Did you know that there is a new version of the CMS 1500 form? You need to be prepared to switch.

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1 Introduction Did you know that there is a new version of the CMS 1500 form? You need to be prepared to switch. We are now in the dual use time frame. Payers are accepting the new form (CMS /12) as well as the old form (CMS /05). By April 1, the old form will no longer be accepted. OPIE has created functionality to handle this transition in the new version of OPIE Billing that you will be receiving soon. During the transition, OPIE Billing can be configured to generate forms in either format. It is up to you to determine when you will begin submitting in the new format to a particular insurance company, or to all companies via the global default setting. We suggest that you begin the process of submitting forms in the new format as soon as possible to ensure you are ready for the April 1 deadline. The National Uniform Claim Committee has valuable information about the timeline and differences in the forms. NUCC has also provided this instruction manual for the 02/ Claim Form. The Coming Update to OPIE Billing 737 Before April 1, 2014, all OPIE Billing sites will be updated to Build 737 (Final General Release Version Number TBD). After the update, new forms and settings will appear in OPIE billing which will allow you to control which version of the 1500 form and the accompanying electronic form will be sent to each of your payers. Essentially, you will be able to set a GLOBAL default setting for your practice and then override that setting at the Existing Insurance Company level for payers who require something different. Please use these instructions as a guide to how to use and set the appropriate settings. At Update to OPIE Billing Build 737 1) New Global CMS 1500 Form Version setting: You can control the default 1500 Form Version used by all your insurance companies, under Help > Settings > General. When you receive Build 737, the default Version to Use will be set to the 08/05 (old) version of the 1500 form Support: (800) , press 3,3

2 Note: This is how your global default will be set when Build 737 is installed on your system. 2) New Insurance Companies Additional Options Setting: On the Additional Options tab of each Insurance Company (found under Insurance Companies Existing) there will be a new drop down, 1500 Form Version to Use. When you receive Build 737, this drop down will be defaulted to the [Use System Default] value option Form Version to Use must be set to [Use System Default] so that your global setting can be accessed by each insurance company. Note: the setting of the global system parameter value (1500 (08/05)) is shown below to the right of the [Use System Default] selection. 3) New 1500 Form Defaults for the 02/12 Version of the Form: Support: (800) , press 3,3

3 In the past, there were only a few global controls over the individual settings for the 1500 form in OPIE Billing. When you receive Build 737 under Help > Settings, there is a new 1500 Form tab that allows you to set global defaults for all of the individual settings for the new, 02/ form (See Page 4). IMPORTANT: These settings will only be used on new insurance companies that you create. Because most of the settings on the new 1500 form will be the same as the old form, OPIE will automatically copy all of your old settings for that insurance company. Therefore, you should not generally need to worry about the new 1500 form settings tab during the transition as long as the payer in question is not requiring something different in the new version. However, there are two things you should be aware of for the new 1500 form version. Two new settings will appear on the 02/ Form tab. They are: (17) Qualifier and (24J) Allow Custom Line-level Rendering Provider Other ID. (17) Qualifier This new parameter value has five drop down options: Blank, DN, DK, DQ and [Default]. Upon upgrade, this parameter is set to match the value selected for (17) Physician to Use. If (17) Physician to Use to set to Leave Blank then (17) Qualifier is set to Blank. If (17) Physician to Use to set to Referring Physician then (17) Qualifier is set to DN. If (17) Physician to Use to set to Primary Care Physician then (17) Qualifier is set to DK. Note: To date we have received no specific directions from NUCC on the use of the DQ setting. (24J) Allow Custom Line-level Rendering Provider Other ID This new parameter value can be set to Yes, No, or [Default]. Upon upgrade, this parameter is set to No. This parameter controls whether the Rendering Provider Other ID can be set at the line level. This functionality was added because many state Medicaid agencies are requiring line level authorization codes. Having this parameter set to yes will change on the display on the codes tab of the claim. Each service line (L-Code) will be able to be assigned a different Rendering Provider Other ID which can be the live level Authorization code for Medicaid. If a Qualifier for the data entered in 24J is required, it can be keyed into column 24i as shown below Support: (800) , press 3,3

4 When submitting a claim, each service line (L-Code) will be able to be assigned a different Rendering Provider Other ID. Note: when this parameter value is set to Yes, then on the Review and Submit (Override) form, box 24 ID Qualifier/Rendering Provider ID # (top boxes only) will be disabled. Here is a screen print of the new 1500 Form tab under Help/ Settings. when you are updated to the OPIE Billing Build 737. It shows the values that will appear by default Support: (800) , press 3,3

