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HIPAA X12 Ve rsion 5010 Re lease Notes

for Healthland Classic

Copyright September 26, 2011 - Healthland All Rights Reserved.

http://support.healthland.com 1.888.868.0040
Please note: All other company, product, or brand names mentioned herein, indicated or otherwise, may be trademarks of their respective owners.

H I PA A X 1 2 Ve r s i o n 5 0 1 0 U p d a t e

c o n t e n ts
Chapter 1

Introduction.................................................................................................... 5
About the HIPAA X12 Version 5010 Regulatory Update ................................................................... 6

Chapter 2
Hospital System............................................................................................. 7
837 Billing Changes .......................................................................................................................... 8 Admissions/Discharges/Transfers (ADTs)................................................................................... 8 Patient Management ................................................................................................................. 12 Billing ................................................................................................................................. 12 Patient Information (File Maintenance) .............................................................................. 15 Doctor Setup: Changed processes to include the attending and operating provider secondary identification in the v5010 837 download only if an individual record for that doctor is set up. The default record set up for all doctors will not be considered for secondary identification. Health Information Management .......................................................................................................... 16 5010 Setup Instructions for Hospital 837 Billing .............................................................................. 19 Eligibility Verification (270/271) Changes ........................................................................................ 24 Admissions/Discharges/Transfers (ADTs)................................................................................. 24 Patient Information (File Maintenance) ..................................................................................... 24 5010 Setup Instructions for Hospital Eligibility Verification (270/271) ............................................. 25 835 Processing Changes ................................................................................................................ 26 5010 Setup Instructions for Hospital 835 Processing ...................................................................... 26

Chapter 3
Clinic System (PPM).................................................................................... 27
837 Billing Changes ........................................................................................................................ 28 Physician Practice Management ............................................................................................... 28 Billing ................................................................................................................................. 28 Daily Work.......................................................................................................................... 31 File Maintenance................................................................................................................ 31 5010 Setup Instructions for Clinic 837 Billing .................................................................................. 34 Eligibility Verification (270/271) Changes ........................................................................................ 42 Physician Practice Management ............................................................................................... 42 5010 Setup Instructions for Eligibility Verification (270/271) ........................................................... 44 835 Processing Changes ................................................................................................................ 44

Appendix A: Database Changes ................................................................. 45

H I PA A X 1 2 Ve r s i o n 5 0 1 0 U p d a t e

Introduction

In This Chapter
About the HIPAA X12 Version 5010 Regulatory Update 6

About the HIPAA X12 Version 5010 Regulatory Update

About the HIPAA X12 Version 5010 Regulatory Update


The HIPAA X12 Version 5010 Regulatory Update is a new set of standards that regulate the electronic transmission of health care transactions, including eligibility benefit inquiry and response, claim remittances, and claim submissions. Healthland is releasing this update in phases, with Phase 1 containing changes for the 270/271 Eligibility Verification transaction sets and 837 Institutional and Professional (837I and 837P) Billing. Phase 2 contain changes for 835 Billing (ERAs). This software is compliant with the HIPAA X12 Version 5010 transactions set. If an individual or State has or in the future set requirements outside the HIPAA X12 transaction set, they may not be supported in this release. Individual State companion guides are beginning to appear on the internet sites if you have concerns about your state. The compliance date for use of the 5010 standards is January 1, 2012 as required by Federal law. The 5010 standards accommodates the upcoming ICD-10-CM code sets, which are scheduled to be implemented on October 1, 2013. This document contains a list of 837 and 270/271 changes made to the Healthland system in accordance with HIPAA regulations, as well as accompanying setup instructions to properly configure your system for the 5010 format so you can begin testing your 270 and 837 download files with your clearing house.

No changes were made to paper UB and 1500 forms.

H I PA A X 1 2 Ve r s i o n 5 0 1 0 U p d a t e

Hospital System

In This Chapter
837 Billing Changes 8
Admissions/Discharges/Transfers (ADTs) 8 Patient Management 12 Doctor Setup: Changed processes to include the attending and operating provider secondary identification in the v5010 837 download only if an individual record for that doctor is set up. The default record set up for all doctors will not be considered for secondary identification. Health Information Management 16

5010 Setup Instructions for Hospital 837 Billing Eligibility Verification (270/271) Changes 835 Processing Changes 26 24

19 25

5010 Setup Instructions for Hospital Eligibility Verification (270/271)

837 Billing Changes

837 Billing Changes


The following modules in the Hospital system were changed for 837 Billing to accommodate the HIPAA X12 Version 5010 Regulatory Update: Patient Management Health Information Management

Valid code qualifiers have changed for v5010. Only data with valid qualifiers will be processed in the 837 file; data with invalid qualifiers will be ignored or sent to the assignment work bucket in the Healthland system. Refer to your companion guide(s) for valid qualifiers and determine if you need to change your setup based on the 5010 specifications. Refer to Healthlands 837 5010 Data Element Reference Guides (located on Central Station) to learn where data elements are set up in the Healthland system. Verify the information in the following screens in Patient Management: Doctor Setup Payer Code Setup UB 837 > Billing/Pay To Provider Info 1500 837 > Billing/Pay To Provider Info All previous codes will still be available so that they can be used for the 4010 format until you begin using the 5010 format. Once you switch to the 5010 format, only the valid qualifiers will be processed for the 5010 format.

Admissions/Discharges/Transfers (ADTs)
Admission > Physician tab: Added the Rendering field on the Physicians tab for clerks to enter the rendering provider at the claim level. This is required in the 837I and 837P downloads when the rendering provider is different than the billing provider. The rendering provider is the person or company (lab or other company) who rendered the care, i.e. delivers or completes a particular medical service or non-surgical procedure. In the case of a substitute provider, enter the providers information here. Added the Supervising field on the Physicians tab for clerks to enter the supervising physician at the claim level. This is required in the 837P download (1500) when the Rendering Provider is supervised by a physician.

837 Billing Changes

Figure 1.1: New Rendering and Supervising fields on the Admission > Physicians tab

Admission > Ambulance tab: Added the ability to enter the point of destination (drop-off) information. This information is required for ambulance claims that are being billed in the v5010 837P. To accommodate this change, the Point of Pick-Up Information and Point of Drop-Off Information are displayed on two separate sub tabs. (See Figure: 1.2)

Figure 1.2: Point of Pick-Up Information and Point of Drop-Off Information sub tabs

The Code field is available on each sub tab for entering the service location. Ambulance Billing service location codes are set up in the Locations Setup parameter with a Conflict Code of AMB. Only location codes assigned to the AMB conflict code are available for selection via the Code look-up screen located on the Point of Pick-Up and Point of Drop-Off sub tabs. To set up

