MCS News Update March 2005 - Temporary Change to Payment Floor

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Edit Implementation Transition to the Multi-Carrier System (MCS)

Attention New York Part B Electronic Claim Submitters

As part of our education efforts related to the transition to MCS from our current system, we will keep you informed of differences that will impact you by posting them to the Web site as we become aware of them. In this document, we have also included edits that we have previously posted to the Web so that you have access to them again, just in case you might have missed them.

IMPORTANT – Social Security Number in the Subscriber Loop

*Please be aware that many submitters are sending a Social Security Number (SSN) in the subscriber loop. According to the Implementation Guide (IG), this is not valid for Medicare claim submissions. We will be editing for this information in the near future, and if the SSN is present in the 2010BA loop, your claim will reject in front-end validation processing with the following edit:

Edit M026- Invalid Medicare Value

The Provider Taxonomy Code SetMedicare Part B does not require you to submit the Provider Taxonomy Code Set, but if you do submit a taxonomy code, it must be valid. HIPAA requires that submitted data, which is part of a named code set, must be valid data from that code set. The health care provider taxonomy is a named code set in the 837 professional implementation guide, thus carriers must validate the inbound taxonomy codes against their internal HPTC tables. If you submit a claim with an invalid taxonomy code, your claim will reject in front-end validation with the following edit/error message:

Edit 1456 -Invalid Taxonomy Code

The HPTCs are updated twice per year, in April and October. The HPTC code list is available in two forms from the Washington Publishing Company: http://www.wpc-edi.com/codes/taxonomy

Provider Numbers (PIN)

It is extremely important that the provider identification number (PIN) come to us in the proper format. Empire Medicare Services requires the provider number to be in a 10-position format. Your claim will be rejected if the format is not submitted correctly. An example of the correct format follows:

Mary Smith, MD Provider Number 999991 =

Correct- MS09999910 (10 digits)

If your claim is submitted with an incorrect format to the provider number, the claim will reject in the front-end validation process with the following error/edit message:

Edit M013 - Submit BPRV Not on File

This format must be used consistently for both the individual and the group and must be valid for proper adjudication.

If more than one solo provider treats the same patient; a separate claim must be submitted for each provider.

When billing under a group provider ID, you must enter an individual Provider ID in the Rendering Provider 2310B loop.

Provider Number used for Medicare Part B Claims Processing

The Billing Provider ID is required in Loop 2010AA. (Format must be valid)

Must have the actual address where the service is performed.

If the address is not the actual address, use the 2310D loop to list the address.

The Rendering Provider ID in 2310B is used when the 2010AA is a group number.

This lets us know who the provider is who rendered the service. Each provider must be enrolled with Medicare as part of the group. (Format must be valid)

The Medicare Processing System will use this number to adjudicate the claim when you have an invalid format in your group number in the 2010AA loop

Medicare Part B Format

The provider Number has ten positions, as follows:

The format used for both the individual and the group must be valid for proper adjudication.

Positions User Entry

1-2	Enter one of the following:
	Individual Provider Only: Enter two alphabetic characters identifying the initials of the Provider’s first and last name. For example, ‘JS’ for ‘John Smith.’
	Group Provider Only: Enter the first two characters of the Group or Corporate Provider Name (where the first letter of the Group or Corporate Name may be followed by a blank – a blank will be used). For example, ‘WE’ would be entered for ‘West Medical Group’ or ‘N_’ would be entered for ‘N Y Medical Ctr.’ The Group Provider should be for group providers and institutions (ambulance companies, labs, etc.) that are non-person entities.
3	Must contain a zero.
4-8	Contains the Provider Code
9	Identifies the provider’s office where services were rendered (address code 1, 2, 3).
10	Must contain a zero.

If more than one solo provider treats the same patient; a separate claim must be submitted for each provider.

Admission Date Missing

MCS now requires the date of admission for places of service 21 (Inpatient hospital), 51 (Inpatient Psychiatric Facility), and 61 (Inpatient Rehabilitation Facility). If this date is missing, the claim will reject in the front-end validation process with the following error/edit message and you will need to correct that claim and resubmit.

Edit 1473 –Admission Date Missing

Invalid Date Last Seen – NSF - EA0 Record

For those submitters who still submit in the non-HIPAA compliant NSF format, a new edit is being installed as a result of the MCS Migration. In some instances, our submitters are zero filling date last seen fields. In the past, we have been able to accept zero-filled fields. With the migration to the MCS system, we will no longer be able to accept zero-filled fields. If your claim situation does not require the date last seen field to be entered on the claim, do not zero-fill the field. If you zero-fill this date field, your claims will be rejected. MCS does not allow you to zero-fill the date last seen field. Unless this problem is fixed in your program, you will not be able to submit your claim.

Important! New Edit for Electronic Submitters in MCS

Provider Number linked to Submitter ID

Effective April 8, 2005, Empire Medicare Part B will implement a new edit for claims submitted in the non-HIPAA compliant National Standard Format (NSF) and X12 837 pre-HIPAA versions. The new edit will verify that the provider is authorized for the submitter who sent the claim file to Empire Medicare Part B. The provider must be linked with the submitter in Empire’s control file in order to submit claims. The file will be rejected with the front-end edit listed below.

Effective Date and Time for the new edit:
Validation of the provider numbers will begin April 8, 2005 after 11:00 a.m. Medicare Part B claims that contain unauthorized providers will reject with edit BBA0040:

BBA0040 PROVIDER NOT AUTHORIZED FOR MEDICARE PART B SUBMITTER

This edit occurs when the provider in Record BA0, field 2, is not authorized for the submitter in Record AA0, field 2. This edit is applicable only to Medicare Part B claims.

Record Type/Field #: AA0/2

BA0/2

Rendering Provider Name 2310B Loop Is Present – NO 2000PRV

This edit will not allow a 2000A PRV segment (billing provider taxonomy code) with a 2310B loop (Rendering provider name). If 2310B loop is present, do not use the 2000A PRV segment.

Edit 11320 – 2310B, 2000A SENT-PRV REQD AT 2310B ONLY:

Billing and Pay-To Provider Are the Same

If the billing and the pay-to providers are the same, this edit will be received. The 2010AA REF segment and the 2010AB REF segment cannot be the same.

Edit 20282 – Billing and Pay-to Providers are the same.

Attention New York Part B Electronic Claim Submitters – Edit Implementation, March 2005

This article advises electronic submitters that 50 new edits will be implemented immediately.

There are a series of edits that are added to the system that will not allow a range of dates when qualified as a single date.

Changes have been added to the verbiage of the edit 10804.

New edits have been added to the HI segment and the SV1 segment for the diagnosis.

A new edit will identify claims that have multiple payers on Medicare Secondary Payer (MSP) claims. MSP claims with multiple payers will be rejected.

There is a matrix listing the segment, element name, loop and edit.

Listed below is the link for the article that lists these edits.

http://www.empiremedicare.com/news/nynews05/031105edit.htm

Please remember to visit our Web site www.empiremedicare.com

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