POE Advisory Meeting Maryland/DC
Meeting Minutes
November 14, 2007
Providers/Organizations:
- Kristi Pederson-Fundamental Health Care
- Traci Phillips-Maryland Hospital Association
- Audrey Walker- Johns Hopkins Health System
- Randy Zimmerman- Johns Hopkins Health System
- Marybeth Koretke- Five Star Quality Care
- Patrick Hamilton- Centers for Medicare and Medicaid Services
- Lynne Tierney-Centers for Medicare and Medicaid Services
Highmark Medicare Services:
- Ed Sanchez
- Judy Andidora
- Jenn Baran
- Patty Cassel
- Linda Cassel
- Kim Droboniku
- Cathy MacKenzie
Welcome and Introductions
POE Advisory Group Guidelines
The primary function of the POE Advisory Group is to assist us in the creation, implementation, and review of our provider education strategies and efforts. We ask that the POE Advisory Group provide input and feedback on our training topics, provider education materials, and dates and locations of provider education workshops and events. The group also identifies salient provider education issues, and recommends effective means of information dissemination to all appropriate providers and their staff. The POE Advisory Group should be used as a provider education consultant resource, and not as an approval or sanctioning authority.
The focus of the group meetings should remain centered on the development and implementation of effective provider communication materials and strategies.
Current Quarter and Future Education Events
The calendar of events for the next few months was described, for a complete schedule: http://www.highmarkmedicareservices.com/calendar/parta/index.html
We solicited suggestions for the upcoming “Ask the Contractor” Teleconferences and Lunch and Learn teleconferences. The following topics were suggested:
- CR 5653 Medicare Advantage requirements for Hospitals, a teleconference is scheduled for December. It was suggested to include SNF requirements as well.
- NPI- A teleconference is scheduled for December 13th. It was suggested to include NPI requirements on claims and upcoming deadlines.
- Teleconference for SNFs - What is a benefit period? What breaks a benefit period?
In 2008 we will be offering webinars.
CMS Update
Patrick Hamilton announced that the CMS regional office (CMS RO) is reorganizing to take more responsibility oversight over the Fiscal Intermediaries, Carrier and MACs. Lynne Tierney and Patrick are responsible for our region. CMS RO is responsible for all of the regions in the MAC contract J12 except for New Jersey. The CMS Ro in New York is responsible for this state.
Any issues or questions for CMS can be sent to:
- Patrick Hamilton at 215-861-4097 or Patrick.hamilton@cms.hhs.gov
- Lynne Tierney at 215- 861-4763 or Lynne.Tierney@cms.hhs.gov
CERT Update
Kim Droboniku asked for feedback on the best way to educate providers on billing the correct RUG code. Most of the SNF RUG errors are due to rehabilitation services being provided for fewer minutes than the RUG code requires during a particular assessment period. It was suggested that a letter be generated from the Medical Director to the Administrators of the SNFs.
EDI Update
NPI for Primary Providers
This information is included in the November 2007 Part A EDI Xchange located on our website at: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange_1107.pdf
Effective January 1, 2008, your Medicare fee-for-service claims must include an NPI in the primary provider fields on the claim (i.e., the billing and pay-to provider fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI. The secondary provider fields (i.e., attending, operating and other) may continue to include only your legacy number, if you choose. Failure to submit an NPI in the primary provider fields will result in your claim being rejected beginning January 1, 2008.
In addition, if you already bill using the NPI/legacy pair in the primary provider fields and your claims are processing correctly, now is a good time to submit a small number of claims containing only the NPI in the primary provider fields. If the claims are not rejected, we strongly encourage you to increase your NPI claim volume.
Medicare Fee-for-Service (FFS) National Provider Identifier (NPI) Final Implementation
This information is included in the November 2007 Part A EDI Xchange located on our website at: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange_1107.pdf
Currently, Medicare FFS allows submitters to send both the NPI and legacy PIN for inbound transactions. No later than May 23, 2008, providers should ensure that all HIPAA transactions sent to Medicare contain only valid NPI numbers (no legacy provider numbers).
Once CMS ends its NPI contingency, the legacy number will NOT be permitted on any inbound or outbound electronic transaction (there are exceptions to the 835 remittance advice - see CR5452). Once instructed to do so by CMS, Medicare contractors will begin rejecting claims, including claims submitted via Direct Data Entry (DDE), that contain legacy provider numbers for any primary provider instead of or in addition to the NPI number.
For more information, please see the MLN Matters article located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5728.pdf
PC-ACE Pro32 Version 1.87 Upgrade Now Available
This information is included in the November 2007 Part A EDI Xchange located on our website at: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange_1107.pdf
The most recent quarterly upgrade of the PC-ACE Pro32 software was released on October 25, 2007. To streamline the distribution process, Version 1.87 of the PC-ACE Pro32 software program is available via an internet download. This internet download is available free of charge for all new and existing PC-ACE Pro32 customers. Download instructions were mailed to existing PC-ACE Pro32 customers on the release date.