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837 Billing Changes

ambulatory location codes, go to Patient Management > Patient Information > File Maintenance > Add/Change Screens > Location Setup. Press <F1> in the application for instructions on how to use this screen. When setting up ambulatory location codes, Healthland recommends that you create new location codes and use the AMB conflict code. DO NOT change the existing location codes that have a conflict code of ADT. This is because if your site has the ADTLOC alpha table set up, only location codes with the ADT conflict code are available in the Location field for the admission. If you change the conflict code from ADT to AMB, those locations will no longer be available. If the table is not set up, all locations including those with the AMB conflict code will be available. (See Figure: 1.3)

Figure 1.3: Location field for the admission

Admissions > Ambulance tab: Added a new Condition Indicator, 12 = Patient is confined to a bed or chair. Use code 12 only in the v5010 format to indicate the patient was bedridden during transport. In addition, the 02, 03, and 60 condition indicators will become inactive at the end of the 2011 year once v5010 goes into effect. NOTE: The Condition Indicator is required in the 837P download for ambulance billing. Admissions > Admission tab: Condition codes are now sent in the v5010 837P download in the new HI segment. There are additional condition codes, which must be added to the CON1 or CON2 insurance table based on your current table setup. If your CON1 and CON2 tables are full, you will need to delete conditional codes that are no longer used to make room for the new codes as needed. These tables can be set up 4 columns wide. If you need to add columns, you will need to delete the current table(s) and re-create it. Keep in mind, if you make changes to these tables, they do not take effect until after the nightly build. The Condition Codes approved for use on the 1500 Claim Form are available at www.nucc.org under code sets. AA=Abortion Performed due to Rape AB=Abortion Performed due to Incest AC=Abortion Performed due to Serious Fetal Genetic, Defect, Deformity, or Abnormality AD=Abortion Performed due to Life Endangering Physical Condition Caused by, Arising from or Exacerbated by the Pregnancy itself AE=Abortion Performed due to Physical Health of Mother that is not Life Endangering AF=Abortion Performed due to Emotional/psychological health of the Mother AG=Abortion Performed due to Social or Economic Reasons AH=Elective Abortion AI=Sterilization The following is a list of condition codes for worker's compensation claims that are valid for use on the 1500 health care claim form: W2=Duplicate of original bill @3 Level 1 appeal W4=Level 2 appeal W5=Level 3 appeal

837 Billing Changes

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To set up the CON1 and CON2 tables: 1) 2) 3) 4) 5) 6) Go to Patient Management > Patient Information > File Maintenance > Add/ Change Screens > Insurance File Tables: In the Table ID field, type CON1 or CON2. (NOTE: If the table is already set up, the remaining information is displayed.) In the Title field, type Condition Code. In the Columns field, type 2 or up to 4 depending on the number of condition codes you want to enter. Enter column descriptions if desired. The first and third columns contain the condition code, the second and fourth columns contain the code description. Enter the condition code information in the columns, entering a condition code in the first column and corresponding description in the second. If you have 4 columns, enter another code in the third column and its corresponding description in the fourth column. Keep in mind, each table can have a maximum of 256 characters. When setting up the CON1 table and you are going to also set up the CON2 table, be sure to type the word, CON2, in the row before the final row of the CON1 table to indicate a continuation of the table. See below for an example. In the first column of the last row, type END. Click Apply or OK to save the table.

7)

8) 9)

10) If you need to set up both the CON1 and CON2 tables, repeat these steps for the second table. NOTE: Do not do step 7 for the CON2 table. Admission > Billing Information tab: Special Program Indicators 05 and 09 have been added for 837P v5010 specifications for Medicaid claims. Codes 02, 03, and 60 are now invalid for v5010. Update the SPI insurance file table to add the new codes. During the testing phase, keep the unused codes until you change to production mode, then change the code descriptions for 02, 03, and 60 to DO NOT USE or remove them from the table. To edit the SPI table: 1) 2) 3) 4) Go to Patient Management >Patient Information > File Maintenance > Add Change Screens > Insurance File Tables. In the Table ID field, type SPI. The table information is displayed. Click Insert Line to add a row in the table, and add the 05 code and description. Repeat for the 09 code and description. Click OK to save.

Admission > Insurance tab: Changed processes to only accept options I or Y as the Release of Information Code in the v5010 837I download. Currently, all v4010 and v5010 options are available for selection so that you can still send the v4010 codes, if needed. Coding Data Entry: Changed processes to send the POA indicator in the HI segment of the v5010 837 file instead of the K3 segment. If the POA value is blank, the corresponding HI segment is not sent.

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837 Billing Changes

Patient Management
Billing
The following changes apply to both UB and 1500 Billing. EMC Header Information: Changed the Control Version Number and Version/Release/ Industry ID fields to be drop-down lists and added options to these lists to accommodate the new 5010 format. See 5010 Setup Instructions for Hospital 837 Billing on page 19 to activate the 5010 format for 837 processing. EMC Header Information: HIPAA X12 v5010 837 specifications require a nine-digit zip code for the billing provider (2010AA segment). The Zip Code field is not validated in the Healthland system. Please verify that you have entered all nine digits for your billing provider(s). Assign Attachments: Updated the Transmission Code field inquiry to remove obsolete transmission codes.

UB Billing
EMC File Number Assignment: Added the ability to enter a file type for 5010 file submissions so that you can generate the UB billing run in the 5010 format. See 5010 Setup Instructions for Hospital 837 Billing on page 19 for instructions on how to set up the 5010 EMC file number. The full nine-digit zip code is now required for service facilities in the U.S. Ensure you have all nine digits of the zip code entered in your service facility location alpha table (see Figure: 1.4). See the Patient Management Setup & Maintenance Guide for a detailed explanation of this table. If secondary identification is required, ensure your service location table also contains the following codes, which are the only valid codes for service facility secondary identification in v5010: 0B = State License Number G2 = Provider Commercial Number. LU = Location Number

Figure 1.4: Example of Service Location table

837 Billing Changes

13

Added the Edit Billing/Claim Note screen so that billing and claim notes can be submitted in the 837 download file when required by the provider to substantiate the medical treatment. To access this new screen, go to Patient Management > Billing > UB Billing > Edit Billing/ Claim Note. Press <F1> in the application for additional information and instructions on how to use this screen. This screen is also accessible in the Enhanced 1500 Billing menu and in the Health Information Management application under the Links menu.

For the 837I download, if a billing note is not entered in this screen, then the download file will contain information based on how the UB Parameter Setup screen is set up for Locator 80 instead.

Figure 1.5: UB Edit Billing/Claim Note screen in Patient Management

1500 Billing
EMC File Number Assignment: Added the ability to enter a file type for 5010 file submissions so that you can generate the 1500 billing run in the 5010 format. See 5010 Setup Instructions for Hospital 837 Billing on page 19 for instructions on how to set up the 5010 EMC file number. 1500 Reconstruct: Added the Payer Claim Control Number field for users to enter the control number, if known, when the 837 professional (1500) claim is a replacement or is void to a previously adjudicated claim. This number would be provided by the payer.