5 Global Setting values for the 02/ form will be used for any Insurance Company-level 1500 Form setting that is set to the [Default] value option. The global setting for (25) Tax ID to Use will be set to the Default Federal Tax ID configured in the General tab of the Billing Settings form at the time of upgrade. After Update - Changing to the New 1500 Form After you have received Build 737, you will have to decide which of your payers should be switched to getting the new version of the 1500 form (02/12). Theoretically, all payers should be ready to receive the new forms effective 4/1/2014. However, you may want to switch some of your payers to the new format early so that there will be some time to make sure that there are no issues between you and that payer. Our Recommendation: On April 1 st, switch the global setting under Help > Settings > General to the 1500 (02/12) setting as shown here. If you have made no changes to the insurance company-level setting for the 1500 Form Version, then changing the global Support: (800) , press 3,3

6 default setting in Billing Settings will result in all insurance companies being set to the new version. Then you can proceed to send out your claims in the new format and deal with any problems with payers which may not be ready to handle the new formats, as they may occur. Based upon the limited information that we have gotten on the subject of payer readiness, it would be good for you to call state Medicaid agencies first to see if they will be ready. REMEMBER: When you change the 1500 form setting to 1500 (02/12) on April 1 st, both your 1500 forms and your electronic submissions (to ZirMed) will be in the new format and will include the two new fields mentioned on previous page. (NOTE: If, before you make this global change, you have set any of your existing insurance companies manually to Form Version 08/05, when you click on the Save and Close button, the system will display an informational prompt that will include a list of payers that are hard-coded with the old 1500 Form Version (08/05). Paste this list into a word document and print it. You will want to review this information to determine why they were set to the old version and if they can now be set to print the new form.) Dealing with Payer Unreadiness for the New 1500 Form: If a payer has received the new form from you and has rejected it either because they aren t ready to process the new form at all, or because there are settings that they require you to change, follow these steps. 1) Open the claim 2) Go to the Primary or Secondary insurance tab (depending on which is the payer affected) and click on Open Company Info. 3) If the payer can t currently receive the new 1500 form at all, go to the Additional Options tab and change the form for that payer to 1500 (08/05). This will change all forms for this payer for this and all future claims, back to the old form. Then resubmit the form. Later, when the payer is ready to receive the new 1500 form, go into the Existing Insurance Company for that payer, go again to the Additional Options tab and change the 1500 Form Version to Use back to [Use System Default]. There is no technical issue with leaving these payers to be hard-coded to generate the old 1500 Form (08/05). The OPIE Billing module will continue to generate the old 1500 Form (08/05) and there are no current plans to discontinue support for the form Support: (800) , press 3,3

7 4) If the payer can receive the new 1500 form but wants you to change a setting, go instead to the 1500 form tab for that payer and make the change that they require. If you need help at this point, call OPIE Support. New Interface Features in OPIE Billing On the following pages we have outlined the changes in the OPIE Billing interface that are part of the new OPIE Billing Build 737. Some have already been described above, other are additional changes that you will see on other windows in billing. Please keep them handy for quick reference. New Global CMS 1500 Form Version setting: The main global control for the 1500 Form Version that is selected as the default is located in Billing Settings. You can control the 1500 Form Version by setting a global default for all insurance companies under Help > Settings > General. Note: The Insurance Company-level setting for the 1500 Form Version to Use must be set to [Use System Default], otherwise that insurance company will not pick up the setting from the Help > Setting > General tab Claim Submission Queue Changes: The Queued Claims interface has been updated to display the 1500 Form Version for each queued claim submission Support: (800) , press 3,3

8 When claims are processed, the system will sort the claim submissions by the 1500 Form Version and prompt the user to load the appropriate form in the printer prior to generation of the PDF output. You ll see a message like this if you are submitting claims to the old form. After the old form claims generate you ll see a message like this for the new form. Review & Submit form changes: When a claim is submitted in the new format, the Review & Submit form will change to accommodate all of the new fields. If you have special requests from payers to populate a particular value in one of the new fields, you will likely need to use the Review & Submit form to enter those values for the time being.( As it becomes clear what types of values payers are requesting in particular fields, OPIE will add additional 1500 form settings to accommodate these.) Support: (800) , press 3,3

