GE Healthcare 5010: Cynthia Klain April 2011. Agenda Who are we? 5010 Background Payer Readiness and Testing Areas of Impact Processing Strategy Questions?

GE Healthcare

5010: Cynthia Klain

April 2011

Agenda

• Who are we?

• 5010 Background

• Payer Readiness and Testing

• Areas of Impact

• Processing Strategy

• Questions?

GE Centricity® EDI Services

A full service EDI solution dedicated to improving your

revenue cycle through service and automation.Delivering Value With Integrated Transactions:

Eligibility - 270/271Claims Status – 276/277Referrals - 278Electronic Claims - 837Electronic Remit - 835

GE Centricity® EDI Services

Healthcare Transactions per month:1800+ Customers

4 GE Centricity PMs (Practice, Group, Business, Enterprise)

~16 million Claims/month

~$6 Billion in gross charges!!/month

~15 Million Remits/month

~5.5 Million Eligibility/month

5010 BACKGROUND

5010/ICD-10 Timeline

‘09 ‘11 ‘12

Enforcement DateJanuary 1, 2012

Compliance DateJanuary 1, 2011

‘13

Implementation DateOctober 1, 2013

5010

ICD-10

June 18, 2010:

Centricity EDI

Services is ready for

5010

April 1, 2011; payers

should be ready to test with “errata”.

Only ~30% are ready

Claims with Date

of Services on October 1, 2013 or after will

utilize ICD-10!

• 270/271 Eligibility Inquiry & Response

• 837 Professional and Institutional Claim

• 835 Remittance Advice

• 276/277 Claim Status Request & Response

• 837 Dental claims

• 278 Referral/ Authorization Request & Response

Transactions that are Changingwith X12-4010A1 X12 5010

5010 Overview

Who’s affected?Customers

Centricity EDITrading Partners

Payers

Mandate Overview

The X12 5010 transactions replace the 4010 HIPAA transactions and are needed to accommodate ICD-10 codes and address other identified issues with 4010

Changes Impact

New Data Elements/Records New Storage locations/Processing/Screens and Updated Segments Translations Scripts/Tools/PM

Update Data requirements Updated Edits/rejections

Updated Adjudication Systems New Edits/Billing processes

PAYER READINESS AND TESTING

Update on Payer ReadinessTarget Date Activity

May 2010 Centricity EDI began Trading Partner Readiness Calls-Repeated calls every 30 days to 90 days

Summer 2010

Continued Payer Calls, but received very little information. One payer indicated readiness soon; Highmark (PA BCBS)

August – December

2010

•Began testing with Highmark (PA BCBS)-Tested various billing specialties & input formats (4010 & 5010).-Mid-Oct = Highmark Production!

•All payers contacted for 5010 readiness

April 2011 •30 of 143 payers indicate readiness to test, but all require testing in April with the “Errata” Version•Currently TESTING with our top 30 claim payers•Currently PRODUCTION with Kansas Medicaid, Highmark BCBS and Emdeon. Production approved with several others (GA Medicaid, most Noridian payers)•Testing with CMS/Medicare Eligibility in the next few weeks

Q3 2011 Most payers available for testing

Trading Partner Readiness Outreach•When can we begin testing 5010 with you? (for each transaction 837P, 837I, 835, 270&271)•Is 5010 testing required?•When (what date) is 5010 transaction mandated? (for each transaction type 837P, 837I, 270)•If we send a 5010 claim file (837) will we be able to get the 5010 remit back (835)?•When will the 5010 remit (835) be available?•Will 5010 testing be only for compliance or will it also test payer specific edits?•Will we be getting reports back after testing 5010?•Will you be ready to test and go live on 5010 across all transactions at the same time? (837, 835, 270&271) If not at the same time, what is the schedule?•Are you planning to allow dual submissions of 4010 and 5010 at the same time or will it be a hard cutover only to 5010 claim submissions?

•Will there be any transmission/connection changes to how we technically send you are claims?•Will there be any enrollment or re-enrollment required before submitting 5010?•Will we be able to test the 270 and get 271 transaction back?•How will you be communicating when you cutover or mandate the 5010 transaction? (website, letter, email, etc.)•Will you be changing the length of any of the fields in the 835 (ERA) (policy #, check #, ICN) •When we go live with 5010 will you be replacing the 997 report with the 999 report? Will there be any other changes to reports or new reports?•Are you mandating with implementation of 5010 that the Billing Provider Address(2010AA N3) no longer be a PO Box and that it MUST be a street address? Will the providers need to complete re-enrollment if they are currently sending the PO Box and need to start sending the street address?

