In addition, where possible, CMS will be making system enhancements concurrent with the 5010/D.0 changes. These enhancements include capabilities such as:
• Implementing standard acknowledgement and rejection transactions across all jurisdictions (TA1, 999 and 277CA transactions)
• Improving claims receipt, control, and balancing procedures
• Increasing consistency of claims editing and error handling
• Returning claims needing correction earlier in the process
• Assigning claim numbers closer to the time of receipt

What do Providers need to know about the Administrative Simplification Act?
The Administrative Simplification Act (ASCA) requires the use of electronic claims (except for certain rare exceptions) in order for providers to receive Medicare payment. Therefore, effective January 1, 2012, providers must be ready to submit your claims electronically using the X12 Version 5010 and NCPDP Version D.0 standards. This also is a prerequisite for implementing the new ICD-10 codes. The HIPAA standards, including the X12 Version 5010 and Version D.0 standards, are national standards and apply to transactions with all payers, not just with Fee-for-Service (FFS) Medicare. Providers must be prepared to implement these transactions with regard to their non-FFS Medicare business as well. Medicare expects to begin transitioning to the new formats January 1, 2011 and ending the exchange of current formats on January 1, 2012.

As always, HCIM is here to help however we can. If you have any questions, contact HCIM Product Support at support@hcim.com or 888-454-0202, option 2.

Queries can be performed on either single or multiple folders using the “Query Module” interface. Simply right-click on the desired level folder on the left side of the screen, then select either “Quick Folder Query,” “New Folder Query,” or “New Multiple Folder Query,” depending on whether you would like to search across multiple folders or in a single folder. The “Quick Folder Query” is generally the most utilized option because users can set up archive folders with different forms having different indexes.

A list of all the indexed fields for that folder will be displayed on the right side of the screen. The “Operator” column features a drop-down list that allows the user to specify which operator to use (=, >, <, >=, <=, <>, Like, List, Between, Null, and Not Null). The default operator is “=.”

When the user selects “Like” as the operator, the “Field Value” column can be used in conjunction with the wildcard character “%.” For instance, when searching the “Document Number” field for all images scanned on 8/10/2010, the user can enter S20100810 with the “%” wildcard character (S20100810%) in the appropriate “Field Value” field.

The “%” wildcard character can be used to match any number of characters up to the size of the field. The underscore character (_) can also be used in combination with the partial contents of an index field to search for values by length with each “_” representing a single character. In this case, the “Field Value” column of S____ (four underscore characters) would return names like “Smith,” but not “Sampson.”

The mathematical operators >, <, <=, and >= can also be used to return the desired results. In the above document number example, the operator “>=” could be used with S20100810 (no wildcard character) to return all document numbers scanned on or after that date.

For more information on AnyDoc® BROKERit, click here.

Back in those days, doing eligibility meant that I would get printouts of members who were active that month and would sit for hours making tick marks on who was eligible and who wasn’t. I would then term those not on the list, add those who were, and make changes to those who needed updating. After a couple years of this (and rapidly diminishing eyesight), I was able to load eligibility electronically, which saved time so I could help out in other areas of the business as well.

As the claims volume grew, so did the need for a system that could process claims more efficiently. After the new claims system was purchased, I was chosen to be on the team involved in the conversion. During the kickoff meeting, I met four consultants who were hired to analyze our business process and advise the best approach to set up the new system. They knew everything about the system and were invaluable to the implementation. Those four consultants changed the course of my career, as I realized that I wanted to be a consultant so I could make a difference, too.

After over 12 years of Eligibility, Provider Maintenance and Provider Contracting, I took a leap of faith and joined HCIM as a Client Services Consultant. Now, I implement and configure claims management systems in addition to working on benefits, contracts, Providers, enrollment, fee schedules, and anything else that the client needs assistance with. Recently, a client was experiencing an abnormal amount of claims pending in the system, so I helped to determine the problem and recommended how to resolve the issue. I’m currently working on a project where the client is bringing up a new line of business.

I’ll be celebrating two years with HCIM this month and I must say that I couldn’t have found a better company to work for and I truly love what I do. I’ve found a career that challenges me and allows me to help people with the same frustrations that I used to have. I’ve come a long way and I have HCIM and those four consultants to thank for it.

Amy Sipe
Client Services Consultant at HCIM

1. In either Windows Notepad or an Excel spreadsheet, simply enter the column of claim numbers and save the file:
   File Type: *.txt
   Destination: SymKey\Files\Source directory
2. Browse for the file as usual within the SymKey Professional or Hospital Claims module.

• To accommodate ICD-10 coding.
• 4010 technology is outdated. It has been in use for five years and was written three years prior to that.
• Many of the situational and required rules did not fit health care industry practices. This is especially true for the 278, where many entities had reply on companion guides and thus became non-standard.
• Over 500 change requests are included in 5010.
• Most rules in 5010 are the same in all transactions and are more consistent.
• Includes D.0 of the NCPDP transactions for retail pharmacies.
• Adapts version 3.0 of the NCPDP for subrogation of Medicaid pharmacy payments.
• Clear rules will reduce analysis, time and minimize need for companion guides.
• Improved eligibility responses and better search options will improve efficiency and reduce phone calls.
• Clarification of misunderstood areas resulting in consistent implementation of 835 (Remittance Advice).

The X12 5010 transactions are meant for administrative communications between trading partners. These administrative communications include Claims, Enrollment, Eligibility, Claim Status, and Auths and Referrals.

5010 ushers in improvements in structural, front matter, technical, and data content (such as improved eligibility responses and better search options). The adjustments required for the 5010 transactions to enable them to facilitate the ICD-10 codes are simple. Space for expanded code length and additional instances of diagnoses need to be added. Space for a single digit code indicating the version of ICD codes being billed needs to be added also.

