Part B News: EDI News

EDI News

Articles:

New NPI Rejections Effective September 10, 2007
Medicare Fee for Service (FFS) National Provider Identifier (NPI) Final Implementation―Key Implementation Dates
New NPI Informational Edits―January 2008
Claim Status Category Code and Claim Status Code Update
ASCA and Railroad Medicare―January 2008
Bank Mergers, Acquisitions, and Closed Accounts―What About My EFT?
Informational Edits Are VERY Important
Use Caution When Enrolling for EDI

New NPI Rejections Effective September 10, 2007

On September 10, 2007, National Government Services, Inc. Medicare Part B began editing the National Provider Identifier (NPI)/legacy ID combinations for validity against the NPI crosswalk file for claims submitted on paper or electronically. Where a match cannot be located on the crosswalk, claims are being rejected or returned to the provider.

When the claim is rejected or returned, a provider should first verify that the correct NPI was submitted. If the correct NPI was submitted, you will need to verify that your legacy identifier (PIN) number corresponds with the information on file with the National Plan and Provider Enumeration System (NPPES). NPPES data may be checked, or updated as appropriate, online at https://nppes.cms.hhs.gov . Once corrected, please send a small volume of claims using your NPI. If the claims are not rejected, we strongly encourage you to increase your NPI claim volume.

If your NPPES information is correct and you have included and matched ALL Medicare legacy identifiers with a corresponding NPI in NPPES, but you are experiencing provider identifier problems with your claims that contain an NPI, you may need to submit a Medicare enrollment application (i.e., the CMS-855). Please contact your contractor if you need more information.

More information and education on the NPI may be found on the CMS NPI page at http://www.cms.hhs.gov/NationalProvIdentStand on the CMS Web site. Also, providers can apply for an NPI online at: https://nppes.cms.hhs.gov .

Medicare Fee-for-Service (FFS) National Provider Identifier (NPI) Final Implementation

Currently, Medicare FFS allows submitters to send both the NPI and PIN for HIPAA inbound transactions. No later than March 1, 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 electronic or outbound electronic transaction (there are exceptions to the 835 remittance advice; refer to CR 5452). Once instructed to do so by CMS, Medicare contractors will begin rejecting claims 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 .

Medicare’s Key Dates for NPI Usage

Date	Implementation Steps
January 1, 2008	Part A 837I electronic claims and UB-04 paper claims without an NPI in fields identifying the primary provider (billing and pay-to) will be rejected. Legacy identifiers paired with NPIs in the primary provider fields on the claim will still be acceptable as will legacy-only numbers in secondary provider fields.
March 1, 2008	Medicare Part B FFS 837P and CMS-1500 claims must include an NPI in the primary fields on the claim (i.e., the billing, pay-to, and rendering fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI on the claim. You may not submit claims containing only a legacy identifier in the primary fields. Failure to submit an NPI in the primary fields will result in your claim being rejected or returned as unprocessable. Until further notice, you may continue to include legacy identifiers only for the provider secondary fields.
May 23, 2008	In keeping with the contingency guidance issued on April 3, 2007, CMS will lift its NPI contingency plan, meaning that only the NPI will be accepted and sent on all HIPAA electronic transactions (837I, 837P, NCPDP, 276/277, 270/271, and 835), paper claims and SPR remittance advice. This also includes all secondary provider fields on the 837P and 837I. The reporting of legacy identifiers will result in the rejection of the transaction. CMS will also stop sending legacy identifiers on COB crossover claims at this time.

New NPI Informational Edits

Effective with electronic claims received after 4:00 p.m. on Friday, October 8, 2007, National Government Services Part B began editing claims for primary provider identifiers (i.e., billing, pay-to and rendering provider fields). For those claims received without the NPI for primary providers, new informational edits are being issued. (Refer to article below entitled “Informational Edits Are VERY Important” for more information.) When the billing, pay-to, or rendering provider NPI is omitted, the informational edits occur at the batch or claim level. You will see the following edit number and message on the MCS Edit Report:

Edit ID	Edit Message	Loop	Segment	Edit Condition
M389	Invalid Value	2010AA	NM108	The edit sets when the 2010AA loop and the NM1 are submitted but NM108 does not contain XX.
M390	Invalid Value	2010AB	NM108	The edit sets when the 2010AB loop and NM1 are submitted but NM108 does not contain XX.
M391	Invalid Value	2310B	NM108	The edit sets when the 2310B loop and NM1 are submitted but NM108 does not contain XX.
M392	Invalid Value	2420A	NM108	The edit sets when the 2420A loop and NM1 are submitted but NM108 does not contain XX.

If you now report both the NPI and legacy ID combination in the primary provider fields, and your claims are processing correctly, you are encouraged 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.