If you require a CD-ROM to download PC-ACE Pro32 Version 1.87, there is a quarterly $25 shipping and handling fee for all PC-ACE Pro32 requests via CD-ROM. This fee is billed at $100 annually, covering the initial shipping and handling of the CD-ROM and the shipping and handling for any additional upgrades issued within the next year. To save time and money for you and the Medicare program, we strongly encourage you to download this program when enrolling or upgrading.
If you are interested in more information about PC-ACE Pro32 or would like to enroll to begin using this product, please visit our website at http://www.highmarkmedicareservices.com/parta/edi/pcace32.html.
The PC-ACE Pro32 Release Newsletter can be viewed on our website at: http://www.highmarkmedicareservices.com/parta/edi/qtrly-pcace-newsletters.html
Claim Status Category Code and Claim Status Code Update
This information is included in the November 2007 Part A EDI Xchange located on our website at: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange_1107.pdf
The Health Care Claim Status Codes and the Health Care Claims Status Category Codes for use in the X12N 276/277 Claim Status Inquiry/Response Transaction Set were updated on July 9, 2007. Although these codes are available now for review, the codes designated as “updated 07/09/2007” will not be used by Medicare Contractors until January 7, 2008. The new codes are available for review at: http://www.wpc-edi.com/products/codelists/alertservice.
For more information, please see the MLNMatters article located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5687.pdf
Rejection of Electronic Claim Status Requests that Lack National Provider Identifiers (NPIs)
This information was recently received from CMS:
Beginning May 23, 2008, all electronic claim status requests (X12 276) must use the HIPAA-mandated NPI for provider identification. Claim status requests that do not contain the NPI will be returned to the sender. All claim status responses (X12 277) returned to the sender as a result of the claim status request will contain only NPIs as of May 23, 2008, even if the claim status request is received prior to May 23, 2008, using a legacy number. In returning the NPI, Medicare will use a crosswalk file that relates the legacy number to the provider’s NPI. If the legacy number maps to more than one NPI, Medicare will return the first active NPI in the 277 response. The same policy applies to direct data entry claim status inquiries. (It also applies to Internet claims status screens operated under an Internet demonstration program, but this is not permitted for this contract area.) The absence of an NPI as of May 23, 2008, will result in rejection of the inquiry by these direct data entry processes.
Providers are strongly encouraged to begin submitting their NPIs in their X12 276 inquiries prior to May 23, 2008. It is particularly important if the provider has more than one NPI, but was assigned only one legacy number by Medicare for claims submission purposes. For more information, please read the MLN article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5726.pdf
If a provider has a change of ownership, when a provider makes an adjustment on a claim how will the NPI be impacted since they will have a different NPI? Patrick Hamilton is researching this question.
Provider Enrollment
Highmark Medicare Services, in accordance with Section 7.1.1 of Chapter 10 in the Program Integrity Manual, will request a complete CMS-855 application, if a provider/supplier requests any change to the information on their file, and they are not in the CMS Provider Enrollment Chain and Ownership System (PECOS). In the event of such a request, the provider/supplier has 60 calendar days from the date of the request to furnish the entire CMS-855 application.
If the provider/supplier fails to submit a complete application within the 60-day period, we are now required by CMS to take steps to recommend revocation of the provider’s/supplier’s billing privileges.
To avoid revocation, please submit all information requested by Highmark Medicare Services within 60 calendar days from the date of the request.
Medicare Updates
The following topics were presented:
- Organ Transplant Facility Requirements
- MSP EOB Requirements
- 32148 Reason code, bulletin coming soon
- CERT report will be posted to website soon- providers had no suggestions for additional fields
Provider Contact Center
The following were suggestions made to improve communications with the contact center:
- Systems issues need to be relayed to providers much more quickly to alleviate calls to the contact center. The providers expressed that they would like us to report that we are aware of the problems and then provide updates as needed.
- Post to website a description of the new Medical Review reason codes and what we are looking for.
- Providers expressed a lot of claims are hitting Medical Review edits, even though no ADR is generated. If these claims need to be adjusted, a hard copy claim needs to be submitted because it received these edits.
- -KX modifier claims are rejecting over the maximum by Medical Review, overturned on appeal.
- Johns Hopkins Health System noted that they felt that overall service has greatly improved; they are getting consistent and accurate answers.
- Status location SMV801 has long delays; the end result is that the claim is RTPd.
- All providers expressed concern over being put on hold after only their names were requested. The providers expressed they would rather be on hold longer.
- Providers have received information that CMS-838 forms need to be submitted to someone else other than June Plutschak. Providers were assured they would get to the correct person, but we will issue the new contact person for the reports.
The next meeting will be held on February 20, 2008.