E-Commerce Connection
April 2006, Volume 02–Issue 02
The AdminaStar Federal E-Commerce Connection online newsletter is produced by the AdminaStar Federal E-Commerce Consultants for all Medicare electronic submitters serviced by AdminaStar Federal as their Part A Fiscal Intermediary, Part B Carrier, and the Region B Durable Medical Equipment Regional Carrier (DMERC), as well as software vendors, billing services and clearinghouses. · Questions regarding the information contained in this newsletter should be addressed through the Electronic Data Interchange (EDI) Helpdesk (or as otherwise noted). The toll free number for the EDI Helpdesk is 1-877-ASF-4EDI (1-877-273-4334) · The E-Commerce Connection online newsletter is published by AdminaStar Federal Corporate Communications · The next E-Commerce Connection issue is scheduled for June 2006. · The AdminaStar Federal Web site is: www.adminastar.com
In This Issue
E-Commerce Report
EDI Helpful Hints
EDI Updates
EDI Web Site Changes & Additions
Part A EDI Updates
Part B EDI Updates
Part B and DMERC EDI Updates
DMERC EDI Update
HIPAA Updates
External Resources and Helpful Links
AdminaStar Federal Contact Information
E-Commerce Connection Feedback Survey
E-Commerce Report
Overview of EDI Products and Services
AdminaStar Federal, in conjunction with the Centers for Medicare & Medicaid Services (CMS), strongly encourage electronic data interchange (EDI) transactions. As a company, AdminaStar Federal offers products and services in the EDI environment beyond the submission of electronic claims. To maximize the benefits received as an electronic submitter, incorporate all of our EDI tools in your daily business routines.
An overview of the EDI Products and Services available on our website can be obtained by clicking on one of the following links:
Part A: www.adminastar.com/Providers/EDI/Intermediary/Products/Products.html
Part B: www.adminastar.com/Providers/EDI/Carrier/Products/Products.html
DMERC: www.adminastar.com/Providers/EDI/DMERC/Products/Products.html
EDI Helpful Hints
Electronic Funds Transfer Agreement
All providers/suppliers signing up for Electronic Funds Transfer (EFT) must include a voided blank check or bank affidavit in order for AdminaStar Federal to process your request. At the top of page one on the EFT agreement it states: “**AdminaStar Federal must receive a voided blank check or bank affidavit in order to process your EFT request.**”
AdminaStar Federal cannot process your request with a preprinted deposit slip because the bank routing number may be incorrect or not listed.
Note: The voided blank check should be a preprinted check.
To sign up for electronic funds transfer, click on one of the links below:
Part A: www.adminastar.com/Providers/EDI/Intermediary/Agreements/Agreements.html
Part B: www.adminastar.com/Providers/EDI/Carrier/Agreements/Agreements.html
DMERC: www.adminastar.com/Providers/EDI/DMERC/Agreements/Agreements.html
EDI Claims Transmission and Reports Download on AdminaStar Federal Holidays
AdminaStar Federal’s front end edit reports are available as follows for your electronic claim transmissions:
Normal Weekday Schedule (Excludes Weekends and Holidays):
LEVEL I REPORTS – RJ/Reject, TA1, 997 and the ANSI Pre Processor ISA Error Reports
—available for download from one to three hours after claim transmission.
Claims that are accepted on the Level I reports will be edited and produce Level II reports.
LEVEL II REPORTS – for claim files that pass Level I edits
—available for download the next business day for claim files transmitted before approximately 5:00 p.m.*
—available for download on the second business for claim files transmitted after approximately 5:00 p.m.
Weekend and Holiday Schedule:
The AdminaStar Federal Translator does not run on weekends or holidays. Claim files transmitted on weekends or holidays are processed on the next business day.
LEVEL I REPORTS – RJ/Reject, TA1, 997 and the ANSI Pre Processor ISA Error Reports
—available for download on the next business day.
Claims that are accepted on the Level I reports will be edited and produce Level II reports.