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837 Billing Changes

The full nine-digit zip code is now required for service facilities in the U.S. Ensure you have all nine digits of the zip code entered based on how your system is configured to pull information for the 837P download. The Rendering Facility (Box 32) field in the Form Control Parameter controls which address to include in the download, (Billing > Enhanced 1500 Billing > Parameter/Maintenance Screens > Form Control Parameter > Box 32-33 tab): If Header Info, then Billing > Enhanced 1500 Billing > Process EMCS > Professional 837 Setup > EMC Header Information If Location, then Patient Information > File Maintenance > Add/Change Screens > Location Setup If Alternate Address, then Billing > Enhanced 1500 Billing > Parameter/Maintenance Screens > Form Control Parameter > Box 32-33 tab Added the Edit Billing/Claim Note screen so that billing notes can be submitted in the 837 download file when required by the provider to substantiate the medical treatment. NOTE: This screen is identical to the UB Edit Billing/Claim Note screen; however, only the billing note option is used for the 837P download; claim notes are not included in the 837P download. To access this new screen, go to Patient Management > Billing > 1500 Enhanced Billing > Edit Billing/Claim Note. Press <F1> in the application for additional information and instructions on how to use this screen. This screen is also accessible in the UB Billing menu and in the Health Information Management application under the Links menu. (See Figure: 1.6)

Figure 1.6: 1500 Edit Billing/Claim Note screen in Patient Management

Form Control Parameter: Added the ability to include the Mammography certification number by revenue code in the v5010 837 Professional download file. To accommodate this change, the EMC Mammography Id # check box was added to the Box 32-33 tab of the Form Control Parameter. If this box is checked, then the Revenue Code and Mammography No. fields are enabled for you to enter revenue code/mammography certification number combinations to the parameter. If a claim matches one of the combinations, the mammography certification number is included in the 837P download file.

837 Billing Changes

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Patient Information (File Maintenance)


Charge File Maintenance: Added new Product/Service ID Qualifiers, which allow compound drug information to be submitted in the 837 download. These qualifiers are available via the Prod/Serv ID Code field. The following codes are valid for v5010: ER = Jurisdiction Specific Procedure and Supply Codes HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes HP = Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV = Home Infusion EDI Coalition (HIEC) Product/Service Code WK = Advanced Billing Concepts (ABC) Codes In addition, the following values have an inactive date of 12/31/2011: ID N1 N2 N3 N4 ZZ The Prod/Serv ID Code field inquiry was updated so that active codes with a future inactive date are now displayed. The above Prod/Serv ID code changes apply to the stand-alone Charge File Maintenance and Tier Charge Setup screens, as well as the combined Charge File Maintenance screen. In the combined Charge File Maintenance, the Prod/Serv ID Code field is located on the Base and Tier sub tabs of the PM tab, and on the Base sub tab of the PPM tab.

Charge File Maintenance / Combined Charge Maintenance: Added the ME = Milligram option to the NDC Unit of Measurement field. Payer Code Setup: A new source of payment code, K = Federal Employees Program, is now available. If your site will be using this source of payment, you will need to update your SCPYMT insurance file table in Patient Management to make this new code available in the Source of Payment drop-down list in the Payer Code Setup screen. See the instructions below to update the SCPYMT table. 1) 2) 3) 4) 5) 6) Go to Patient Management > Patient Information > File Maintenance > Add/ Change Screens > Insurance Tables. In the Table ID field, type SCPYMT. The table information will display. Click Insert Line. A blank row will be added to the table. In the first column, type K. In the second column, type FED EMP PRG. Click Apply to save and remain in the window, or click OK to save and exit. (See Figure: 1.7)

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837 Billing Changes

Figure 1.7: The updated SCPYMT insurance file table

Follow the steps below to update the source of payment for those payers associated with the Federal Employees Program. 1) 2) 3) 4) Go to Patient Management > Patient Information > File Maintenance > Add/ Change Screens > Payer Code Setup. In the Payer Code field, select the payer code you want to set up with the Federal Employees Program source of payment. The remaining fields are displayed. In the Source of Payment field, use the drop-down to select K - FED EMP PRG. Click Apply to save and remain in the window or click OK to save and exit.

TESTING NOTE: If you are submitting a 5010 test file and need to continue using the 4010 format until the test file is approved, you will need to return to this screen after you have generated the test file to change the payer(s) back to the source of payment code you used for the 4010 format.

Payer Code Setup: Updated Primary ID Code Qualifier field to mark invalid values (for 4010 or 5010) with an inactive date of 12/31/2011. The following codes are valid for the 4010 & 5010 formats: PI = Jurisdiction Specific Procedure and Supply Codes XV = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes; (not yet mandated) NOTE: Use PI until the HIPAA National Plan Identifier is mandated.

Doctor Setup: Changed processes to include the attending and operating provider secondary identification in the v5010 837 download only if an individual record for that doctor is set up. The default record set up for all doctors will not be considered for secondary identification. Health Information Management Coding Data Entry: Changed processes to send the POA indicator in the HI segment of the v5010 837 file instead of the K3 segment. If the POA value is blank, the corresponding HI segment is not sent. Physician Information > Physician Info tab:

837 Billing Changes

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Added the Rendering field on the Physician Info tab so that coders and billers can enter the rendering provider at the claim level. This is required in the 837I and 837P downloads when the rendering provider is different than the billing provider. The rendering provider is the person or company (lab or other company) who rendered the care, i.e. delivers or completes a particular medical service or non-surgical procedure. In the case of a substitute provider, enter the providers information here. Added the Supervising field on the Physicians tab for clerks to enter the supervising physician at the claim level. This is required in the 837P download (1500) when the Rendering Provider is supervised by a physician.

Figure 1.8: New Rendering and Supervising fields in the Physician Information screen

Physician Information: Added the Charge Phy tab to this screen so that the HIM Coder can edit the provider attached to each charge so the correct rendering/performing provider is billed. Press <F1> in the screen for detailed instructions on this tab.

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837 Billing Changes

Figure 1.9: New ChargePhy tab in the Physician Information screen

Patient Data: Added the Initial Treatment Date and Date Last Seen fields to allow for more accurate billing. This information, if entered, is included in the 5010 format of the 837 download.

Figure 1.10: New Initial Treatment and Date Last Seen fields in the Patient Data screen

5010 Setup Instructions for Hospital 837 Billing

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5010 Setup Instructions for Hospital 837 Billing


The instructions below allows you to configure your Hospital system for submitting the 837 file(s) in the 5010 format. Assuming you need to send a test file to your clearing house, these instructions include steps for setting up and submitting the test file. TEST FILE SUBMISSION: If you are required to send a 5010 test file to your clearing house, pay close attention to the TESTING NOTES for each step. If you need to continue using the 4010 format until your test file is approved by the clearing house, you will need to change your settings back to the 4010 format after you have generated your 5010 test file.

