NPI Utilization in Healthcare EFT Transactions March 5, 2012

Transcription

1 WEDI Strategic National Implementation Process (SNIP) WEDI SNIP Transactions Workgroup EFT Subworkgroup EFT NPI Utilization Issue Brief NPI Utilization in Healthcare EFT Transactions March 5, 2012 Workgroup for Electronic Data Interchange Sunrise Valley DR., Suite 100, Reston, VA (t) / (f) Workgroup for Electronic Data Interchange, All Rights Reserved 1

2 CONTENT Contents CONTENT...2 Disclaimer...3 Introduction...4 Purpose of this Issue Brief...5 Scope:...5 Considerations:...5 Pharmacy... Error! Bookmark not defined. NACHA CCD+ ACH Format...5 Reassociation...6 Constraints...7 Payers...7 Banks...8 Providers...9 Software Vendors Solution Summary Acknowledgements

3 Disclaimer This document is Copyright 2012 by The Workgroup for Electronic Data interchange (WEDI). It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. If you require legal advice, you should consult with an attorney. The information provided here is for reference use only and does not constitute the rendering of legal, financial, or other professional advice or recommendations by the Workgroup for Electronic Data Interchange. The listing of an organization does not imply any sort of endorsement and the Workgroup for Electronic Data Interchange takes no responsibility for the products, tools, and Internet sites listed. The existence of a link or organizational reference in any of the following materials should not be assumed as an endorsement by the Workgroup for Electronic Data Interchange (WEDI), or any of the individual workgroups or subworkgroups of the WEDI Strategic National Implementation Process (SNIP). Document is for Education and Awareness Use Only 3

4 Introduction To provide information regarding healthcare claim payments, the ASC X12 Healthcare Claim Payment / Advice (835) transaction is utilized for the healthcare claim payment advice, and the ACH Corporate Credit or Debit Entry Plus Addenda (CCD+) transaction is utilized to provide Electronic Funds transfer (EFT) payment information. Both transactions include information needed to reassociate the transactions to each other, and to post the information to providers systems. Currently, in some cases, the CCD+ Addenda record is being customized to include the National Provider Identifier (NPI) in the healthcare EFT transaction. While NPI is not a mandated data element on the CCD+ EFT transaction, a number of providers have stated that without the Payee NPI on the payment transactions they are receiving from their bank, they are having difficulties in identifying the correct account that the funds should be applied to. In addition, some providers need the NPI information in the EFT transaction in order to route the transaction correctly in their system, particularly in situations where the 835 transaction and the EFT transaction arrive separately at the provider s system, and the file routing to the different systems occurs prior to the 835 and the EFT transaction being reassociated. In the current environment, when a payer sends an EFT transaction to their bank, it has the Tax Identification Number (Tax ID) and in the addenda record, the Reassociation Trace Number Segment (TRN) is included. This process works fine if the provider s accounts are setup by Tax Id. If the provider has a single Tax ID, but elected to setup separate bank accounts based on their NPI, then this creates an issue when the provider tries to reconcile the EFT data. They do not know where to apply the funds because they do not have the Payee NPI. Also, situations where providers have more complex routing requirements can necessitate additional information beyond what is included in the TRN segment. To meet requirements around EFT in the Patient Protection and Affordable Care Act (ACA), the National Committee on Vital and Health Statistics (NCVHS) has recommended use of the CCD+ format for use for the healthcare EFT transactions. 1 The Department of Health and Human Services (HHS) has now published an Interim Final Rule with Comment Period (IFC) requiring use of the CCD+ transaction from the payer to the payer s bank, and also requiring the TRN segment included in the Addenda record of the CCD+ transaction to be compliant with the 835 TR3 requirements. 2 The CCD+ transaction includes the entire TRN segment from the associated 835 transaction, for use in associating the 835 and the EFT transactions. Specifically the Trace Number (TRN02) and Company ID (TRN03) are the key data elements used to match the payment record with the 835 Electronic Remittance Advice. As of the effective date of the IFC (January 1, 2014), customization of the CCD+ Addenda record to include any additional information other than the TRN segment as it appears in the 835 takes the transaction out of HIPAA compliance due to restrictions in the 835 TR3, so efforts should be made to include the information within the standard fields in the transaction CMS-0024-IFC: Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice, January 10,