LEVEL II REPORTS – for claim files that pass Level I edits
—available for download on the second business day after the Monday holiday, if a claim file is transmitted on the weekend (Saturday or Sunday) prior to a Monday holiday.
—available the next business day after the holiday, if a claim file is transmitted on a holiday prior to approximately 5:00 p.m.
—available the second business day after the holiday, if a claim file is transmitted on a holiday after approximately 5:00 p.m.
* “Approximately 5:00 p.m.” is for files transmitted and delivered to the translator for processing at the 5:00 p.m. cycle. Claims submitted between 4:45 p.m. and 5:00 p.m. may not be delivered in time for the 5:00 p.m. translation cycle.
Example: Files transmitted at 4:45 p.m. may not make the 5:00 p.m. cutoff because they have not reached the Mainframe.
The following holiday schedule will be observed by AdminaStar Federal in 2006.
Monday, May 29, 2006 – Memorial Day
Tuesday, July 4, 2006 – Independence Day
Monday, September 4, 2006 – Labor Day
Thursday, November 23, 2006 – Thanksgiving Day
Friday, November 24, 2006 – Day after Thanksgiving
Monday, December 25, 2006 – Christmas Day
EDI Updates
EDI Helpdesk
EDI Helpdesk 1–877–ASF–4EDI (1–877–273–4334)
Our EDI Helpdesk consists of highly trained experts in the field of EDI. They are available to assist providers/suppliers with any electronic needs. Times of operation are as follows:
8:00 a.m. – 11:30 a.m. and 12:00 p.m. – 4:00 p.m. (EST) Monday, Tuesday, Wednesday and Friday
8:30 a.m. – 11:30 a.m. and 12:00 p.m. – 4:00 p.m. (EST) Thursday
The EDI Helpdesk can also be contacted via email at asf.edi.a@anthem.com for Part A, asf.edi.b@anthem.com for Part B, or asf.edi.dmerc@anthem.com for DMERC Region B.
Our EDI Helpdesk associates receive feedback from the customers they assist through post call surveys. During a post call survey, the Helpdesk lead will ask questions on how the Helpdesk associate handled the call. All Helpdesk associates get to view the results of these post call surveys for training purposes. The results are also part of their annual performance review.
If you have never been contacted for a post call survey and would like to provide feedback on the service provided to you through our EDI Helpdesk, click on the link below to answer a few questions. Your feedback is very important to us. This survey should only a few minutes to complete.
EDI Helpdesk feedback survey: www.adminastar.com/Providers/EDI/secure/customersatisfactionsurvey.cfm
Meet an AdminaStar Federal EDI Associate
Part A EDI Helpdesk Analyst
Jennifer Moberly
AdminaStar Federal would like to introduce Jennifer Moberly to all electronic data interchange (EDI) customers. Jennifer is the Part A EDI Helpdesk Analyst and works closely with Mark Ziels, Abiy Asfaw, Shane Brennan and Donald Hoskins.
Jennifer has been with AdminaStar Federal/Anthem for over fifteen years and has over fourteen years of experience specifically in EDI, nine of those as an EDI Analyst.
Currently, Jennifer is working on converting all electronic remittance advice receivers to the Health Insurance Portability and Accountability Act (HIPAA) compliant 835 transaction. If you are reading this and have not converted to the 835 HIPAA compliant electronic remittance advices (ERA), you can expect to hear from her soon. Some of you may already hear from her on a daily basis.
Jennifer can be described as having a great sense of humor, supportive, a team player and a joy to be around. Here are some quotes from her team:
—“She goes above and beyond when assisting customers. She is always willing to help others when needed.”
—“She has always represented AdminaStar Federal with the utmost professionalism and courtesy. The many contributions she has given through her 15 years here are an inspiration to us all. She is always cheerful and ready to jump right in and help or contribute to the unit goals.”