To set up the v5010 format STEP 1 - Edit EMC File Numbers


This step allows you to set up your EMC file numbers with the 5010 file type so that you can generate and submit the 837 file in the 5010 format. You will need to complete this step for both the 837I and 837P downloads as it applies to your site. 1. Edit the EMC File Numbers in the following screens as it applies to your site: 837 Institutional (UB): Go to Patient Management > Billing > UB Billing > Parameters Menu > Parameter Menu #2 > EMC File Number Assignment. 837 Professional (1500): Go to Patient Management > Billing > Enhanced 1500 Billing > Process EMCs > EMC File Number Assignment.

Before you change to the 5010 settings in this screen, record your current 4010 settings so that you can re-enter the information if you should need to return to the 4010 format after you have submitted your 5010 test file. The following screen examples illustrate how the screen appears based on which version (4010 or 5010) you are setting up. (See Figure: 1.11 and Figure: 1.12). Once the v5010 format is set up, there are fields that are no longer used and that information will need to be re-entered if you return to v4010. Healthland suggests you take a screenshot or take note of that information should you need to re-enter it. If returning to the v4010 format, please note that the 4010 version should be entered as UB92837V4010Aux.mmc -T; there must be a space between mmc and -T.

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5010 Setup Instructions for Hospital 837 Billing

Figure 1.11: Example of EMC File Number Assignment for v4010

Figure 1.12: Example of UB EMC File Number Assignment for v5010

2.

In the File Type field, select the 5010 file type according to the screen you are in: 837 Institutional (UB): 4 - 837 Transaction Set (5010) 837 Professional (1500): 837 Transaction Set (5010)

5010 Setup Instructions for Hospital 837 Billing

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3.

Click Apply to save and remain in the window, or click OK to save and exit.

TESTING NOTE: If you are submitting a 5010 test file and need to continue using the 4010 format until the test file is approved, you will need to return to this screen after you have generated the test file to change your EMC file numbers back to the file type for the 4010 format.

STEP 2 - Update the Control Version Number


1. Set the Control Version Number in the following screens as it applies to your site: 837 Institutional (UB): Go to Patient Management > Billing > UB Billing > Process EMCs > UB 837 Setup > EMC Header Information. 837 Professional (1500): Go to Patient Management > Billing > Enhanced 1500 Billing > Process EMC > Professional 837s Setup > EMC Header Information.

Figure 1.13: Example of Control Version Number settings for the 5010 format

2.

In the [UB/1500] EMC File No. field, select the EMC file number for which you want to activate the 5010 format. The remaining fields are displayed. In the Control Version Number field, select 00501 for the 5010 format. The Usage Indicator field is set to Production to generate the 837 download file and indicates to the clearing house that it is the actual EMC file. If the clearing house requires you to send a test file for approval, use the drop-down list to select the Test mode. This indicates to the clearing house that the file is a test file. In the Version/Release/Industry ID field, select the appropriate 5010 version according to the screen you are in: 837 Institutional (UB): 005010X223A2 837 Professional (1500): 005010X222A1

3. 4.

5.

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5010 Setup Instructions for Hospital 837 Billing

Verify that the Zip Code field contains all nine digits based on 5010 837 requirements for the billing provider (2010AA segment).

6.

Click Apply or OK.

TESTING NOTE: If you are submitting a 5010 test file and need to continue using the 4010 format until the test file is approved, you will need to return to this screen after you have generated the test file and enter the following settings: In the Control Version Number field, select 00401 for the 4010 format. In the Usage Indicator field, select Production. In the Version/Release/Industry ID field, select the appropriate 4010 version.

To generate v5010 EMC files STEP 1 - Resubmit the EMC files


1. Resubmit your EMC files using the following screens as it applies to your site: Go to Patient Management > Billing > UB Billing > Process EMCs > Resubmit EMC File. Go to Patient Management > Billing > Enhanced 1500 Billing > Process EMCs > Resubmit EMC File.

2. 3.

In the EMC File No field, select the EMC file number you have set up for your 5010 file. In the Sub Date From field, enter the submission date of the last bill run that was completed. You must enter a From and To date; if not entered, you will recall all past claims and cause performance issues with your system. Click OK.

4.

STEP 2 - Run EMC Formula


1. 2. 3. Go to Patient Management > Billing > Automated Billing Run/Setup. From the grid, select the formula that corresponds to the EMC files you are trying to create. Click Run.

STEP 3 - Download and submit EMC file


1. 2. 3. Go to Links > Archiver. The Entry-Modules Archived window is displayed. Click Billing Reports. Double-click UB EMC Claims and 1500 EMC Claims respectively to view the EMC file information in the Archived Reports Inquiry. Select the file you just created in Step 1 above and click Download.

4.

5010 Setup Instructions for Hospital 837 Billing

23

5. 6.

Select your download options and click OK. Submit your file to the clearing house according to your facilitys procedures.

STEP 4 - Reset parameters to 4010 format


If you submitted a test file, reset the following parameters to the 4010 format until the file is approved. Complete this step for both UB and 1500 billing as it applies to your site. EMC File Number Assignment screen: 837 Institutional (UB): Go to Patient Management > Billing > UB Billing > Parameters Menu > Parameter Menu #2 > EMC File Number Assignment. Select the EMC file number you used for the 5010 test, and reset the File Type field back to 3 - 837 Transaction Set. 837 Professional (1500): Go to Patient Management > Billing > Enhanced 1500 Billing > Process EMCs > EMC File Number Assignment. Select the EMC file number you used for the 5010 test, and reset the File Type field back to 837 Transaction Set (4010). EMC Header Information screen: 837 Institutional (UB): Go to Patient Management > Billing > UB Billing > Process EMCs > UB 837 Setup > EMC Header Information. 837 Professional (1500): Go to Patient Management > Billing > Enhanced 1500 Billing > Process EMC > Professional 837s Setup > EMC Header Information. Select the EMC file number you used for the 5010 test, and reset the following fields: In the Control Version Number field, select 00401 for the 4010 format. In the Usage Indicator field, select Production. In the Version/Release/Industry ID field, select the appropriate 4010 version. UB - 004010X096A1 1500 - 004010X098A1

STEP 5 - Assign a submission date to claims in test mode


Use a submission date that is NOT the same as the date actually used. Healthland recommends a weekend date or holiday date. This is because if you should need to recall the file you submitted in the 4010 format, you can get back only the claims you submitted in that file and not those used for testing.

1.

Assign a submission date to your test file claims using the following screens as it applies to your site: Go to Patient Management > Billing > UB Billing > Process EMCs > Assign Submission Date to EMC Claims. Go to Patient Management > Billing > Enhanced 1500 Billing > Process EMCs > Assign Submission Date to EMC Claims.

2. 3.

In the EMC File No field, select the file number you used for testing. In the Submission Date field, select a date that is NOT the same as the date actually used, (e.g. weekend date or holiday). See note above.