Effective February 4, 2008, the following pre-pass edits will be set to informational. These edits will be turned on to reject at a later date in accordance with full NPI implementation.

Edit Number	Loop/Data Element		Name	Description
M393	2310A	NM108	Referring Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M394	2310C	NM108	Purchased Service Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M395	2310D	NM108	Service Facility Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M396	2310E	NM108	Supervising Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M397	2420B	NM108	Purchased Service Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M398	2420C	NM108	Service Facility Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M399	2420D	NM108	Supervising Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M400	2420E	NM108	Ordering Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M401	2420F	NM108	Referring Provider Identification Code Qualifier	Edit will set if qualifier is not XX or blank, or if qualifier field is blank and the loop has a REF segment.
M402	2010AA	REF01	Billing Provider Secondary Identification	The edit sets when qualifier field = 1C or 1G.
M403	2010AB	REF01	Pay-To Provider Secondary Identification	The edit sets when qualifier field = 1C or 1G.
M404	2310B	REF01	Claim Rendering Provider Secondary Identification	The edit sets when qualifier field = 1C or 1G.
M405	2420A	REF01	Detail Rendering Provider Secondary Identification	The edit sets when qualifier field = 1C or 1G.
M406	2330E	REF01	Other Payer Rendering Provider Secondary Identification	The edit sets when qualifier field = 1C or 1G.
M417	2310A	REF01	Referring Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M418	2310C	REF01	Purchased Service Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M419	2310D	REF01	Service Facility Location Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M420	2310E	REF01	Supervising Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M421	2420B	REF01	Purchased Service Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M422	2420C	REF01	Service Facility Location Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M423	2420D	REF01	Supervising Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M424	2420E	REF01	Ordering Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M425	2420F	REF01	Referring Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M426	2330D	REF01	Other Payer Referring Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M427	2330F	REF01	Other Payer Purchased Service Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M428	2330G	REF01	Other Payer Service Facility Location Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.
M429	2330H	REF01	Other Payer Supervising Provider Reference Identification Qualifier	The edit sets when qualifier field = 1C or 1G.

Claim Status Category Code and Claim Status Code Update

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 MLN Matters article located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5687.pdf .

Reporting Tips

ASCA and Railroad Medicare

Effective January 1, 2008, Administrative Simplification Compliance Act (ASCA) enforcement review decisions made by non-railroad (non-RR) Medicare contractors will apply also to the same providers when billing the Railroad (RR) Medicare Carrier (RMC).

The Administrative Simplification Compliance Act (ASCA) requires that providers submit claims to Medicare electronically to be considered for payment, with a limited number of exceptions, including an exception that allows providers that submit fewer than 120 claims per year (no more than 10 claims per month or 30 claims per quarter) to Medicare to continue to submit paper claims. See the Medicare Claims Processing Manual, Chapter 24, Sections 90-90.6 at http://www.cms.hhs.gov/manuals/downloads/clm104c24.pdf .

Due to the dispersion of railroad (RR) retirees in the United States, however, few physicians/practitioners/suppliers treat a large number of RR Medicare beneficiaries. As a result, many of these providers submit fewer than ten claims a month to the RR Medicare Carrier (RMC), and they have been allowed to continue to submit paper claims to the RMC. In addition, the same providers generally treat non-RR Medicare beneficiaries and submit more than ten claims a month to other Medicare contractors.

However, ASCA electronic claim filing exceptions apply to Medicare overall, and do not differentiate based on contractors or between RR and non-RR contractors. Providers that submit paper claims to multiple Medicare contractors, including both RR and non-RR Medicare contractors, are subject to ASCA Enforcement Review by each of those contractors.

If a non-RR Medicare contractor: 1) determines that a provider does not meet criteria which would permit that provider to continue to submit Medicare claims on paper and 2) notifies the provider that all paper claims submitted on or after a specific date will be denied, then that same decision is to be applied to that provider if submitting paper claims to the RMC even if that provider would not normally submit ten or more paper claims to the RMC monthly.

For more information regarding these upcoming changes, please read the MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5606.pdf.

Bank Mergers, Acquisitions and Closed Accounts ― What About My EFT?

If you use electronic funds transfer (EFT) and are notified regarding a merger or acquisition of your financial institution, your bank routing number and account number may change. When this occurs, you need to contact National Government Services Medicare so we can update our records with your new EFT banking information. We cannot automatically update your banking information, and we cannot guarantee your financial institution will continue depositing funds into your account indefinitely with the incorrect information. Therefore, we need a new EFT Agreement Form from you with the updated information. If your financial institution merged with or was acquired by another institution, please contact that institution and ask if either their routing number and/or account number has changed. If the number(s) changed, you can download an EFT Agreement Form at http://www.empiremedicare.com/partbny/billing/nyforms.htm.