—“She runs at the speed of a dervish, with projects and call-taking, but never seems harried or without time to consult. She is one of the most knowledgeable people I’ve met at AdminaStar Federal. She maintains the patience of a Saint and she can cook!”
When asked what she liked most about her current position, Jennifer said, “Interacting with both internal and external customers. I also thoroughly enjoy assisting others in resolving issues.” When asked about her team, Jennifer sincerely stated, “We have a great team! The camaraderie, respect, knowledge and sense of humor make this a great place to work every day.”
EDI Web Site Changes & Additions
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Article Additions |
Line of Business |
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Medicare Part A |
Medicare Part B |
DMERC |
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Claim Status Category Code and Claim Status Code Update |
X |
X |
X |
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Healthcare Provider Taxonomy Codes (HPTC) Update (CR4254) |
X |
X |
X |
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Medicare Remit Easy Print (MREP) Enhancements, and Clarification of Check Issue/Electronic Funds Transfer (EFT) Effective Date (CR4289) |
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X |
X |
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Medicare Remit Easy Print (MREP) Software (SE0611) |
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X |
X |
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Remittance Advice Remark Code (RARC) and Claim Adjustment Reason Code (CARC) Update (CR4314) |
X |
X |
X |
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Remittance Advice Remark Code and Claim Adjustment Reason Code Update (CR4326) |
X |
X |
X |
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Revision to Chapter 31 - 270/271 Eligibility (CR 4193) |
X |
X |
X |
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Revision to Chapter 31 – Attestation Form for Conducting Real Time Eligibility Inquiries with Medicare (CR4093) |
X |
X |
X |
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Shared Systems Medicare Secondary Payer (MSP) Balancing Edit and Administrative Simplification Compliance Act (ASCA) Enforcement Update (CR4261) |
X |
X |
X |
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Stage 1 Use and Editing of NPI Numbers received in EDI Transactions via DDE Screens, or Paper Claims form (CR4320) |
X |
X |
X |
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Termination of the Existing Eligibility File-Based Crossover Process at All Medicare Contractors Provider Types Affected (CR4231) |
X |
X |
X |
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Termination of the Medicare Health Insurance Portability & Accountability Act (HIPAA) Incoming Claim Contingency Plan, Addition of a Self-Assessable unusual Circumstance, Modification of the "Obligated to Accept as Payment in Full"(OTAF) Exception, and Modification of Administrative Simplification Compliance Act (ASCA) Exhibit Letters A, B and C (CR 4119) |
X |
X |
X |
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Additions |
Line of Business |
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Medicare Part A |
Medicare Part B |
DMERC |
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Announcement of NPI Webpage |
X |
X |
X |
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Break in Service Claims |
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X |
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NPI News: Information on Electronic File Interchange (EFI) Released |
X |
X |
X |
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PC Ace Service Pack |
X |
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Updates |
Line of Business |
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Medicare Part A |
Medicare Part B |
DMERC |
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COB Trading Partner listing |
X |
X |
X |
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DMERC Front End Edit Manual |
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X |
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February OCNA Updates |
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X |
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Helpdesk Change in Hours |
X |
X |
X |
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January ANSI Approved Entities Listing |
X |
X |
X |
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January OCNA Updates |
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X |
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January Release Front End Edit Manual |
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X |
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DMERC January Release Edits |
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X |
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MREP 1.6 Now Available |
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X |
X |
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NCPDP COB Companion Doc |
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X |
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NCPDP Companion Doc |
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X |
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PC Ace 1.73 Exe |
X |
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PC Ace 1.73 Instructions |
X |
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PC Ace 1.73 Manual |
X |
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PCACE Forms |
X |
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Phone Support Change in Hours |
X |
X |
X |
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Registration Package |
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X |
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Revision to SE0611 |
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X |
X |
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Part A EDI Updates
The following updates apply to Medicare Part A providers in the states of Illinois, Indiana, Kentucky and Ohio.