5 Purpose of this Issue Brief This issue brief was developed to provide the industry with an overview of the issues caused by customization of the CCD+ Addenda record in the healthcare EFT transaction. This brief will document the correct use of the CCD+ Addenda record and identify possible solutions for including the Payee NPI in the EFT transaction so that providers who have separate accounting systems per NPI and logic for routing files to those systems prior to the EFT and 835 reassociation will be able to accurately route files to the correct systems and to reconcile their accounts. The ideal solution would be one that does not impact all payers, banks, or providers. A number of providers use the Tax Id to distinguish accounts and that process works in today s environment. The solution developed should not require that all entities make changes to their processes and systems if they do not need the NPI provided in the EFT transaction. Scope: This document specifically focuses on healthcare claim payments to healthcare providers. Entities involved, including payers and banks, need to consider the process used for these payments, along with payments made to sources other than healthcare providers to ensure that those processes are not negatively impacted by changes made to meet the needs of healthcare providers. Pharmacy Because pharmacy environments and processes differ from medical processes, they may not experience the same issues regarding use of the NPI in the payment transactions. This Issues Brief deals exclusively with medical processes, and does not address pharmacy transactions at this time. Considerations: NACHA CCD+ ACH Format The CCD transaction, or Cash Concentration or Disbursement transaction (as termed in the 835 TR3) or Corporate Credit or Debit Entry (as named in the NACHA Operating Rules section 8.20), when used as a credit transaction, is used by an Originator to move funds to the accounts of its branches, franchises or agents or another organization. The CCD Plus Addenda (CCD+) transaction is the same transaction, but includes an additional Addenda record to include supplemental information. This transaction moves money and up to 80 characters of data, enough to reassociate dollars and data when the dollars are sent through the ACH and the data is sent on a separate path. For EFT used to pay healthcare claims, these additional 80 characters of data should contain the entire TRN segment from the 835 transaction that must be reassociated to the EFT transaction. 5

6 The CCD+ Addenda Record information may only be used for the purpose of transmitting payment related information; any other use is prohibited. (NACHA Operating Rules, Appendix One, Part 1.4., Page OR 60 in 2011 edition). For healthcare EFT, the payment-related information is conveyed in an additional 80 characters of data that is the TRN segment from the 835 transaction. This additional data is used to reassociate the 835 to the EFT transaction. The NACHA Operating Rules state that for the CCD+ the Payment Related information in the Addenda Record must contain valid payment-related ASC X12 data segments or NACHA endorsed banking conventions (chart on page OR 61), and that the delimiters used are * for the element delimiter and \ for the segment terminator. (NACHA Operating Guidelines Section V, Chapter 39, page OG 141 in 2011 edition). The ASC X implementation guide (TR3) also specifically states what is to be carried in the Addenda record 3 (page 22): When sending a separate ACH payment, the CCD+ ACH format is used. Using this method, the Reassociation Key Segment in its entirety is contained in the ACH Addenda Record. Note that by ReAssociation Key Segment, the ASC X TR3 is referring to the entire TRN segment in the 835. In addition, the actual segment name is Reassociation Trace Number, and the 5010 TR3 front matter is inconsistent in this situation. Reassociation The 835 is capable of sending health care claim payment remittance data with or without the dollars represented by the data. It is important to facilitate re-association when the remittance data is sent separately from the monetary amounts. Reassociation requires that both remittance and monetary data contain information that allows a system to match the items received. The provider should have a method to ensure that payment and remittance advice are reconciled in the patient accounting/accounts receivable system. Pg 21 Two key pieces of information facilitate reassociation -- the trace number in the Reassociation Key Segment, TRN02, and the Company ID Number, TRN03. The trace number in conjunction with the company ID number provides a unique number that identifies the transaction. Pg Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. Health Care Claim Payment/Advice (835), X221. Washington Publishing Company, April < Accredited Standards Committee X12, Insurance Subcommittee, ASC X12N. Type 1 Errata to Health Care Claim Payment/Advice (835), X221A1. Washington Publishing Company, June < 6

