Copyright 2009, National Academy of Ambulance Coding Unauthorized copying/distribution is strictly prohibited

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1 Your instructor Claims Submission Formats / Issues National Academy of Ambulance Coding Steve Johnson Executive Director National Academy of Ambulance Coding Over 20 years experience in the EMS industry Served as EMT, and later as Director of a Municipal Ambulance Service Established and served as Training Coordinator and Lead Instructor for a State Certified EMS Training Institution Served as Training Coordinator, Instructor and Consultant for a large national EMS Billing software company Served as Director of a national EMS Billing Service Contact: NAAC s.johnson@ambulancecoding.com Disclaimer This information is presented for educational purposes only. This educational program does not constitute legal or consulting advice, and should not be relied upon as such. Nothing in this program is intended to provide specific instructions on the coding or submission of any particular claim for payment or reimbursement by any payor, public or private. User agrees to release NAAC and its employees, contractors, agents, officers and directors from any and all liability, including but not limited to liability arising out of any billing and/or coding decisions. By enrolling in the National Academy of Ambulance Coding and/or taking or completing any courses and/or lessons from NAAC, and/or obtaining certification as a Certified Ambulance Coder, the user agrees to these terms and conditions. All materials are Copyright, National Academy of Ambulance Coding. Any distribution of these materials in any form - electronic, video graphic, photographic, audio, digital, and/or paper or any other form - is prohibited without the express written permission of the National Academy of Ambulance Coding. Registered enrollees may print these materials and/or save an electronic copy, for their own use in completing their Certified Ambulance Coder course work. Lesson Objectives Upon completion of this lesson, the Certified Ambulance Coder (CAC) candidate will be able to: Define National Provider Identifier Describe paper claim submission requirements Compare requirements and benefits of electronic claim submission to paper claim submission Explain the HIPAA Transaction and Code Sets (TCS) requirements Key Terms National Provider Identifier (NPI) NPI National Provider Identifier TCS Transaction & Code Sets EDI Electronic Data Interchange ERA Electronic Remittance Advice EFT Electronic Funds Transfer HIPAA Health Insurance Portability and Accountability Act Issued by the NPI Enumerator National Plan & Provider Enumeration System (NPPES) Page 1

2 Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT) Electronic Deposit of your payment to your Bank Account No paper check If you enroll in Medicare, as a new provider / supplier, you will be required to submit a CMS-588 (EFT Authorization) form, along with your CMS-855B (enrollment) form All payments will be made via EFT Electronic Funds Transfer (EFT) If you are already enrolled in Medicare and are not receiving Medicare payments via EFT, any change to your enrollment information will require you to submit a CMS-588 form All future payments will then be made via EFT Paper Claim Submission CMS-1500 Form Same piece of paper, but requirements vary by payor type Example Box 23 Medicare requires Zip Code of point of pickup Some Medicaid programs require Prior Auth # Some commercial insurers may not require anything Page 2

3 CMS 1500 Claim Form (1 13) CMS 1500 Claim Form (14 33) Name and Address of Payor Medical Necessity Narrative Patient s Medicare Number Condition Code(s) Patient s Name Second Condition Code Zip Code of Pickup Location Patient s Address Patient City ST A0426 NH GA Your NPI Pt Zip Code A0425 NH GA 1, Your NPI SAME NONE MEDIGAP Policy/Group Number Insurance Address, City, Zip 9 Digit PAYORID of Medigap Insurer MCD ############# Signature On File Signature Date Signature On File Federal Tax ID Your Call # Your Payment Mailing Address Pickup & Drop-Off Info fàxäxç `A ]É{ÇáÉÇ 3/17/2009 Your NPI Paper Claim Advantages/Uses Payors who require attachments in order to properly process ambulance claims Appeals Electronic Claim Submission HIPAA Mandated Standards Privacy & Security Administrative Simplification Electronic Data Transmission Transactions Code Sets Identifiers Data Protection Security Privacy Privacy Defines rights of individuals and responsibilities of providers, health plans Security Defines process and technology standards for electronic protected health information Covered in detail in Lesson 5C Page 3

4 Transaction & Code Sets - TCS Mandates Standard transaction formats Standard codes Unique Identifiers Providers have one ID number for all Payors TCS Rule According to the HIPAA Transactions and Code Sets (TCS) rule, all electronic claims must be in a HIPAA standard format Any entity that wishes to transmit electronic claims files must sign a Trading Partner Agreement and be certified to submit in the HIPAA standard format All HCPCS codes, diagnosis/condition codes, and modifiers must be national standard codes Taxonomy Codes What is EDI? Ambulance 3416A Air Transport 3416L Land Transport 3416S Water Transport Non-emergency Medical Transport (Van) Electronic Data Interchange Standardized electronic exchange of data between computers Way of arranging data so a computer can read it No human intervention Transact business quickly, and cost effectively EDI Required Small Provider/Supplier Exception Since October 16, 2003 Exceptions Provider < 25 FTE Supplier < 10 FTE There is no waiver for which to apply if you believe your organization meets the small provider/supplier exception, however You must retain documentation of meeting this exception Even if you do qualify for this small provider / supplier exception, electronic claim submission has advantages Page 4