Medicare Part A Top 5 Most Common Front End Errors
The following is a list of the Top 5 Most Common Front End Errors that are received by the AdminaStar Federal
EDI Helpdesk:
ERROR: ADMIT DIAG CODE INVALID
PRIN DIAG CODE INVALID
OTH DIAG CODE INVALID
LOOP/DATA ELEMENT: 2300.HI.02
DESCRIPTION: Diagnosis code must be valid for the date range reported on the claim.
PROBLEM: Providers are using diagnosis codes that are no longer effective or are not to the highest level of specificity.
SOLUTION: Verify all diagnosis codes are effective for dates reported on the claim and are being billed to the highest level of specificity by visiting: www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/
ERROR: ICD9 PRIN PROC CODE INVALID FOR TOB
LOOP/DATA ELEMENT: 2300.HI.01
DESCRIPTION: Procedure code invalid for type of bill
PROBLEM: Providers are submitting procedure codes on outpatient bills
SOLUTION: Providers should NOT submit procedure codes on outpatient bills.
ERROR: INVALID CONTROL STRUCTURE
LOOP/DATA ELEMENT: ISA
DESCRIPTION: Invalid structure in file
PROBLEM: Providers are submitting claims and the claim file was not transmitted in its entirety. May be caused from static on the phone line or poor connection.
SOLUTION: Providers need to make sure that the entire file has been transmitted in it’s entirety and providers must view their activity report. If a file has not been transmitted in its entirety retransmit the entire file and verify with the activity that it was successfully transmitted.
ERROR: CLAIMS NOT ENTERED INTO CLAIMS SYSTEM
LOOP/DATA ELEMENT: Entire File
DESCRIPTION: Claims are not clearing EDI and being sent to the Claims Processing system
PROBLEM: Providers are not checking the “NOTE” field at the bottom of the rejection report to learn that claims are not clearing EDI and being sent to the Claims Processing system
SOLUTION: Providers need to check the “NOTE” field on the rejection report to verify that all claims submitted have cleared EDI and are being sent to the Claims Processing system. If you do have claims that are rejected on the rejection report, correct and resubmit only the claims shown.
ERROR: TRANSACTION HAS BEEN REJECTED BY THE TRANSLATOR
LOOP/DATA ELEMENT: Entire File
DESCRIPTION: Entire file submitted did not clear EDI and is NOT being sent to the Claims Processing System,
PROBLEM: Providers are not checking the “NOTE” field at the bottom of the rejection report to learn that the entire transmission are not clearing EDI and being sent to the Claims Processing system.
SOLUTION: Providers need to check the “NOTE” field on the rejection report to verify that the entire file submitted has cleared EDI and is being sent to the Claims Processing system. If you do have an entire transmission that is rejected on the rejection report, correct the claim(s) in error and resubmit the entire transmission.
Part B and DMERC Updates
The following updates apply to Medicare Part B providers in the states of Indiana and Kentucky, and Region B DMERC suppliers in the states of Illinois, Indiana, Maryland, Michigan, Minnesota, Ohio, Virginia, Washington DC, West Virginia, and Wisconsin.
Medicare Remit Easy Print
In June 2005, CMS announced to AdminaStar Federal their Remittance Advice (RA) Initiative, which included plans to reduce the number of Standard Paper Remittance Advices (SPRs) printed and mailed as well as increase usage of the Electronic Remittance Advice (ERA).
As part of the RA initiative, CMS developed Medicare Remit Easy Print (MREP) software to enable physicians and suppliers to read and print the HIPAA–compliant ERA (also known as Transaction 835 or “the 835”).
Benefits of Using MREP Software
1. Save Time and Money
Remittances can be printed directly from your computer the day the HIPAA 835 is available. No more time is spent waiting for the mail!
2. Create and Print Special Reports
MREP creates several useful reports including:
—Deductible Service Lines Report: Shows claim service lines that have a deductible amount.
—Adjusted Service Lines Report: Shows claims within a single remittance that have a claim status 22 (reversed claim).