7 The table below outlines the data elements used to reassociate the 835 to the EFT transaction, and where those data elements are located in the two transactions. X ERA Data Federal Tax ID (Payer) Located in BPR10 and TRN03 BPR*I*306.04*C*ACH*CCP*01* *DA* * * *01* * *DA* * ~ AND TRN*1* * ~ Provider Site Tax ID (TIN) or NPI Loop 1000B (PE-Payee) Located in N104 N1*PE*PROVIDER SITE NAME*FI* ~ OR N1*PE*PROVIDER SITE NAME*XX* ~ Trace Number Segment The TRN02 (trace number) is used for reconcilement as well as the payer tax ID TRN03 TRN*1* * ~ ACH CCD+ Company ID Batch Header, Record Type 5, Field Number 5, positions HEALTHPLAN CCDEFTP. Identification Number / ID Record Type 6, Field Number 7, positions (Optional) Trace Number Record Type 7 (Addenda), Field Number 3, positions Use the entire TRN segment from the related 835 transaction 705TRN*1* * \ Note that the data element Trace Number exists in both the NACHA CCD+ format Detail Record Type 6, and in the ASC X TRN segment, element 2. While these data values exist in both formats, they do not contain the same information, and cannot be used interchangeably. The Trace Number field in the CCD+ format is a sequential number used within the CCD+ itself to order the Record Type 6 Detail records in the file. The Trace Number used within the ASC X format contains the Check or EFT Number, and is used to link the 835 transaction to the payment medium. This value from the 835 is what is then copied into the CCD+ Addenda record to be used for re-association. Constraints Formats for both the 835 TRN and the CCD+ format are well documented. Strict adherence to the standard formats is required for NACHA formats and ASC X12 formats, as well as any and all applicable operating rules that might impact the ERA and EFT transactions. Adding data and customizing the transactions outside the standards or operating rules are not HIPAA compliant. Payers Payers have to create payments for the providers, which can be grouped either by Tax ID or by NPI, and this grouping may be determined by billing provider identifiers submitted on the claim, contractual obligations between the payer and provider, provider enrollment, and even payer system requirements. Payers must also create the corresponding 835 files, which 7

8 includes the NPI in the Payee section of the 835 (corresponding to the NPI sent in the loop 2010AA/NM109 (Billing Provider) of the ASC X12 Healthcare Claim (837) format or another NPI if mutually agreed to by the provider and payer) when the provider is eligible for an NPI. Payers must be prepared to provide the information needed by the banks to include in the Addenda record of the CCD+ transaction. Providers must work with both the payer and bank to request delivery of the addenda information, and negotiate the grouping and information included in the file, including NPI if the provider needs it for routing and posting, and validate that the location of that information in the EFT file is the standard location, Record 6 field 7 (see Solutions paragraph below). Although this is an optional field, payers may be delivering information in that field currently and, if so, will need to make system changes to place the NPI in this location for healthcare EFTs that are associated with ERAs. Payers and their bank(s) will need to work together to ensure that any change in the values sent in this field do not disrupt existing payment flows. Banks The NACHA CCD+ format that has been recommended by NCVHS to use for the EFT process, has been in place for a number of years and is used across the financial industry for business-to-business purposes beyond healthcare. Enhancements to the CCD+ Addenda record to accommodate additional data elements would impact areas other than healthcare, requiring implementation across the entire financial industry, which would be risky and have low potential for adoption and implementation. Because it is unlikely that enhancements will be forthcoming in the CCD+ format, any additional data that is needed in the healthcare EFT transaction must be included in the format as it exists today, following the documentation standards for the CCD+ format. Information for the EFT and 835 transactions begins with the payer, who creates the transactions and forward to their appropriate trading partners. In the case of EFT, the payer forwards information to their bank / Depository Financial Institution (DFI). To meet the requirements of the IFC mentioned previously, this must be done in the CCD+ format and include the TRN segment from the corresponding 835 transaction. The payer s DFI will then forward the EFT transaction through the ACH network to the provider s bank / DFI, who will then notify the provider of the deposit information. While the transaction should flow through this process with the EFT information remaining intact, each touchpoint does provide an opportunity for the transaction to be modified, and the provider may need to interact with their bank and their payer to ensure that no such modifications take place. 8

