* PREPARING FOR THE TRANSITION TO HIPAA VERSION 5010: MISCELLANEOUS CHANGES IN FACILITY BILLING AS A RESULT THE TRANSITION TO VERSION 5010 *

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1 * PREPARING FOR THE TRANSITION TO HIPAA VERSION 5010: MISCELLANEOUS CHANGES IN FACILITY BILLING AS A RESULT OF THE TRANSITION TO VERSION 5010 * Read this bulletin on-line via NaviNet NOVEMBER 3, 2010 MS-PROV TO: FROM: SUBJECT: (1) CHIEF FINANCIAL OFFICER (2) DIRECTOR/MANAGER OF PATIENT ACCOUNTS (3) BILLING OFFICE STAFF (4) DIRECTOR OF INFORMATION SYSTEMS MOUNTAIN STATE BLUE CROSS BLUE SHIELD PROVIDER RELATIONS MISCELLANEOUS CHANGES IN FACILITY BILLING AS A RESULT OF THE CONVERSION TO HIPAA VERSION 5010 REFERENCE: ======================================================================= PURPOSE During Mountain State Blue Cross Blue Shield s and Highmark Health Insurance Company s (HHIC s) transition to HIPAA Version ( Version 5010 ), certain changes will occur in facility billing requirements. This bulletin highlights several of the categories of changes that facilities may encounter once they begin to submit claims to Mountain State and HHIC in Version (As always, facilities and their vendors should consult the national implementation guides for complete information.) In addition, this bulletin offers general information about improvements providers may experience in the level of detail for rejected claims via the 277 Health Care Claim Acknowledgment (277CA) Transaction. Important: Provider Experience Will Vary; Discuss With Your Vendor! Providers should understand that although the changes described in this bulletin will occur as part of Mountain State s and HHIC s implementation of the new Version, not all facilities will experience

2 them in the same way. For example, one claim submission software vendor may require users to enter data into a particular field; a second vendor may derive the data through a behind the scenes calculation and automatically populate the field. In both cases, the requirement is being met, but a facility using the first vendor would experience it as a change, while a facility using the second might not even be aware that something new has taken place. Therefore, providers are advised to discuss the changes described in this bulletin with their vendors to determine whether their claim submission activities will need to be modified in any way. BACKGROUND/OVERVIEW Several Categories of Changes Not all of the changes discussed below are requirements of the new Version. Some are changes Mountain State and HHIC have implemented in the past but will now formalize as they move to Version Some other changes were driven by the National Uniform Billing Committee (NUBC) but will become operative through the system upgrades associated with the 5010 transition process. Regardless of their source, the categories of changes addressed in this section are as follows: Information that will now be required, though not required in the past Information that will no longer be used, reportable or valid on the 837I Transaction Format changes and new rules Changes in valid values in a variety of fields/elements A change in the way prior payer information is to be reported if there is no procedure code on the service line (not applicable to providers submitting claims through NaviNet) Information That Will Be Required, Though Not Required in the Past Upon their transition to Version 5010, facilities may need to report certain information that has not been required in the past. As always, this requirement can be handled in various ways by particular claim submission software vendors; providers should consult their vendors to find out what they can expect in their own specific situation. The appropriate Patient Discharge Status code will be required for all claims. The appropriate Point of Origin for Admission or Visit code will be required for all inpatient and outpatient claims. The name and NPI of the Attending Provider is required for all inpatient and outpatient claims other than those for non-scheduled transportation (e.g., ambulance). When Priority (Type) of Admission/Visit Code 1, 2 or 5 is reported on an outpatient claim, along with revenue code 045X, 0516, 0526 or 0762, the provider must report the diagnosis that led to the visit in the Patient Reason for Visit field, and not in the Admitting Diagnosis field. Information That Will No Longer Be Used, Reportable or Valid on the 837I Transaction

3 Providers have already been made aware that they are required to submit their claims using their National Provider Identifier (NPI) rather than other identifiers such as their Mountain Stateassigned provider number. When a facility transitions to Version 5010, the Mountain Stateassigned provider number will no longer be used. Certain other information facilities now report will no longer be reportable in Version 5010: Major Medical Indicator In NaviNet, the field previously used to identify a claim for adjudication against the member s Major Medical benefits has been removed. As a result, effective with NaviNet s transition to Version 5010, this specific category of claims will need to be an exception to Mountain State s and HHIC s electronic claim submission requirement. Since at that point there will no longer be a way to submit Major Medical claims electronically while still properly identifying them as such, providers will need to submit these claims via paper. This change is currently scheduled for December 10, A separate bulletin will be issued to address the practical aspects of this change. HCPCS Codes No Longer Reportable for Claim-Level Principal Procedure or Other Procedure As providers are already aware, HCPCS codes are no longer acceptable as the claim-level Principal Procedure or Other Procedure code. In connection with this change, there is no qualifier available to identify a Principal Procedure or Other Procedure code as HCPCS. Patient Paid Amount This information will no longer be reportable once a facility begins submitting claims in Version Accommodation/Unit Rate (Inpatient Claims) When a facility transitions to Version 5010, the Accommodation/Unit Rate will no longer be reportable for accommodation revenue lines. Gender and Date of Birth for Other Insurance Insured Currently, when it is known that other insurance applies to a claim, the facility needs to report the gender and date of birth for the individual in whose name the other insurance is registered (the Other Insurance Insured ). Once a facility begins submitting its claims in Version 5010 format, this information will no longer be reportable on an institutional claim. Still other information will be considered invalid, once a provider begins to submit claims in Version 5010: Post-Office Box or Lock-Box in the Billing Provider Address As communicated in previous bulletins, a Post-Office Box or Lock-Box number will be considered invalid in the Billing Provider Address data element, effective with the facility s conversion to Version 5010.