—Denied Service Lines Report: Shows only claim service lines that have an allowed amount of zero and are associated with a claim that does not have a claim status 22 (reversed claim).
3. Print and Forward Claims for Other Payers
MREP provides the ability to print remittance information for individual or multiple selected claims, and it allows you to forward only those claims that are needed by other payers for secondary payment. You may view and/or print as many or as few claims as needed. This eliminates the need for you to darken individually identifiable data on the SPR, as you may do today, that does not pertain to the claim for which you are requesting payment.
4. Navigate and View Remittance Information
MREP organizes and presents information in a manner that makes it easy for you to view. It also provides separate tabs to access the following:
—A list of claims;
—Details for individually selected claims;
—Summary information;
—Glossary information containing Claim Adjustment Reason Codes, Remittance Advice Remark Codes, and their definitions;
—A data view that allows you to look at the various loops and segments containing data in the HIPAA 835; and
—A search-function to find claims containing specific information.
5. Search for Claim(s) Information Quickly and Easily
MREP’s search function can help you find a claim (or multiple claims) based on your customized search criteria. Using it, you can search by names, numbers, and even portions of information such as:
—Health Insurance Claim Number (HICN);
—Beneficiary Last Name;
—Internal Control Number (ICN);
—Beneficiary Account Number,
—Procedure Code,
—Service Date, and
—Rendering Provider Number.
Note: MREP’s search capability provides a powerful way to save time and money when examining remittance information.
6. Eliminate Need for Physical Filing and Storage Space
MREP software imports a HIPAA 835 (once you have received it from your carrier/DMERC) and saves the information as a separate Import file to help ensure that the original HIPAA 835 file remains intact.
It also provides an easy-to-use method to archive, restore, and delete these Import files as you maintain your remittance records (further reducing the need for physical filing of printed copies and additional storage space).
As you gain familiarity with the MREP software, you will be able to take advantage of the numerous keystroke shortcuts designed to streamline use of the software and save you time while viewing your remittance information.
Installing and Using MREP Software
To install and use the MREP software, your computer system(s) must meet the following minimum criteria:
—IBM-compatible PC;
—Windows XP (Recommended), Windows 2000, Windows NT, or Windows 98 SE;
—2.0 GHz processor;
—256 MB RAM;
—3 MB hard disk space; and
—.NET Framework version 1.1 or higher.
MREP software can save you time resolving Medicare claim issues, and it provides features unavailable with the Standard Paper Remittance. MREP is available to you free of charge, and further information on the software (including how to obtain a free copy) is available at:
Part B: www.adminastar.com/Providers/EDI/Carrier/ERA/ERA.html
DMERC: www.adminastar.com/Providers/EDI/DMERC/ERA/ERA.html
Part B EDI Updates
The following updates apply to Medicare Part B providers in the states of Indiana and Kentucky.
Medicare Part B Top 5 Most Common Front End Errors
The following is a list of the Top 5 Most Common Front End Errors that are received by the AdminaStar Federal EDI Helpdesk:
ERROR CODE: M310 & M311
NAME: Invalid Diagnosis
LOOP/DATA ELEMENT: 2300.HI
DESCRIPTION: Diagnosis code must be valid for the date range reported on the claim.
PROBLEM: Providers are using diagnosis codes that are no longer effective or are not to the highest level of specificity.
SOLUTION: Verify all diagnosis codes are effective for dates of service reported on the claim and are being billed to the highest level of specificity by visiting www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/
ERROR CODE: 1473
NAME: Admission Date
LOOP/DATA ELEMENT: 2300/2400.DTP
DESCRIPTION: Missing Segment. Error occurs if POS is 21, 51, or 61 (2300.CLM05–1/2400.sv105) and admission date is not given (2300.DTP*435). Error also occurs if POS is 41 or 42 (2300.CLM05–1/2400.SV105) and condition indicator is “01” (2300/2400.CRC03–CRC07) and admission date is not given (2300.DTP8435).