Top 30 Payer Testing Status

•16 of the 30 have major or minor delays. We’re tracking when we can move to PRODUCTION, since test and production are often not the same.

•We are testing both 5010 and upconverted 4010. LIVE with some upconverts!

•Team meets weekly to track status, identify new payers to test, discuss issues. 143 unique connections.

AREAS OF IMPACT

High to Medium Impact

Issue What is this? Work Around What to do NOW!

PO Box in the Billing Provider and Service Location Loops

PO BOX address are no longer allowed in these fields. A physical street address must be sent.

Send the physical address! We’ve also had some success with POBOX and P0B0X.

Know what you are submitting! Look for WARNINGS and ALERTS as we do more end to end testing.

Zip+4 is required in the Pay-To-Provider Loop

The 5010 specification requires the zip+4 in some loops

Send the zip+4! We’ve also has some success with a default value of 9998

Know what you are submitting! Look for WARNINGS and ALERTS as we do more end to end testing.

Subscriber Definition changes

If the dependent has a unique member ID, then this is submitted in the subscriber loop (the patient loop is not used

TBD – Dependent on payer interpretation

Know what you are submitting

Medium to Low Impact

Issue What is this? Work Around What to do NOW!

Place of Service = HOME

If the Place of Service is HOME, this must be the physical street address of the patient.

Send the physical address! We’ve also had some success with POBOX and P0B0X.

Front desk protocol check – are you capturing the street address? Look for WARNINGS.

Anesthesia Claims

Should be reported only as minutes

Submit correctly Know what you are submitting.

Ambulance Billing

Now requires physical pick-up/drop off address

Submit correctly. TBD on how payers will do this (ex: mile marker 25?)

Know what you are submitting.

Worker’s Comp Claims

Several new fields required

Submit correctly.

Know what you are submitting

PROCESSING STRATEGY

Electronic Claims Strategy

Payer Ready to

Test

Assumptions/Clarifications

- Centricity EDI Can translate X12 4010 TO X12 5010 most of the time

-Centricity EDI Can translate X12 5010 TO X12 4010 all the time

-After your CPS upgrade, Centricity EDI does not need to make customer set up changes to accept updated versions of Inputs.

-Centricity EDI will begin sending X12 5010 transactions to payers as payers are ready and/or mandate it

Centricity EDI Alerts internal teams. Begins 5010 “certification process”

with various input and claims types for a sub-set of customers

As payer mandate date approaches, Centricity EDI begins sending X12 5010

for all customers

Process is Complete

Validation Receipt of file (reports)

Payment

Electronic Remit StrategyNew

Mandate Identified

1st 5010 ERA file is received

Is Customer able to process x12 5010 (835)?

YN

Centricity EDI Translates Incoming

file to X12 4010

Customer is upgraded

Centricity EDI begins sending customer X12

5010 files

Process is Complete

Centricity EDI alerts internal teams

Eligibility Strategy-Assumptions/Clarifications

- Centricity EDI Can translate X12 4010 TO X12 5010 most of the time for BOTH 270 and 271

-Centricity EDI Can translate X12 5010 TO X12 4010 all the time

-After your CPS upgrade, Centricity EDI does not need to make customer set up changes to accept updated versions of Inputs.

-Centricity EDI will begin sending X12 5010 transactions to payers as payers are ready and/or mandate it

Payer Ready to

Test

Centricity EDI Alerts internal teams. Begins 5010 “certification process”

with various input and claims types for a sub-set of customers

As payer mandate date approaches, Centricity EDI begins sending X12 5010

for all customers

Process is Complete

Validation

Receipt of 271

Summary• Get ready for CPS v10!

• Impacted Areas: Know what your sending!

• Look for WARNINGS and ALERTS (Centricity EDI Users).

• Look for additional monthly updates and webinars.

• Prepare for a few hiccups. Payers are delayed in testing.

Useful ResourcesICD-10

Resources

• General Informationhttp://www.ahima.org/icd10/

5010 Resources

• Government Bills – legislation

www.gpoaccess.gov/bills/index.html

• HHS Web Site – regulatory

www.aspe.hhs.gov/admnsimp/index.shtml

• Workgroup for Electronic Data Interchange (WEDI)

www.WEDI.org

• Washington Publishingwww.wpc-edi.com/registry

• ANSI X12www.x12.org

Questions?