4 Format Changes and New Rules When a facility begins to submit its claims in 5010 format, the following formatting changes will apply. As above, facilities may experience these changes in various ways (or potentially not at all), depending upon the solutions adopted by their own claim submission software vendors. Facilities should consult their own vendors to learn what to expect. ZIP+4 Codes are required for the Billing Provider and Service Facility Location address elements. All such codes must be reported as 9 full bytes. Zeros (0s) or blanks are invalid in the last four positions of the ZIP+4 code. The Disability End Date and Statement Through Date elements cannot contain future dates. Line-level descriptions of Not Otherwise Classified (NOC) codes now must be reported in line-specific Description fields, rather than in the Notes field. The Present on Admission indicator, when required, now must be reported with each diagnosis code. Once a facility begins submitting claims in Version 5010, it will need to report Covered Days, Non-Covered Days, Coinsurance Days and Lifetime Reserve Days via Value Codes 80, 81, 82 and 83, respectively. (This will mirror the instructions for paper claim submission.) Changes in Valid Values in a Variety of Fields/Elements Effective with a facility s transition to Version 5010, users may notice additions to and/or deletions from the values available for selection/entry in certain fields. Depending upon the vendor with which a provider works for its claims submission, these changes may be more or less apparent to the user: For each claim, providers will have the option to enter up to 12 External Cause of Injury codes and up to three Patient Reason for Visit codes. The list of available Relationship Code values will be decreased to 8 (in addition to Self). (As always, the complete list of valid values can be obtained through the NUBC s UB-04 Data Specifications Manual.) A new value (W, meaning Patient refuses to assign benefits) has been added for the Provider Accept Assignment indicator. Secondary Claim Submissions in Version 5010: Facilities That Do Not Submit Their Claims via NaviNet As of October 13, 2010, the government has mandated additional changes to the 5010 version of the claim submission transactions. Mountain State and HHIC expect to update the system to implement these changes (commonly called the Errata changes ) in the spring of Until that time, facility providers submitting in Version 5010 that do not use the NaviNet Claim Submission function will need to make a change in the way they report prior payer information on secondary claims in certain situations, to avoid unnecessary claim rejections.

5 Until the Errata changes are complete, when prior payer information is reported at the line level on a secondary claim in Version 5010, the information reported must include a procedure code. However, if the prior payer did not submit a procedure code on the service line, HCPCS procedure code must be submitted as a default value in the COB information for that particular service line. (Important: Please note that the default code must not be reported in the field reserved for the procedure code on the service line.) Until Mountain State and HHIC have completed the Errata changes, facility claims of this type submitted in Version 5010 without a procedure code as specified above will be rejected. Providers will be notified when the changes are complete. At that time, this requirement will be eliminated. Providers Using the NaviNet Claim Submission Function Facilities that submit their claims via the NaviNet Claim Submission function will not need to make the change described above. The 277CA Health Care Claim Acknowledgment Transaction Mountain State and HHIC are taking the opportunity presented by the implementation of Version 5010 to increase the specificity of the information it provides for rejected claims via the 277CA Transaction. Wherever possible, Mountain State and HHIC will make use of the more specific Claim Status Category Codes below to assist providers in resolving edits received on rejected claims reported in the 277CA Transaction: A6, indicating that the information is missing A7, indicating that the information is invalid A8, indicating that there is a conflict between certain elements submitted on the claim IMPACT/ACTION The changes presented in this bulletin are those being made by Mountain State Blue and HHIC in their own implementation of Version Providers are asked to discuss this information with their claim submission software vendor(s), to identify any impacts they should expect when they begin to submit claims in Version TIME FRAME The majority of the changes noted above apply to claims submitted in Version Depending on the approach of their particular claim submission software vendor, providers may experience some or all of these changes when they begin to submit claims in the new Version. For those providers that use NaviNet for electronic claim submission, the Major Medical indicator will no longer be available for their use as of December 10, ASSISTANCE This Bulletin

6 Inquiries about Electronic Edit Reports or Changes to Electronic Transactions Questions about electronic edit reports or changes to electronic transactions should be directed to your facility s software vendor(s), or to Mountain State s EDI Operations Department at or Other Inquiries about This Bulletin Other questions about this bulletin should be directed to your assigned External Provider Relations representative. Inquiries about Eligibility, Benefits, Claim Status or Authorizations For inquiries about eligibility, benefits, claim status or authorizations, Mountain State and HHIC encourage providers to use the electronic resources available to them NaviNet and the applicable HIPAA transactions prior to placing a telephone call to Facility Customer Service. FreedomBlue is a service mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. NaviNet is a registered trademark of NaviNet, Inc. NaviNet, Inc., is an independent company that provides a secure, Web-based portal between providers and health care insurance plans.