Highmark Medicare Services
Provider Outreach & Education (POE) Advisory Group - Pennsylvania
Meeting Minutes
February 6, 2008
9:30 AM – 11:00 AM
Welcome and Introductions
Denise Church, Manager Outreach and Education, welcomed the group to the PA POE Advisory meeting, introductions were made of those that participated by phone and those that were present.
Current Quarter and Future Education Activities
Kim Droboniku, Supervisor Outreach and Education, advised the committee of the upcoming FISS Basic and FISS Advance (see schedule below) classes scheduled for February and March. However, moving forward POE will host FISS Basic classes starting on an every other month rotation. The FISS Advance classes do to low attendance will be conducted quarterly. POE is also looking in utilizing the CMS on-line tutorial for FISS to enhance our education.
|
FISS Basic |
FISS Advanced |
||
| Camp Hill | 2/12/08 | Camp Hill | 3/11/08 |
| Timonium | 2/21/08 | Timonium | 3/18/08 |
| Pittsburgh | 2/26/08 | Pittsburgh | 3/25/08 |
POE will be doing a Lunch and Learn on February 27, 2008 on modifiers. The committee asked specifically what modifiers were going to be discussed, e.g., 25, KX? The POE staff at today’s meeting received specific modifiers to be discussed. The staff will incorporate the requested modifiers into the Lunch and Learn.
The teleconferences scheduled for February are:
- Medicare Claims Errors (2/26)
- RHC/MSP (2/27)
For the month of March, the Provider Outreach and Education department will be offering New Provider workshops, a Lunch and Learn on ESRD and a teleconference on Psych/Hospital. Please watch our website at: http://www.highmarkmedicareservices.com/parta/outreach/index.html
As a reminder, the ACT is scheduled for March 4th from 1-2:30 p.m. If you have any topics you would liked discussed, please email them to Kim.Droboniku@highmarkmedicareservices.com .
CERT
A CERT update was provided by Kim Droboniku. The claims sampled from 7/2006 – 6/2007 indicated that the Pennsylvania Paid Claims Error Rate is 1.5%. This represents an 80% increase from last month’s error rate of 0.64%.
Review of the last two feedback files (Jan 08) identified the following errors:
- 36415 Venipuncture medically unnecessary
- 97110 PT Insufficient documentation
- 97113 Aquatic Therapy Insufficient documentation
- 97116 Gait Training Insufficient documentation
- P9604 Travel Allowance Insufficient documentation
Reminder: Please respond to CERT Requests in a timely manner.
Medicare Updates
The following topics were discussed:
- February is American Heart Month
- Draft LCDs coming February 2008
- CR 5764- New Patient Status
- CR 5850- Point of Origin Indicator
Provider Contact Center
The committee was asked to comment regarding the time and topics of the Customer
Contact Center Representative training. The committee wanted to know what the procedure was for calls that cannot be answered by a CSR. These questions are to be given to a Technical Supervisor and/or the Research Specialist for a response. In certain circumstances or if you feel you issue needs immediate attention you may call or email either Kim Droboniku, Denise Church or Ed Sanchez.
Reminder: Training for customer service representatives will be conducted every Monday until 9:30 a.m.
EDI
An EDI update was provided by Patti Cassel regarding the following topics:
New NPI Edits for Secondary Providers
Effective May 23, 2008, claim rejections will occur if the secondary provider’s National Provider Identifier (NPI) is missing on a claim when secondary provider information is reported on the claim. Secondary providers include attending, operating, other, and facility providers. When secondary provider information is submitted, the NPI must be submitted or the claims will be rejected.
The following new rejection edits will be encountered on the IG Edit Report for electronic claims received effective May 23, 2008, when a valid NPI is not received for secondary providers.
|
Edit Message |
Loop |
Segment and Data Element |
Edit Logic |
|
ATT/OPER/OTH UPIN NOT ALLOWED |
2310A |
REF01 |
The value reported in the REF segment is equal to 1G and the receipt date is on or after the ‘Allow UPIN’ in the system control file |
|
ATT/OPER/OTH NPI REQD |
2310A |
NM108 |
The value reported in NM108 is not equal to XX and the receipt date is on or after the ‘SEC NPI’ in the system control file |
Rejection of Electronic Claim Status Requests that Lack National Provider Identifiers (NPIs)
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 have 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. The absence of an NPI as of May 23, 2008, will result in the 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.
PC-ACE Pro32 Version 1.89 Upgrade Now Available
PC-ACE Pro32 is a Medicare software product that offers the ability to prepare Medicare Part A HIPAA- compliant electronic claim files. To provide the most up-to-date information within PC-ACE Pro32, the product is updated quarterly. The most recent upgrade was released on January 23, 2008. To streamline the distribution process, 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.
As of September 5, 2006, there is a quarterly $25 shipping and handling fee for all PC-ACE Pro32 requests via CD-ROM. This fee will be 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.
New Look to EDI Enrollment Forms
EDI Enrollment Forms are often updated to ensure the most relevant data is collected and to make the enrollment process more efficient. Highmark Medicare Services has revised the separate Part A and Part B EDI Enrollment Forms and combined them into one set of forms, which can be used when enrolling for EDI under either EDI Part A or Part B. However, you cannot enroll for both EDI Part A and Part B on one form. If you wish to enroll for both EDI Part A and Part B you must submit one set of forms for Part A enrollment and one set of forms for Part B enrollment. The new forms show a revised date of 01/08.