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Eligibility Verification (270/271) Changes

Eligibility Verification (270/271) Changes


The following areas of the Patient Management module in the Hospital system were changed for Eligibility Verification to accommodate the HIPAA X12 Version 5010 Regulatory Update:

Admissions/Discharges/Transfers (ADTs)
Single Eligibility (SEND button) > Diagnosis Code Selection: Added the following codes to the Place of Service Type search screen: 01 - Pharmacy 03 - School 04 - Homeless Shelter 05 - Indian Health Service Free-standing Facility 06 - Indian Health Service Provider-based Facility 07 - Tribal 638 Free-standing Facility 08 - Tribal 638 Provider-based Facility 13 - Assisted Living Facility 14 - Group Home 15 - Mobile Unit 20 - Urgent Care Facility 49 - Independent Clinic 57 - Non-residential Substance Abuse Treatment Facility

Removed the Eligibility Verification Background Process menu option from the Eligibility Verification menu.

Patient Information (File Maintenance)


Control Numbers: Changed the Control Numbers screen (in the Eligibility Verification Setup menu) to include the following changes: Added the Version (GS08) field, which defaults the version specified in the EDI Payer Maintenance screen for all payers and is read-only. This field toggles between the 4010 and 5010 (005010X279A1) versions so that the 4010 version can be used for payers until the 5010 test file is verified with the clearing house. Added the Usage Indicator (ISA15) field to select Test when you are sending a test file to the clearing house, or Production once the test file has been approved. Added the Update Usage Indicator in All EDI Payer Records check box to apply the Usage Indicator to all EDI payers. If not selected, no EDI Payer records will be updated with the changes.

5010 Setup Instructions for Hospital Eligibility Verification (270/271)

25

If, for any reason, you need to revert back to the 4010 format, and you do not want to update the Test/Production Usage Indicator on all payers, you can uncheck this box. You can toggle the Usage Indicator for a single payer directly in the EDI Payer Maintenance screen. This is particularly useful when you need to add a new payer record and need to test the payer with the clearing house (i.e. Test mode) before it can be put in Production mode.

EDI Payer Maintenance: On the General tab, changed the Version (GS08) field on the General tab to be read-only based on the version as set up in the Control Numbers screen. On the ISA tab, changed the Usage Indicator on the ISA tab to display the default value from the EDI Control Numbers screen. This can be edited for a single payer as needed; however, can be overwritten by the Update Usage Indicator in All EDI Payer Records check box in the Control Numbers parameter if checked and applied. On the Reference tab, when using the Information Receiver qualifier OB for the state license code, you are required to enter the correct two-character state code in the Description field. On the Subscriber/Dependent tab, additional ID codes have been added; however, only the following IDs are allowed: For the Subscriber area: Plan Number (18) Group / Policy Number (IL) Insurance Policy Number (IG) Social Security Number (SY)

For the Dependent area: Social Security Number (SY) On the PRV/Provider Info tab, removed the PRV02 Qualifier field as this value is set according to the version in the Taxonomy ID field. Increased the Description field from 35 characters up to 60 characters.

5010 Setup Instructions for Hospital Eligibility Verification (270/271)


Healthland staff will be contacting you to activate the v5010 format.

26

835 Processing Changes

835 Processing Changes


Phase 2 of the v5010 update contains changes to allow payments from an 835 file in the v5010 format to be processed. Please note the following: The v5010 format can be identified in the 835 file as 005010X221A1. The CAS segment from the 835 file will be included in the v5010 837 download file for secondary claims.

In addition to the 5010 ERA changes, we also made screen changes and improvements to the overall ERA process. Please refer to the Healthland Classic v9.6 Release Notes for more information.

5010 Setup Instructions for Hospital 835 Processing


Healthland Classic Financial v9.6 contains changes to improve the overall 835 process. While these changes are not specific to the v5010 update, you must review and complete the following parameters before you can upload and process an 835 file after you have upgraded to v9.6. ERA File Transfer Parameters - Ensure the 835 Archived Location field is entered with the directory path where you want to copy or FTP the actual 835 file to be stored for troubleshooting purposes (i.e. 835archive). (Go to Patient Management > Patient Information > File Maintenance > ERA Setup/Work > Edit File Transfer Parameters. Press <F1> in the application for detailed instructions.) ERA Payment Type Cross Reference - This screen contains new fields: Claim Type, NPI, and Outlier Payment Type. Before you can run the ERA Upload, this screen must be reviewed to ensure the information for your existing cross references is complete. Verify that the Payment Type column has a payment type entered for each record. (Go to Patient Management > Patient Information > File Maintenance > ERA Setup/Work > ERA Payment Type Cross Reference. Press <F1> in the application for detailed instructions.) ERA Adjustment Exceptions - This screen contains the most current reason codes and default exception records so that payments and adjustments are calculated correctly from the 835 file. Review this screen and add or delete exception records based on your sites specific needs. (Go to Patient Management > Patient Information > File Maintenance > ERA Setup/ Work > ERA Adjustment Exceptions. Press <F1> in the application for detailed instructions.)

H I PA A X 1 2 Ve r s i o n 5 0 1 0 U p d a t e

Clinic System (PPM)

In This Chapter
837 Billing Changes 28 34 44 42 5010 Setup Instructions for Clinic 837 Billing Eligibility Verification (270/271) Changes 835 Processing Changes 44

5010 Setup Instructions for Eligibility Verification (270/271)

28

837 Billing Changes

837 Billing Changes


The following changes were made in the Physician Practice Management (PPM) application for 837 Billing to accommodate the HIPAA X12 Version 5010 Regulatory Update. Valid code qualifiers have changed for v5010. Only data with valid qualifiers will be processed in the 837 file; data with invalid qualifiers will be ignored. Refer to your companion guide(s) for valid qualifiers and determine if you need to change your setup based on the 5010 specifications. Refer to Healthlands 837 5010 Data Element Reference Guides (located on Central Station) to learn where data elements are set up in the Healthland system. Verify the information in the following screens: Provider Maintenance Insurance Maintenance Batch 1500 (ST) Information Batch Institutional (ST) Information All previous codes will still be available so that they can be used for the 4010 format until you begin using the 5010 format. Once you switch to the 5010 format, only the valid qualifiers will be processed for the 5010 format.

Physician Practice Management


Billing
Assign Attachments: Updated the Transmission Code field inquiry to remove obsolete transmission codes.

Pre-Billing Maintenance
Edit Ticket Information: Added the Initial Treatment Date and Date Last Seen fields to allow for more accurate billing. This information, if entered, is included in the 5010 format of the 837 download. These fields were also added to the Additional Information window in Daily Work > Charge Entry and Daily Work > Edits & Deletes > Edit Unposted Charges. Edit Ticket Information: Added the ability to enter up to 20 characters for the Prior Authorization. Also added the ability to enter a Primary, Secondary, and Tertiary Treatment (Prior) Authorization, (at the Insurance level, the Prior Authorization Number can be up to 30 characters). This information, if entered, is submitted in the 837I download. These fields were also added to the Additional Information window in Daily Work > Charge Entry and Daily Work > Edits & Deletes > Edit Unposted Charges.