PROBLEM: Providers are not entering an admission date when billing POS 21, 51, or 61 or when billing POS of 41 or 42 with a condition indicator of “01.”
SOLUTION: Verify that an admission date is being billed when billing POS 21, 51, or 61 or when billing POS of 41 or 42 with a condition indicator of “01.”
ERROR CODE: M012 & M013
NAME: Billing Provider Additional Identifier
LOOP/DATA ELEMENT: 2010AA.REF
DESCRIPTION: Submitter/Billing Prov not on file.
PROBLEM: Providers are submitting claims for provider numbers and/or group numbers that have not been linked to their Sender ID or have not been enrolled with EDI.
SOLUTION: Providers need to make sure that all provider numbers and/or group numbers that they are billing for are linked to their Sender ID by completing an EDI Enrollment form found on the AdminaStar Federal Web site at: www.adminastar.com/Providers/EDI/Carrier/Agreements/Agreements.html
ERROR CODE: M020
NAME: Subscriber Insurance Type Code
LOOP/DATA ELEMENT: 2000B.SBR05
DESCRIPTION: Value Required if Medicare Secondary. Values do not match 12, 13, 14, 15, 16, 41, 42, 43, or 47 (if SBR01 is not “P”).
PROBLEM: Providers are not indicating beneficiary’s primary insurance type when billing MSP (Medicare Secondary Payer) claims.
SOLUTION: When filing MSP claims, the beneficiary’s primary insurance type must be entered.
Valid values are:
12–Working Aged Beneficiary or Spouse with Employer Group Health Plan
13–End Stage Renal Disease
14–No-fault Insurance including Auto is Primary
15–Workers Compensation
16–Public Health Service (PHS) or other Federal Agency
41–Black Lung
42–Veteran’s Administration
43–Disabled Beneficiary under age 65 with Large Group Health Plan (LGHP)
47–Other Liability Insurance is Primary
ERROR CODE: M301 & M304
NAME: Required info Missing & 2400/AMT or 2430/SVD Req.
LOOP/DATA ELEMENT: 2430.SVD & 2320AMT
DESCRIPTION: Error occurs if the 2400 AMT01*AAE (Amount Approved) segment is submitted on the claim but the 2430.SVD02 (Adjudication Paid Amount) is not submitted & Error occurs if there is more than one 2320 AMT01*B6 (Allowed Amount) and 2320.AMT*D (Payer Paid Amount) and either the 2400 AMT01*AAE (Amount Approved) or 2430.SVD02 (Adjudication Paid Amount) are submitted on the claim but not both.
PROBLEM: Providers are not entering the amount paid and/or the allowed amount found on the EOB from the primary insurance.
SOLUTION: Verify that all adjustments and/or paid amount from the primary insurance EOB are reported on the claim. For additional assistance locating the proper fields to report MSP information within your software please contact your software vendor.
EDI Customer Profile
Is your EDI Customer Profile up to date? Medicare Part B Indiana and Kentucky providers must notify AdminaStar Federal when changing their vendor, clearinghouse, or billing service by completing an EDI Enrollment Form. If both the group and individual Medicare provider number is not linked to the electronic submitter/sender ID, the file will reject with error code “M013” (2010AA.REF02 Billing Provider Additional Identifier) on the PrePass Edit Report.
If a “M013” rejection is received, copy and paste the following hyperlink into your internet browser to complete the EDI Enrollment form: www.adminastar.com/Providers/EDI/Carrier/Agreements/Agreements.html
On the EDI Enrollment Form please indicate the group number(s), individual provider number(s) and the submitter/sender ID that will be used to send claims. Once the EDI Enrollment form has been received and processed, claims that previously rejected with “M013” may be resubmitted.
Examples of changes that must be provided in writing to AdminaStar Federal include:
—Change in address, contact person, phone number, and fax number;
—Change in clearinghouse;
—Change in billing service;
—Change in vendors;
—Vendor ceases operations;
—Vendor is purchased by, or merged/aligned with another vendor or organization;
—Change in services provided by a vendor; and
—Discontinued use of vendor services by a provider.