9 Insurance Company Settings Insurance Company-level 1500 form settings: When one of your existing insurance companies is set to use the new format on April 1st, you will see that the 1500 form settings tab changes. Because most of the settings on the new 1500 form will be the same as the old form, OPIE will automatically copy all of your old settings for that insurance company. Therefore, you should not generally need to worry about the new 1500 form settings tab during the transition as long as the payer in question is not requiring something different in conjunction with the new format Support: (800) , press 3,3

10 The insurance company s 1500 form settings will look something like this: You will notice that only fields (17) Qualifier and (24J) Allow Custom Line-Level Rending Provider Other ID: will be given new assigned values because the fields didn t exist in the old version. As described on Page 3 above, the (17) qualifier will be set based on what you have select for (17) Physician to Use. (24J) Allow Custom Line Level Rendering Provider Other ID will be set to No. If you add a new insurance company in OPIE once you have changed your Global Default Setting in billing to the 1500 (02/12) form and send through a claim, the 1500 form tab on that insurance company will look like this: Support: (800) , press 3,3

11 Notice that each of the fields is set to [Default]. This indicates that whatever settings appear on the 1500 form tab in Help > Settings > will automatically pull through on this insurance company. If you want all new insurance companies to have other defaults, go to Help > Settings > 1500 Form and change the global defaults on the form. However, if you want some of these defaulted settings (as shown on the left) to be different for this payer, make the modifications on the Insurance Company Information 1500 Form tab itself. This process will ensure that the global defaults will remain consistent while also allowing OPIE Billing users the flexibility to manage the payer requirements of each insurance company individually. At the bottom of the screen you will see an Unlink from Defaults button Support: (800) , press 3,3

12 Important: If you don t want the values on this payer to change in case someone edits the global settings found in Help > Settings> 1500 Form, click on the Unlink from Defaults Button. This will replace the {Default] settings with their equivalent but not using the word default. Existing Settings All the settings on the new 02/ Form have the same drop down options with the exception of the new option value of [Default]. If a setting is set to [Default], then the global 1500 Form setting value is used. There are 3 settings on the 02/ Form tab that look different but are really the same as the 08/ Form tab. These settings are: 1) Show Year as 4 Digits 2) (17) Use PCP ID for Referring Physician 3) (28-29) Use Individual Page Totals. These three parameters behavior has not changed. The only change is the appearance from a checkbox to a drop down. This change was to allow for a third value of [Default]. New Settings There are two new settings on the 02/ Form tab. They are: (17) Qualifier and (24J) Allow Custom Line-level Rendering Provider Other ID. (17) Qualifier This new parameter value has five drop down options: Blank, DN, DK, DQ and [Default]. Upon upgrade, this parameter is set to match the value selected for (17) Physician to Use. If (17) Physician to Use to set to Leave Blank then (17) Qualifier is set to Blank. If (17) Physician to Use to set to Referring Physician then (17) Qualifier is set to DN. If (17) Physician to Use to set to Primary Care Physician then (17) Qualifier is set to DK. (24J) Allow Custom Line-level Rendering Provider Other ID Support: (800) , press 3,3

13 This new parameter value can be set to Yes, No, or [Default]. Upon upgrade, this parameter is set to No. This parameter controls whether the Rendering Provider Other ID can be set at the line level. If set to yes, additional columns will appear on the Claim Form. When submitting a claim, each service line (L-Code) will be able to be assigned a different Rendering Provider Other ID. Note: when this parameter value is set to Yes, then on the Review and Submit (Override) form, box 24 ID Qualifier/Rendering Provider ID # (top boxes only) will be disabled. Managing Line-Level Rendering Provider Other ID fields: With the implementation of the new 1500 Form functionality, the system will allow users to assign custom Line-Level Rendering Provider Other ID numbers in the Codes tab of the claim form. These new manual entry fields will be displayed on the Codes tab if any payer listed on the claim has the (24J) Allow Custom Line-level Rendering Provider Other ID setting activated in their insurance company settings. Billing users will then be able to manually type in individual values for the 24I Rendering Provider Other ID Qualifier and 24J Rendering Provider Other ID fields. If the custom Line-Level Rendering Provider Other ID fields are used, then the system will only populate the custom information on submissions that are generated for the insurance company with the setting activated. All other insurance companies associated with the claim will continue to populate the mapped values defined by the (24J) Rendering Provider Other ID setting. If the custom Line-Level Rendering Provider Other ID fields are used, and there are multiple insurance companies associated with the claim that have the setting activated, then the Billing user will need to Support: (800) , press 3,3