EMC Billing setup changes


Transmission Information: Added the ANSI 837 (5010) selection to the EMC File Format drop-down list so that UBs can be generated in the 5010 format. See 5010 Setup Instructions for Clinic 837 Billing on page 34 for instructions on how to set up the 5010 EMC file format. EMC Header Information: Changed the Control Version Number and Version/Release/ Industry ID fields to be drop-down lists to allow for the new 5010 format. Also, in this screen, the zip code must be entered in the full nine digits based on 5010 837 requirements for the billing provider (2010AA segment). See 5010 Setup Instructions for Clinic 837 Billing on page

837 Billing Changes

29

34 to activate the 5010 format for 837 processing.

1500 Billing
Added the Edit Billing/Claim Note screen so that billing and claim notes can be submitted in the 837 download file when required by the provider to substantiate the medical treatment. User security permissions must be set up in order to access this new screen. See the PPM 837 Setup Instructions below to configure your system. User security permissions must be set up for users who need access to the Edit Billing/Claim Note screen. 1) 2) 3) 4) 5) 6) Go to Security > Entry > User Security. In the Login Name field, enter the users login. Select the PPM tab. Select the Billing sub tab. Locate the Billing/Claim Note option and select Yes in the Access field. Click Apply or OK. Repeat steps 1-6 for each user who needs permissions set up.

To access this new screen, go to Physician Practice Management > Billing > 1500 Forms > Edit Billing/Claim Note for the 837P (1500) download. Press <F1> in the application for additional information and instructions on how to use this screen.

Figure 2.14: 1500 Edit Billing/Claim Note screen in PPM

Edit 1500 Forms: Added the Payer Claim Control Number field to the Claim Information tab for users to enter the control number, if known, when the 837 professional (1500) claim is a replacement or is void to a previously adjudicated claim. This number would be provided by the payer.

30

837 Billing Changes

UB Billing
837 Institutional Download: The 2300 CL1 segment that contains the patient Discharge Status, Admit Type, and Admission Source is now required for the 5010 format. The Discharge Status and Admit Type are both required; the Admission Source is optional. You have a few options for reporting this information in this segment: (Recommended) Set up the Institutional Validation Setup screen to have default values populate on the claim at the time of the print and pass. Go to PPM > Billing > Billing Setup > Institutional Validation Setup to enter the default values. (Enter the required values in 17 Discharge Status (Patient Status) and Locator 14 Admit Type.) Enter the data in the Edit Institutional Information. Go to PPM > Billing > Pre Billing Maintenance > Edit Institutional Information and enter the data for each claim. Edit the claim in history after it has been built. Go to PPM > Billing > Institutional > Edit Institutional Forms and enter the data in the edit records. Added the Edit Billing/Claim Note screen so that billing and claim notes can be submitted in the 837 download file when required by the provider to substantiate the medical treatment. User security permissions must be set up for users who need access to the Edit Billing/Claim Note screen. 1) 2) 3) 4) 5) 6) Go to Security > Entry > User Security. In the Login Name field, enter the users login. Select the PPM tab. Select the Billing sub tab. Locate the Billing/Claim Note option and select Yes in the Access field. Click Apply or OK. Repeat steps 1-6 for each user who needs permissions set up.

To access this new screen, go to Physician Practice Management > Billing > Institutional > Edit Billing/Claim Note for the 837I (UB) download, Press <F1> in the application for additional information and instructions on how to use this screen. For the 837I Download, if a billing note is not entered in the screen, then the download file will contain information based on how the Institutional Parameter Record is set up for Locator 80 instead.

837 Billing Changes

31

Figure 2.15: UB Edit Billing/Claim Note screen in PPM

Daily Work
Charge Entry > Additional Information: Added the Initial Treatment Date and Date Last Seen fields to allow for more accurate billing. This information, if entered, is included in the 5010 format of the 837 download. These fields were also added to the Additional Information window in Edits & Delete > Edit Unposted Charges and Pre-Billing Maintenance > Edit Ticket Information. Charge Entry > Additional Information: Added the ability to enter up to 20 characters for the Prior Authorization. Also added the ability to enter a Primary, Secondary, and Tertiary Treatment (Prior) Authorization, (at the Insurance level, the Prior Authorization Number can be up to 30 characters).This information, if entered, is submitted in the 837I download. These fields were also added to the Additional Information window in Edits & Delete > Edit Unposted Charges and Pre-Billing Maintenance > Edit Ticket Information. Charge Entry > Additional Information: Updated processes to send the EPSDT Indicator in the v5010 837 file in Loop 2400 (Service Line Number) Segment SV111 (Professional Service); as required when Medicaid services are the result of a screening referral. NOTE: This change applies to v5010 only.

File Maintenance
Procedures (CPT-4) Maintenance: Added new Product/Service ID Qualifiers, which allow compound drug information to be submitted in the 837 download. These qualifiers are available via the Prod/Serv ID Code field. The following codes are valid for the 5010 format: ER = Jurisdiction Specific Procedure and Supply Codes

32

837 Billing Changes

HC = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes HP = Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code IV = Home Infusion EDI Coalition (HIEC) Product/Service Code WK = Advanced Billing Concepts (ABC) Codes

In addition, the following values have an inactive date of 12/31/2011: ID N1 N2 N3 N4 ZZ The Prod/Serv ID Code field inquiry was updated so that active codes with a future inactive date are now displayed.

The above Prod/Serv ID code changes apply to the stand-alone Procedures (CPT-4) Maintenance and the combined Procedures (CPT-4) Maintenance screen (also known as Combined Charge File Maintenance). In the combined Procedures (CPT-4) Maintenance, the Prod/Serv ID Code field is located on the Base and Tier sub tabs of the PM tab, and on the Base sub tab of the PPM tab.

Procedures (CPT-4) Maintenance: Added the ME= Milligram option to the NDC Unit of Measurement field. Insurance Maintenance: Added a new Source of Payment code, 20 = FED EMP PRG (Federal Employees Program), to the Source drop-down list on the Options 1 tab. Follow the steps below to update the source of payment for those payers associated with the Federal Employees Program. 1) 2) 3) 4) Go to Physician Practice Management > File Maintenance > File Maintenance 1 > Insurance Maintenance. In the Insurance field, select the payer code you want to set up with the Federal Employees Program source of payment. The remaining fields are displayed. In the Source field, use the drop-down to select 20 - FED EMP PRG. Click Apply to save and remain in the window or click OK to save and exit.

If you are submitting a 5010 test file and need to continue using the 4010 format until the test file is approved, you will need to return to this screen after you have generated the test file to change the payer(s) back to the source of payment code you used for the 4010 format.

Insurance Maintenance: Updated Primary ID Code Qualifier for Institutional field to mark invalid values (for 4010 or 5010) with an inactive date of 12/31/2011. The following codes are valid for the 4010 & 5010 formats: PI = Jurisdiction Specific Procedure and Supply Codes XV = Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes; (not yet mandated) NOTE: Use PI until the HIPAA National Plan Identifier is mandated.