DMERC EDI Updates
The following updates apply to Region B DMERC suppliers in the states of Illinois, Indiana, Maryland, Michigan, Minnesota, Ohio, Virginia, Washington DC, West Virginia and Wisconsin.
DMERC Top 5 Most Common Front End Errors
The Region B DMERC conducts a front end edit analysis quarterly to determine which front end edits occur most frequently for electronic claims. The analysis for electronic claims transmitted for the first quarter beginning January 1, 2006 revealed that the following edits and edit combinations rejected over two million claims.
The explanation begins with the rejection number and wording found on your error listing report. Next is the edit explanation as found in the Region B DMERC ANSI X 12N 4010A1 Front End Edit Manual. This manual can be found at: www.adminastar.com/Providers/EDI/DMERC/Manuals/Manuals.html
These explanations are more detailed and are designed to provide reasons as to why the edit occurred and what you need to do to correct the error to resubmit the claim electronically. Therefore, some of the “Items to Check” may duplicate parts of the edit explanation.
ERROR CODE: 40022
NAME: PROCEDURE CODE/MODIFIER INVALID
CLAIMS AFFECTED: Approximately 30,000
DESCRIPTION: The procedure code or modifier listed on the claim line is invalid. The procedure code was either billed with an invalid modifier, was missing a required modifier that was needed, or the pricing modifiers were out of order.
SOLUTION: Verify the procedure code and the modifier combinations are effective for the date of service billed. If submitting a National Drug Code (NDC), verify that the NDC is valid for the date of service billed. The first position cannot contain a space.
ITEMS TO CHECK: 1. Refer to the Region B Supplier Manual, chapter XVI, (HCPCS Codes) to verify the procedure code(s) and modifier(s) are effective for the dates billed. This chapter provides information regarding the effective dates, payment category and modifiers used by the DMERC.
2. Refer to the Region B Supplier Manual, chapter XVI, Section 12–Modifiers. This section lists the valid modifiers that can be used for each payment category.
3. Refer to the Region B Supplier Manual, chapter XVII, (Medical Policy). This chapter lists HCPCS codes, HCPCS modifiers, coverage and payment rules, and coding guidelines for each policy group.
ERROR CODE: 40073
NAME: DATES OF SVC INVALID WITH PROCEDURE CODE
CLAIMS AFFECTED: Approximately 23,000
DESCRIPTION: The HCPCS or NDC code was not valid for the date of service. The code was either deactivated before or was not activated until after the submitted date of service.
ITEMS TO CHECK: 1. Review the Statistical Analysis DMERC (SADMERC) online coding site at www.palmettogba.com/palmetto/Other.nsf/Home/Other+Medicare+Partners+SADMERC+Home?OpenDocument
2. Contact the Statistical Analysis DMERC (SADMERC) at 1–877 735–1326 for further assistance on selecting the correct procedure code for the date of service.
ERROR CODE: 11304–11306 and 20269–20276
NAME: DIAGNOSIS INVALID: HEADER DIAG INVALID: POINTER DIAG INVALID
CLAIMS AFFECTED: Approximately 16,000
DESCRIPTION: The diagnosis code is either invalid for the date of service for a specific charge line (pointer), is not specifically referenced by a charge line but is invalid for the entire range of dates for the claim (header), or is completely invalid.
ITEMS TO CHECK: Contact the physician to verify that the diagnosis code is accurate for the date of service.
ERROR CODE: 40066–40068
NAME: INVALID/UNNECESSARY CMN SUBMIT; INVALID/UNNECESSARY CMN VERSION SUBMIT; INVALID/UNNECESSARY CMN QUESTION SUBMIT
CLAIMS AFFECTED: Approximately 12,000
DESCRIPTION: Either a Certificate of Medical Necessity was submitted for a procedure code that does not require a CMN or the version of the CMN is invalid. If an invalid or unnecessary CMN question was submitted, the question number entered is not valid for the DMERC CMN form being sent with the claim line.