9 Providers The provider defines how they want to set up their bank accounts and reconcile their system. The provider may have a single bank account by Tax ID with all checks going to this single account. They may have a single bank account and internally have multiple locations, systems, or NPI divisions to track information by NPI, but funds received for individual NPIs still feed into that single account. Or a provider may have many bank accounts set up, one per NPI, so each individual check received per NPI is deposited into a separate account. Situations may also arise when the healthcare EFT and ERA arrive separately at the provider, are routed prior to the reassociation step taking place, and need the NPI information in order to be routed to the correct system, as described in the picture below. This is why it is important for the NPI to be carried in the healthcare EFT transaction when requested by these providers so the internal routing can take place and the EFT and ERA can be routed to the correct billing location to be reassociated and posted. Information needed by the provider in the healthcare EFT transaction (the CCD+ transaction) must be supplied by the bank if requested. The provider should be aware that they need to notify their bank of the need to supply the addenda information in the EFT transaction, and include in those discussions any requirements to include the information in the EFT transaction, record 6 field 7, and ensure that this information is communicated by all banks for delivery to the provider. Providers should be aware that the timing of implementation of these recommendations by payers may vary, and that any values currently in this field may not be their NPI. 9

10 Software Vendors While some of the larger provider organizations may maintain their own software applications for re-association and posting, a number of the smaller provider organizations rely on software vendors to provide that functionality. If the provider utilizes NPI to identify their accounts, then their software vendor must support the use of NPI in Record 6 Field 7 of the CCD+ format. Solution In order to accommodate inclusion of the NPI in the NACHA CCD+ format, the Identification Number field in the NACHA Record Type 6 (field 7) can be utilized for the NPI. NACHA Operating Rules state that this field may be used by the Originator to insert its own number for tracking purposes. (NACHA Operating Rules Appendix Three, Page OR 108 in 2011 edition) Since the NPI is considered an identification number for providers, then this is the appropriate record and field in the NACHA format to transmit this information, and provides a standard location for use for this value. The value sent in the Record Type 6, Field 7, position 40-54, matches to the Payee (loop 1000B) N104 value in the 835, which normally would contain the NPI value. The recommended approach is to use Record 6, field 7 of the healthcare EFT transaction to support the transmission of NPI. The NACHA format does not need to be changed to accommodate these recommendations. In order to include the NPI for providers that request that information be included in the EFT transaction, payers will need to make changes to place the NPI in Record 6, field 7 of the NACHA CCD+ format. Banks will need to ensure they can supply the value in Record 6, field 7 of the NACHA CCD+ format to providers. Providers will need to ensure they can receive and use the value in Record 6, field 7 of the NACHA CCD+ format while allowing for the potential to receive other values or no values in this field when payers have not yet implemented these recommendations. Summary Inclusion of the NPI in the detail record of the CCD+ record means that the healthcare EFT transaction includes the NPI, the Tax ID, and the Reassociation Trace Number Segment, providing all information needed to appropriately route the transactions, and reassociate the 835 to the healthcare EFT. The current standards defined for the 835 remittance advice transaction and the NACHA CCD+ EFT transaction include information necessary to reassociate the transactions when they pass through separate systems before being received by the provider. In most circumstances, the information defined in the standards should be sufficient to properly route and reassociate the 835 and healthcare EFT transactions; however, in the event that providers may need additional information to perform routing through a gateway or other systems, it is 10

11 not acceptable to customize the CCD+ Addenda record to include additional information. Including the NPI in the Detail Record (record 6) of the CCD+ transaction would provide a mechanism for including the additional information while remaining compliant with the standards. The recommended approach is to use Record 6, field 7 of the healthcare EFT transaction to support the transmission of NPI. Acknowledgements WEDI EFT SWG Co-Chairs a. Pam Grosze, PNC Bank Healthcare b. Deb Strickland, TIBCO c. Ron Meier, Health Net The co-chairs wish to express their sincerest thanks and appreciation to the members of the EFT Subworkgroup who participated in the creation of this document. 11