HIPPA5010 – Changes

Enrollment

• Enrollment subtotals and reporting categories
• Improved privacy protections
• New Maintenance Reason Codes and policy amount qualifiers

Premium Payment

• Addition of Outer Adjustment Loop
• Additional deductions and payment reporting
• Added Remittance Delivery Method

Eligibility & Benefits Inquiry Response

• Unique ID to clarify subscriber and dependent relationship
• Subscriber ID required on later translations (278, 837, etc.)
• Requires support of different search options
• 45 Service Type Codes added to support queries

Pre-Authorizations & Referrals

• Event Level Detail Reporting includes info on conditions
• Expanded Service Level Detail
• External Code Set – Rejection Reason
• Reconsideration Process

Claims – Professional, Institutional, and Dental

• Attending Physician defined in new usage rule
• Pay-to Address changed only when different from Billing Provider
• Billing Providers carry NPI as Primary Identifier & must be same for all payers
• Rendering Provider added to Institutional Claims
• Patient/Subscriber reporting changed
• POA indicators on Institutional Claims moved from K3 to HI
• Separate HI segments for Principal, Admitting, E-Codes and Patient Reason Codes

Claims Status Inquiry and Response

• Prescriptions and NDC numbers reporting allowed
• Claim Status Codes and Multiple Claim Identifiers allowed
• Modification of Subscriber and Dependent rules

Remittance

• Policy Information can be reported for Denials, Appeals, and Corrections
• Additional Information on Technical Contact and Payer Website allowed
• Clarity for Claims Overpayment Recovery and Balancing Added
• Remark Code usage in connection with Reason Codes
• HIPAA 5010 Transaction

For side-by-side comparisons between the 4010 and 5010 codes, click here.

HCIM’s resources possess a true global understanding of managed care and the configuration requirements of EZ-CAP. All of our benefits matrix configuration is provided by experienced onshore resources. Our team understands the complexity of US healthcare because they’ve worked in claims operations and know far more than how to navigate the application. We’ve worked on your side of the user interface.

As an official EZ-CAP Partner since 2006, HCIM provides a better value because our consultants are MZI EZ-CAP trained. HCIM is also budget friendly and can offer a fixed bid proposal so you will know your exact costs up front. Our rates are competitive with any documented/disclosed competitors’ rates. Plus, for a limited time, HCIM is offering a discounted rate to all EZ-CAP clients who engage HCIM for benefits matrix configuration projects.

If you are interested in experienced EZ-CAP benefits matrix consulting services and would like to hear more about HCIM’s limited time discounted rates, feel free to contact me. 

Jeff Hall
Senior Vice President
Group Director, Consulting Services
888-454-0202, ext. 114
jhall@hcim.com

Microsoft Windows 7, released in October 2009, was released as a much improved operating system over Vista and a worthy replacement for Windows XP. Features include much faster booting and shutdown, faster operation, improved compatibility with Windows XP applications, and several user interface improvements. Since then, the operating system has proven to be a tremendous success, selling over 175 million copies in the first nine months on the market. Both home users and businesses have embraced Windows 7.

Compatibility
In the business community, there still remain many businesses that continue to operate on computers with the Windows XP operating system. In many cases, the delay in upgrading concerns whether applications built for Windows XP will run properly in Windows 7. Microsoft endeavored to make Windows 7 compatible with most Windows XP applications; however, not all are. To overcome compatibility issues, Microsoft added an option called “Windows XP Mode.”

Windows XP Mode
Windows XP Mode is an optional add-on that can be installed along with Windows 7 (available in Windows 7 Professional, Enterprise, or Ultimate editions). It provides a complete licensed Windows XP environment running inside of Windows 7 and runs within Windows Virtual PC. Both XP Mode and Windows Virtual PC can be downloaded for free.

Once installed, a desktop icon is used to launch XP Mode, opening up a complete Windows XP environment where applications can be installed. Applications that do not run properly in Windows 7 can be installed in XP Mode. Once installed, applications are displayed both in the XP Mode Start menu and the Windows 7 Start menu. Often, the application will then run properly within Windows 7; if not, these applications can be run within the Windows XP mode. In most cases, this solves application compatibility issues.

Click here for more information on a comparison of Windows 7 to previous versions.
Click here for more information on Windows 7 XP Mode.
Click here for more information on Windows Virtual PC.
Click here for downloads for XP Mode and Virtual PC.

HealthCare Information Management, Inc. (HCIM) is a Microsoft Partner.

If you wish to contact HCIM, please call 888-454-0202, option 5, and an HCIM associate will be happy to assist.

1. Identify the type of claims that you would like to target (i.e. denying claims that exceed a timely filing threshold).
2. Define what claims fall into this scenario (i.e. timely filing claims may be in-network providers as defined by the “ZZZ” in the Provider Contract field, where the date received is more than 180 days after the DOS).
3. Create a report of claims for input into a SymKey scenario or Batch Processing.
4. Test the report and scenario configuration in SymKey.

At any step along the way, HCIM’s expert Product Support team is available to field questions, offer advice, or work with you to complete the entire process. Contact HCIM Product Support at support@hcim.com or 888-454-0202, option 2.

In addition to SymKey’s standard scenarios in the Professional and Hospital Claims modules, the Batch Processing module allows users to configure their own batches with more control and flexibility.

If you have questions about setting up multiple scenarios or utilizing batch processing for your business needs, please contact HCIM Product Support at support@hcim.com or 888-454-0202, option 2.