14 manually change the values in the Line-Level Rendering Provider Other ID fields to populate the appropriate information for each different insurance company. o Based upon the feedback that we have received in the use of this functionality, we have determined that this would only occur in very unique situations. This functionality may be modified if additional feedback states that this is not the case. If the custom Line-Level Rendering Provider Other ID fields are used, and the Split function is used in the Review and Submit form, then the system will populate the same Line-Level Rendering Provider Other ID information for all split lines. If the custom Line-Level Rendering Provider Other ID fields are used for two separate lines with the same HCPCS code with different ID values, and the Merge function is used in the Review and Submit form, then the system will populate the Line-Level Rendering Provider Other ID information for the last iteration of the service line for the merged line. o Based upon the feedback that we have received in the use of this functionality, we have determined that this would only occur in very unique situations. This functionality may be modified if additional feedback states that this is not the case. General Billing Transition Information Initial Review of Billing Settings: Prior to processing claim submissions after the implementation of the new 1500 Form (02/12), we highly recommend diligent review of billing data. Following the April 1 st implementation date, all OPIE Administrators should be updating the global 1500 Form Version to Use setting to the 1500 (02/12) option. When this change is made in the Billing Settings window and the user clicks on the Save and Close button, the system will display an informational prompt that will include a list of payers that are hard-coded with the old 1500 Form Version (08/05). OPIE Administrators should review this list with their billing staff as these payers will not automatically be updated after the global setting is changed. Note: It may be possible that some payers may not be ready to accept the new 1500 Form on April 1 st. There is no technical issue with leaving these payers to be hard-coded to generate the old 1500 Form (08/05). The OPIE Billing module will continue to generate the old 1500 Form (08/05) and there are no current plans to discontinue support for the form. Managing and Updating Insurance Company Settings: With the implementation of the new Global 1500 Form Settings functionality, users will be able to define the default 1500 Form (02/12) settings for all new insurance companies, as well as any existing insurance companies with individual setting that are linked (Set to [Default]) to the global settings. Although the global settings may represent the most widely accepted values across all payers, individual settings for specific insurance companies may still need to be experimented with and modified to meet payer requirements. In these cases, users should make these modifications to the individual settings in the insurance company-level settings. In terms of managing 1500 Form settings, we recommend the following: 1) In Billing Settings > 1500 Form tab, OPIE Administrators should set the global default 1500 Form Settings to represent the most widely accepted values for the majority of their payers. Once these settings are saved, these settings will be applied to all new insurance companies. For existing insurance companies, only settings with a value of [DEFAULT] will be linked to global default settings Support: (800) , press 3,3

15 2) Once a new insurance company is added, OPIE Billing users should review the insurance company-level settings to hard-code any known variances in the 1500 Form settings tab. For example, if the global default for Field 17 Physician to Use is set to Referring Physician, but this specific insurance company requires the Primary Care Physician to be populated, then the user should change the insurance company-level setting for Field 17 from the [DEFAULT] option to the Primary Care Physician option on the drop-down. 3) As claims are processed for the new insurance company, it may become necessary to change other settings to meet payer requirements. If that is the case, then the user should change the appropriate field setting in the insurance company-level settings to insure that the correct information is sent to the payer. 4) If there is an instance where a common, standardized field setting is required for the majority of payers, it will be in the discretion of the OPIE Billing user to make a change to the field setting in the global default 1500 Form Settings to apply that change to all linked insurance companies. Managing and Updating DX Pointers: With the implementation of the new 1500 Form functionality, the system will make use of two different formats for the DX Pointers that are indicated on the Codes tab of the claim form. If the Primary Insurance Company on the claim is set to use the old 1500 Form (08/05), then the system will populate a 1 as the DX Pointer on each of the service lines, regardless of the number of actual DX Codes that are listed in the Referring Phys/Other tab. o If there are more than four (4) DX Codes on the Referring Phys/Other tab, then the 1500 Form (08/05) output will only list the first four (4) DX codes on the 1500 Form. If the Primary Insurance Company on the claim is set to use the new 1500 Form (02/12), then the system will populate an A as the DX Pointer on each of the service lines, regardless of the number of actual DX Codes that are listed in the Referring Phys/Other tab. If the claim is generated prior to a change being made to the 1500 Form Version that is assigned to the Payer, then the Billing user will need to manually update the DX Pointer in the Codes tab of the claim form prior to any further processing. Billing users will also need to manually update the DX Pointer in the Codes tab of the claim form if there are multiple payers on the claim that are set to use different versions of the 1500 Form Support: (800) , press 3,3