837 Billing Changes

33

Provider Maintenance: Changed the UPIN Number field so that it is no longer a required entry. Provider Maintenance: Changed the Refer Phy Id Qual field on the Alternate Information window (Alt Info button) so that it is no longer a required entry. Location Maintenance: The full nine digit zip code is now required for service facilities in the U.S. Ensure you have the all nine digits of the zip code entered in this screen.

34

5010 Setup Instructions for Clinic 837 Billing

5010 Setup Instructions for Clinic 837 Billing


The instructions below allows you to configure your Clinic system for submitting the 837 file(s) in the 5010 format. Assuming you need to send a test file to your clearing house, these instructions include steps for setting up and submitting the test file. TEST FILE SUBMISSION: If you are required to send a 5010 test file to your clearing house, pay close attention to the TESTING NOTES for each step. If you need to continue using the 4010 format until your test file is approved by the clearing house, you will need to change your settings back to the 4010 format after you have generated your 5010 test file.

To set up the v5010 format STEP 1 - Edit EMC File Numbers


This step allows you to set up your EMC file numbers with the 5010 file type so that you can generate and submit the 837 file in the 5010 format. You will need to complete this step for both the 837I and 837P downloads as it applies to your site. 1. Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Parameters > EMC Transmission Info > Transmission Information.

Before you change to the 5010 settings in this screen, record your current 4010 settings so that you can re-enter the information if you should need to return to the 4010 format after you have submitted your 5010 test file. The following screen examples illustrate how the screen appears based on which version (4010 or 5010) you are setting up. (See Figure: 2.16 and Figure: 2.17). Once the v5010 format is set up, there are fields that are no longer used and that information will need to be re-entered if you return to v4010. Healthland suggests you take a screenshot or take note of that information should you need to re-enter it.

5010 Setup Instructions for Clinic 837 Billing

35

Figure 2.16: Example of v4010 setup in the Transmission Information screen

Figure 2.17: Example of v5010 setup in the Transmission Information screen

2.

In the Type of Submission field, use the drop-down list to select the submission type you want to set up for the 5010 format: Select Institutional for the 837I download. Select 1500 for the 837P download. In the File Number field, enter the file number you want to edit. The remaining fields are displayed.

3.

36

5010 Setup Instructions for Clinic 837 Billing

4. 5.

In the EMC File Format field, select ANSI 837 (5010). Click Apply to save and remain in the window, and repeat this procedure for each file number you want to set up in the 5010 format for both the 837I and 837P downloads. When all file numbers have been set up, click OK to save and exit.

6.

TESTING NOTE: If you are submitting a 5010 test file and need to continue using the 4010 format until the test file is approved, you will need to return to this screen after you have generated the test file to change your EMC file numbers back to the file type for the 4010 format.

STEP 2 - Update the Control Version Number


1. Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Parameters > EMC Transmission Info > EMC Header Information.

Figure 2.18: Example of Control Version Number settings for the 5010 format

2.

In the File field, select the EMC file number for which you want to activate the 5010 format. The remaining fields are displayed. In the Control Version Number field, select 00501 for the 5010 format. The Usage Indicator field is set to P (Production) to generate the 837 download file and indicates to the clearing house that it is the actual EMC file. If the clearing house requires you to send a test file for approval, enter T for the Test mode. This indicates to the clearing house that the file is a test file. In the Version/Release/Industry ID field, select the appropriate 5010 version according to the 837 download you are setting up: 837 Institutional (UB): 005010X223A2 837 Professional (1500): 005010X222A1

3. 4.

5.

5010 Setup Instructions for Clinic 837 Billing

37

Setup Considerations: Verify that when the Entity = Non-Person, only the Organization/Last Name field is entered; do not enter the First Name, Middle Name/Initial, and Suffix fields. Verify that the Zip Code field contains all nine digits based on 5010 837 requirements for the billing provider (2010AA segment).

6.

Click Apply or OK.

TESTING NOTE: If you are submitting a 5010 test file and need to continue using the 4010 format until the test file is approved, you will need to return to this screen after you have generated the test file and enter the following settings: In the Control Version Number field, select 00401 for the 4010 format. In the Usage Indicator field, select Production. In the Version/Release/Industry ID field, select the appropriate 4010 version.

STEP 3 - UB Validation Setup


Set up the Institutional Validation Setup screen to have default values populate on the claim at the time of the print and pass. If you do not set up the default values in the UB Validation Setup screen, you can enter the data for each claim in the Edit Institutional Information screen (PPM > Billing > Pre Billing Maintenance > Edit Institutional Information) or you can edit the claim in history after it has been built (PPM > Billing > Institutional > Edit Institutional Forms). The Admission Source is also collected in the 5010 format; however, it is not required. Set up the default Admission Source as needed.

1.

Go to PPM > Billing > Billing Setup > Institutional Validation Setup. The Institutional Validation Setup window is displayed.

Figure 2.19: Institutional Validation Setup window

38

5010 Setup Instructions for Clinic 837 Billing

2. 3. 4. 5. 6. 7.

In the Insurance field, click the binoculars button select the insurance you want to edit. In the Locator field, enter 17 for the Discharge Status (Patient Status). In the Sequence field, enter 1. In the Default Value field, enter the appropriate value you want to default for Locator 17. Click Apply to save and remain in the window. Repeat this procedure for Locator 14 (Admit Type); enter 14 in the Locator field and enter the appropriate value in the Default Value field. Click OK to save and exit.

8.

To generate v5010 EMC files STEP 1 - Recall EMC Claims


1. Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Maintenance > Recall EMC Claims.

Figure 2.20: Recall EMC Claims screen

2.

Select the EMC file type as it applies to your site: Select Institutional for the 837I download. Select 1500 for the 837P download. In the Select File field, select the EMC file number you have set up for your 5010 file. In the Sub Date From field, enter the submission date of the last bill run that was completed. You must enter a From and To date; if not entered, you will recall all past claims and cause performance issues with your system. Click OK.

3. 4.

5.

5010 Setup Instructions for Clinic 837 Billing

39

STEP 2 - Create the download file


1. Create your EMC files using the following screens as it applies to your site: Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Processing > Create Institutional Download File. Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Processing > Create 1500 Download File.

Figure 2.21: Create Download File screen

2.

In the Submission Date field, enter the date of submission for this file. (The system date will automatically display.) The date entered should be the date of actual transmission. In the Available Download Files field, select the EMC file you have set up for the 5010 format. Check the Check to run Front End Checks for the 837 box if you want to run front end checks on the 837 file for missing information. If checked, enter a printer number in the Printer for Front End Checks field to print the error listing. Click OK.

3. 4.

5.

STEP 3 - Send the file


1. Go to Physician Practice Management > Billing > View/Download EMC File.

Figure 2.22: Example of the View/Download EMC File screen

40

5010 Setup Instructions for Clinic 837 Billing

2. 3. 4.

Select the file you just created in Step 1 above and click Download. Select your download options and click OK. Submit your file to the clearing house according to your facilitys procedures.