5 Benefits of Electronic Claims Most software pre-edits claims to reduce common errors in claims data entry Reduces operating costs Decreases unnecessary denials Eliminates need to re-file previous claims Increases staff productivity Faster feedback on improperly completed claims helps eliminate repeat errors Benefits of Electronic Claims Improves cash flow Faster submission of accurate claims Results in faster payment Reducing receivables Faster Claims Payment Benefits of Electronic Claims Eliminate mail transit time Eliminate time for entry by payor Eliminate data entry errors by payor Medicare Payment Floor By law Medicare cannot pay paper claims until 28 days after receipt By law Medicare can pay electronic claims 14 days after receipt Provides immediate acknowledgement of claims receipt Eliminates the cost of forms, envelopes and postage Eliminates the labor to process bills Eliminates the cost of storing paper documents Submitter ID Submitter ID Identifies the entity submitting the claims Submitter may be the provider Submitter may be a Business Associate of the provider One Submitter ID may submit claims for several Provider NPIs The EDI Submitter ID and password act as an entity s electronic signature An entity s EDI Submitter ID and password is not transferable New owners must obtain their own EDI Submitter ID and password Page 5

6 Testing May Be Required Check With Your Vendor Trading partners can upload test files to the payor and receive nearly immediate feedback on their files Once a file has been submitted and passes the validation criteria, the trading partner will be certified to begin submitting actual live claims (837 transactions) Possible Blanket Approval (No Test Vendor) Vendor has gone through testing/approval process with the Carrier/Intermediary/MAC Eliminates need for testing on your part Approval Prior to Claims Submission Any HIPAA transaction submitted by an entity that does not have a signed trading partner agreement and has not been certified for the transaction may be rejected Standard Code Sets Standard Code Sets Medical code sets Non-medical sets Medical Code Sets Include ICD-9 CM ICD-10 CM CPT-4 HCPCS Page 6

7 Non-Medical Code Sets Include Free Software Gender Postal (Zip) codes Race Claims Status Place of Service Languages Type of Service Claim adjustment reason codes Remittance remark codes Free/low cost HIPAA-compliant software available from Medicare contractors for providers and suppliers to submit Medicare claims electronically Free PC-print software for electronic Medicare remittance advice (835) transactions Free Software Medicare free software can generally not be used for other payors For other HIPAA transactions, providers are expected to obtain their own software Some vendors also offer the use of their software, online, for a monthly fee Clearinghouses Standard Transactions Common Electronic Transactions 837 Claims 835 Remittance Advice (Payment) 276 Claim Status Request 277 Claim Status Response 270 Eligibility Request 271 Eligibility Response TA1 Interchange Acknowledgement 997 Functional Acknowledgement Batch vs. Real-Time Transaction Batch: Grouped together in large quantities and processed en-masse No continuous connection Payors may choose to reject an entire batch or just a single claim Not dictated by HIPAA Payor s business decision Page 7

8 Batch vs. Real-Time Transaction 3 Versions of 837 Real Time: Requires an immediate response Submitter remains connected awaiting response I Institutional P Professional Ambulance D - Dental Understand ISA*00* *00* **ZZ* *ZZ*WHY INC *020524*1718*U*00401* *0*T:~ GS*HC* *WHY INC* *1615*1** ~ ST*837*0001~ BHT*0019*00*0001* *1645*CH~ REF*87* ~ MN1*41*2*MARY SMITH CLEARINGHOUSE*****46* ~ PER*IC*MARY SMITH*TE* *F* *ED* ~ NM!*40*2*MEDICARE PART B*****46* WHY INC~ HL*1*20*1~ What the Payor s MNI*85*2*EYEBALL SURGERY ASSOCIATES*****24* ~ N3*PO BO 1234~ N$*SALISBURY*MO* *US~ computer sees REF*1C*09876~ PER*1C*BILLING PROVIDER CONTACT OFFICE NURSE*TE* *F* TE* ~ during an 837 HL*2*1*22*0~ SBR*P*18**MEDICARE PART B*****MB~ Transaction NM!*IL*1*BENNING*CARRIE****MI* A~ N3*PO BO 123~ N4*NEOMA*MO*67799*US~ DMB*D8* *M~ MN1*PR*2*MEDICARE PART B*****PI*00065~ N3*1000 MAIN ST~ N$*ST LOUIS*MO*66666*US~ CLM*MEDBGOOD-MIS1*1500***11::1*Y*C*Y*Y*B******P~ RE*4*32D ~ NTE*ADD*CLAIM NOTE TET~ HI*BK:3999~ NM1*DN*1*FOLLARD*BEN*J**M.D.* ~ PRV*RF*ZZ*101Y00000N~ RED*1C*B11277 NM!*82*1*TREPED*HOWARD****24* ~ PRV*PE*ZZ*101Y00000N~ RED*1C* ~ L*1 SV1*HC:99213*15000*UN*1*11**1:::**N~ DTP*472*DB* ~ RE*4*32D ~ SE*36*0001~ GE*1*1~ IEA*1* ~ Interchange Acknowledgement TA1 An Interchange Acknowledgement (TA1) is an immediate acknowledgement of the communication and receipt of transmitted files This is the first step in the reconciliation process. Interchange Acknowledgement TA1 997 Interchange Acknowledgements are not an indication that the transmitted files were accepted for processing Functional Acknowledgements (997) are used for this purpose. The 997 response transaction is the second step in the reconciliation process Functional Acknowledgements indicate whether the claims contained in the transmitted files are accepted for processing Page 8

9 997 Eligibility Inquiry 270 / 271 The 997 transaction file will detail the errors that caused a claim s rejection The 997 will also show which claims were accepted The 270/271 transactions allow providers & suppliers to inquire electronically regarding patient eligibility Claim Inquiry/Response 276/277 These transactions allow providers & suppliers to inquire electronically about claim status Summary Claim filing requires proper understanding and use of identifiers Paper claims can offer the advantage of forcing a human to look at the claim Electronic claims are much less susceptible to errors, and are almost always paid faster HIPAA TCS Rule determines the specific requirements for electronic claim transactions Claims Submission Formats / Issues National Academy of Ambulance Coding Page 9