ITEMS TO CHECK: 1. Verify the procedure code and modifier combination was valid and did not reject with the 40022 edit. If the procedure code and modifier is rejected, then all the CMN information will be rejected.
2. Refer to the Region B Supplier Manual, chapter XVIII (Certificate of Medical Necessity Completion) to verify that the correct CMN was attached to the claim for the procedure code billed.
3. Verify that the procedure code billed requires a CMN. Find the procedure code in chapter XVIII and review the chart for the HCPCS codes requiring a CMN or DIF.
ERROR CODE: 40021
NAME: CAPPED RENTAL K MODIFIER MISSING
CLAIMS AFFECTED: Approximately 9,000
DESCRIPTION: The capped rental item was billed without the appropriate K modifier
(KH, KI, or KJ).
ITEMS TO CHECK: Refer to the Region B Supplier Manual Chapter XV1 (HCPCS Codes) page 104 for a listing of the K codes.
If you need assistance after reviewing to the above resources, contact the Region B DMERC Provider Assistance at
1–877–299–7900 for policy clarification or the DMERC EDI Helpdesk at 1–877–ASF–4EDI (1–877–273–4334), option 1 for electronic claim clarification.
HIPPA Updates
AdminaStar Federal HIPAA Statistics for 835 transactions
|
As of February 3, 2006 |
Total # of receivers |
Total in Test mode |
Total in Production mode |
% 835 receivers in Production mode |
|
Medicare Part A (IL, IN, OH, KY) |
682 |
15 |
649 |
91.16% |
|
Medicare Part B (IN, KY) |
602 |
4 |
579 |
96.18% |
|
DMERC |
919 |
12 |
882 |
95.97% |
*Providers/Suppliers that make up the small percentage not receiving their 835 transactions, please contact the EDI Helpdesk at 1–877–ASF–4EDI (1–877–273–4334) to find out how to start receiving your 835 electronically today using Medicare’s FREE 835 Medicare Remit Easy Print (MREP) software for Part B and DMERC customers, and/or using PC-Print software for Medicare Part A providers.
National Provider Identifier (NPI)
The AdminaStar Federal E-Commerce Team has placed an Electronic Data Interchange (EDI) National Provider Identifier (NPI) Reference Document for ANSI X12N 837 HIPAA Compliant Claims on our website to help providers/suppliers in identifying the proper loops, segments and elements when trying to send their NPI number(s) electronically:
Medicare Part A (IL, IN, OH, KY):
www.adminastar.com/Providers/Intermediary/NPI/NPI.htm
Medicare Part B (IN, KY):
www.adminastar.com/Providers/Carrier/NPI/NPI.htm
DMERC:
www.adminastar.com/Providers/DMERC/NPI/NPI.htm
External Resources and Helpful Links
Medicare Frequently Asked Questions (FAQ) Section
This website includes a “search by term” option, a listing of all questions submitted, and it also allows providers/suppliers the opportunity to ask CMS a direct question and see a response. The CMS in many cases references direct links to locations to find additional documentation.
Simply go to:
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=Ugm4Wt1i
AdminaStar Federal Contact Information
Visit AdminaStar Federal on the Web at:
www.adminastar.com
Part A Intermediary for Illinois, Indiana, Kentucky, and Ohio:
www.adminastar.com/Providers/Intermediary/ContactInformation/files/telephonenos.pdf
Part B Carrier for Indiana and Kentucky:
www.adminastar.com/Providers/Carrier/ContactInformation/ContactInformation.html
Region B DMERC for ten state region of Illinois, Indiana, Maryland, Michigan, Minnesota, Ohio, Virginia, West Virginia, Wisconsin, and Washington DC:
www.adminastar.com/Providers/DMERC/ContactInformation/ContactInformation.html
E-Commerce Connection Feedback Survey
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