To ensure that payments continue to be deposited into your account with no delays, you must complete and sign the form, include a voided check or preprinted deposit slip, and send to Provider Enrollment Services immediately. If you use EFT and decide to close your bank account, your financial institution will return all Medicare payments to National Government Services Medicare if payments are sent after the account is closed. It is important that you notify National Government Services as soon as possible, but before you close your account. You must complete and sign an EFT Agreement Form, include a voided check or preprinted deposit slip, and return it to us immediately. This will minimize the negative impact to your cash flow.

Informational Edits Are VERY Important

An informational edit is an educational error on the MCS Edit Report to inform you that there is an issue within a claim that may cause a claim rejection (deletion) edit in the future. This is a warning that immediate action is needed to avoid a future rejection.

Informational Edit Example:

Informational edits do not cause claims to be rejected (deleted). However, when an informational edit is changed to a claim rejection (deletion) edit in the future, claims will be rejected. Therefore, it is important to correct the problem(s) causing informational edits now before it impacts your claims/payment. Any claims and/or transmissions that are rejected (deleted) on the MCS Edit Report are not forwarded to the Medicare processing system for processing (payment or denial) and will not appear on your Standard Paper Remittance or Electronic Remittance Advice (ERA).

What should I do if I receive an Informational Edit?

If you receive rejections (deletions) on this report, use the X12N Transaction User Guide to understand and correct errors. The user guide is located at http://www.empiremedicare.com/mcs_ny/mcs837.pdf.

Verify that the claim data being reported is correct and complete. If the claim data is not correct, make the necessary corrections immediately. If the data is correct, make sure it is reported in the correct loop/segment/element of the ANSI X12N 837 file. Immediate action will help prevent any additional informational edits as well as any future claim rejections (deletions) when the informational edits become claim rejection (deletion) edits.

Use Caution When Enrolling for EDI

Did you know that a high percentage of the electronic data interchange (EDI) enrollment forms received in Medicare EDI Services are returned to the sender for correction or completion? The EDI enrollment forms must be completed accurately and legibly in order to be processed. Incomplete or inaccurate EDI enrollment forms delay your office from taking advantage of EDI billing. The top reasons for returned EDI enrollment forms are listed below. Please review this list and keep it in mind the next time you need to submit EDI enrollment forms.

TIP : Please reference the instructions for completing EDI enrollment forms. EDI enrollment instructions are available on our Web site at: http://www.empiremedicare.com/mcs_ny/mcs837.pdf.

Reason	Corrective Action
Number 1: The NPI of the group, physician, or supplier does not match our NPI records.	The NPI reported on the forms must be assigned to the group, physician, or supplier ID reported on the claims.
Number 2: The address of the group, physician or supplier does not match our records.	The address on file is the legal business address reported on the CMS-855 form. The legal address is also reported on your Medicare checks and standard paper remittance (SPR). To avoid delays in your EDI enrollment, report the address exactly as it appears on your payments or CMS-855 form.
Number 3: The name of the group, physician, or supplier does not match our records.	The name of the group, physician, or supplier on file is the legal business name reported on the CMS-855 form. The name on file is also reported on your Medicare checks and standard paper remittance (SPR). To avoid delays in your EDI enrollment, report the name exactly as it appears on your payments or CMS-855 form.
Number 4: The signature, title, and/or date are missing, invalid, or unauthorized. (i.e., no signature stamps).	The form must be signed (signature stamps are not acceptable), contain the date the form was signed, and the title of the person who signed the form. The only acceptable titles are: Provider Owner Partner President Vice President CEO (Chief Executive Officer) CFO (Chief Financial Officer) COO (Chief Operating Officer) Chairman Medical Director Secretary of Treasurer of Corporation Executive Director Physician Assistant (or Group Provider or Officer of Corporation on behalf of Physician Assistant) Captain (for ambulance or fire specialty use only) Authorized Official
Number 5: Missing information.	This category includes missing forms, missing provider number, missing submitter ID when the box “Add this provider to existing submitter number” is checked. Please carefully complete all fields on the forms and review it for accuracy and completeness prior to submission.
Number 6: Illegible fax.	If EDI enrollment forms are faxed to Medicare and the fax is cut-off, blurry, or has lines that prevent the readability of the form; the form cannot be processed. Please ensure your fax machine is serviced properly if you elect to fax EDI enrollment forms. Providers are encouraged to mail forms to ensure the forms are legible

TIP: Please reference the instructions for completing EDI enrollment forms. EDI enrollment instructions are available on our Web site at http://www.empiremedicare.com/partbny/billing/nyforms.htm.

Posted: 12//28/2007