~encounter%20data~eds%20companion%20guides SCAN FED Requirements_v10.1 Page 86 of 87