It is important that you use the most recent version of any EDI Enrollment Form when enrolling for EDI or updating your existing EDI status. Effective March 3, 2008, Medicare EDI Services will begin to return all EDI Enrollment Forms received that contain a form revision date older than 01/08. The form revision date is located in the lower left-hand corner of all EDI Enrollment Forms. Due to form consolidation, some forms are being eliminated and only the revised forms will be used. The following chart shows the form revisions.
| Form Name | Old Form Number and Revision Date | New Form Number and Revision Date |
| EDI Enrollment Instructions | 10202 W 06/07 (Part B) 10213-1 C 09/06 (Part A PA) 10213 E 09/06 (Part A MD/DC) |
10202 X 01/08 |
| EDI Agreement Form | 8275 H 11/06 (Part B) 8277-1 D 11/06 (Part A PA) 8277 F 11/06 (Part A MD/DC) |
8275 J 01/08 |
| EDI Setup Requirements |
8276 H 06/07 (Part B) |
8276 J 01/08 |
|
PC-ACE PRO-32 Agreement Form |
8287 F 01/07 | 8287 G 01/08 |
| MCE Agreement Form | 8726 W 07/07 | 8726 X 01/08 |
| Electronic Remittance Advice (ERA) Enrollment Form |
8262 J 09/06 (Part B) 8286-I D 09/06 (Part A PA) 8286 E 09/06 (Part A MD/DC) |
8262 K 01/08 |
Before completing and submitting an EDI Enrollment Form, please visit our website at: www.highmarkmedicareservices.com and download the most recent version of all EDI Enrollment Forms. This will ensure you are completing and submitting the most recent version of the EDI Enrollment Forms.
NPI
Data dissemination is coming soon, please check the NPI website to make sure that all of your information is correct and look at the optional fields in case there is information that you don’t want disclosed.
Provider Enrollment
Judy Andidora from Provider Enrollment Service (PES) discussed the PECOS-WEB coming in spring of 2008 and the IACS-PC Enrollment process.
Judy reminded the group that the only way to currently be established as a provider/supplier with Medicare or update information on an already established provider/supplier is by completing a lengthy paper form called the CMS-855 and mailing it to your Medicare carrier. The information on the CMS-855 is then verified and if the provider/supplier meets the criteria for Medicare enrollment, the information is entered into a national database called PECOS (Provider/Supplier Enrollment Chain Ownership System).
The Centers for Medicare and Medicaid Services (CMS) will soon make available to provider/suppliers (other than DMEPOS) internet access to PECOS through a secure CMS website. Access to PECOS via the web will allow providers/suppliers to apply for enrollment in the Medicare program as well as view and request updates to already existing enrollment information. This web-based format will make enrolling in Medicare and keeping provider/supplier information updated much more convenient and user-friendly. The built-in edits and user instructions in PECOS-Web should simplify the process of establishing and maintaining your provider file information with Medicare. While verification of data will still be done by the Medicare contractor, the time spent gathering missing or incomplete information should be greatly reduced by this new process.
Those providers/suppliers who wish to take advantage of the new PECOS-Web application must first register with CMS as a member of the "Individuals Authorized Access to CMS Computer Services – Provider Community" (IACS-PC). A provider has the choice of registering as either an individual or as an organization with a delegated Security Official, User Group Administrator(s), and End User(s). Once registered in IACS-PC, a user login ID and password will be issued for accessing the CMS website and using the new PECOS-Web application based on the established IACS role. While the PECOS-Web application is not yet active, it is expected to be available in early 2008.
Since the IACS-PC application is intended to safeguard the privacy, security and authorized access to Medicare provider/supplier information, enrollment in IACS-PC may take several weeks to be completed. For this reason, CMS is encouraging provider/suppliers to establish their IACS-PC user IDs by following instructions outlined in three MLN Matters articles about IACS-PC.
Links to the article are:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0747.pdf http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0753.pdf http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0754.pdf
You should review each article and the user guides referenced in the articles to fully understand the roles and responsibilities for the various IACS-PC access types.
Continue to watch the Highmark Medicare Services and CMS websites for more information on the features and advantages of PECOS-Web coming to you this spring.
Questions and Comments
Renee Mirilovich from UPMC asked the question about how the secondary providers’ taxonomy codes would be edited?
Answer: If a taxonomy code is reported on the claim, it will be 'edited' against the taxonomy code list. That is the only edit for these codes.
Paul Cefrick from Sharon Regional Health System sent in a few comments after the meeting. They are as follows:
Lunch and Learn topics:
- Compliance rules that Medicare has for certain situations
- 3-day rule, Same Day Readmissions to the same provider, and the transfer DRG rule (billing with correct discharge status codes).
Education Resources
- An updated list of Medicare Advantage plans
Also, I had just one comment about the submission of no-payment claims. The additional Medicare Advantage no payment claims, that we are submitting, as of January 2008, and the MSP no payment claims for claims paid in full by the primary insurance, the process of submitting claims for reporting purposes only is becoming more time consuming and burdensome.
Conclusion
Denise Church wrapped up the meeting by thanking the POE Advisory committee for attending the meeting and reminded everyone that the next meeting of the PA POE Advisory Group will be held on May 7, 2008 at Highmark in Camp Hill, PA.