STEP 4 - Reset parameters to 4010 format


If you submitted a test file, reset the following parameters to the 4010 format until the file is approved. Complete this step for both UB and 1500 billing as it applies to your site. EMC File Number Assignment screen: Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Parameters > EMC Transmission Info > Transmission Information. Select the EMC file number you used for the 5010 test, and reset the File Type field back to ANSI 837. EMC Header Information screen: Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Parameters > EMC Transmission Info > EMC Header Information. Select the EMC file number you used for the 5010 test, and reset the following fields: In the Control Version Number field, select 00401 for the 4010 format. In the Usage Indicator field, select Production. In the Version/Release/Industry ID field, select the appropriate 4010 version. UB - 004010X096A1 1500 - 004010X098A1

STEP 5 - Hold Unprocessed Claims


This step will purge the EMC files for the next billing run. 1. Go to Physician Practice Management > Billing > Electronic Media Claims > EMC Maintenance > Hold Unprocessed Claims.

Figure 2.23: Hold Unprocessed Claims screen

5010 Setup Instructions for Clinic 837 Billing

41

2.

Select the EMC file type as it applies to your site: Select Institutional for the 837I download. Select 1500 for the 837P download. In the Select File field, select the EMC file(s) you just processed. In the Submission Date Range, enter the From and Thru dates of the claims that were submitted. Click OK.

3. 4.

5.

42

Eligibility Verification (270/271) Changes

Eligibility Verification (270/271) Changes


The following modules in the Clinic system were changed for Eligibility Verification to accommodate the HIPAA X12 Version 5010 Regulatory Update: Physician Practice Management Appointment Scheduler

Physician Practice Management


Control Numbers: Changed the Control Numbers screen (in the Eligibility Verification Setup menu) to include the following changes: Added the Version (GS08) field, which defaults the version specified in the EDI Payer Maintenance screen for all payers and is read-only. This field toggles between the 4010 and 5010 (005010X279A1) versions so that the 4010 version can be used for payers until the 5010 test file is verified with the clearing house. Added the Usage Indicator (ISA15) field to select Test when you are sending a test file to the clearing house, or Production once the test file has been approved. Added the Update Usage Indicator in All EDI Payer Records check box to apply the Usage Indicator to all EDI payers. If not selected, no EDI Payer records will be updated with the changes.

If, for any reason, you need to revert back to the 4010 format, and you do not want to update the Test/Production Usage Indicator on all payers, you can uncheck this box. You can toggle the Usage Indicator for a single payer directly in the EDI Payer Maintenance screen. This is particularly useful when you need to add a new payer record and need to test the payer with the clearing house (Test mode) before it can be put in Production mode.

EDI Payer Maintenance: On the General tab, changed the Version (GS08) field on the General tab to be read-only based on the version as set up in the Control Numbers screen. On the ISA tab, changed the Usage Indicator on the ISA tab to display the default value from the EDI Control Numbers screen. This can be edited for a single payer as needed; however, can be overwritten by the Update Usage Indicator in All EDI Payer Records check box in the Control Numbers parameter if checked and applied. On the Reference tab, when using the Information Receiver qualifier OB for the state license code, you are required to enter the correct two-character state code in the Description field. On the Subscriber/Dependent tab, additional ID codes have been added; however, only the following IDs are allowed: For the Subscriber area: Plan Number (18) Group / Policy Number (IL) Insurance Policy Number (IG) Social Security Number (SY) For the Dependent area: Social Security Number (SY)

Eligibility Verification (270/271) Changes

43

On the PRV/Provider Info tab, removed the PRV02 Qualifier field as this value is set according to the version in the Taxonomy ID field. Increased the Description field from 35 characters up to 60 characters.

Single Eligibility (SEND button) > Diagnosis Code Selection: Added the following codes to the Place of Service Type search screen: 01 - Pharmacy 03 - School 04 - Homeless Shelter 05 - Indian Health Service Free-standing Facility 06 - Indian Health Service Provider-based Facility 07 - Tribal 638 Free-standing Facility 08 - Tribal 638 Provider-based Facility 13 - Assisted Living Facility 14 - Group Home 15 - Mobile Unit 20 - Urgent Care Facility 49 - Independent Clinic 57 - Non-residential Substance Abuse Treatment Facility

Changed to send the 2-Non-Person entity type when checking insurance eligibility for nonperson entities, (i.e. for Workers Compensation and Casualty Claims). Use the following settings for non-person entities: There are two ways you can set up non-person entities: Option 1: Set up the organization (employer) as a policy holder for the patient. 1) 2) 3) 4) 5) Go to Daily Work > Patient Entry, and open the patient record. Select the Additional Patient tab. Enter the employers information in the fields provided. Click the Insurances button. Check the Employer is Policy Holder check box. When checking eligibility, the employer name is sent as entered on the Additional Patient tab, and the entity will automatically be sent as a non-person; (there is no need to set the Entity field.)

Option 2: Set up the organization (employer) with their own medical record number. 1) 2) 3) 4) Go to Daily Work > Patient Entry and assign a medical record to the organization. Split the organizations name between the First Name and Last Name fields on the Patient tab as these fields cannot be blank. Select the Additional Patient Info tab. In the Entity field, select 2-Non-Person. When checking eligibility, the First Name and Last Name are sent. NOTE: This is a change from your previous process for 4010s where the Entity was set to 1-Person. Now, for 5010s, you would set this to 2-NonPerson instead.

Removed the Eligibility Verification Background Process menu option from the Eligibility Verification menu.

44

5010 Setup Instructions for Eligibility Verification (270/271)

5010 Setup Instructions for Eligibility Verification (270/271)


Healthland staff will be contacting you to activate the v5010 format.

835 Processing Changes


Phase 2 of the v5010 update contains changes to allow payments from an 835 file in the v5010 format to be processed. There were no screen changes made and there are no new setup instructions needed. Please note the following: The v5010 format can be identified in the 835 file as 005010X221A1. The CAS segment from the 835 file will be included in the v5010 837 download file for secondary claims.

H I PA A X 1 2 Ve r s i o n 5 0 1 0 U p d a t e

Appendix A: Database Changes

In This Chapter
Financial Database Changes for HIPAA X12 Version 5010 46

46

Appendix A: Database Changes

Financial Database Changes for HIPAA X12 Version 5010


TABLE NAME CLDATA TABLES (PPM - Clinic) CHG1AUTH added table to hold prior authorization number for patient visit LRN PATIENT_NO TICKET_NUMBER PRIOR_AUTH_NO_1 PRIOR_AUTH_NO_2 PRIOR_AUTH_NO_3 CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS CHG1ATHH added table to hold prior authorization number for patient visit records in history LRN 20 30 30 30 20 9 Integer Varchar Integer Varchar Varchar Varchar Varchar Timestamp Varchar Timestamp Integer New New New New New New New New New New New DESCRIPTION COLUMN NAME LENGTH / PRECISSION SQL TYPE NEW / ALTERED

PATIENT_NO TICKET_NUMBER PRIOR_AUTH_NO_1 PRIOR_AUTH_NO_2 PRIOR_AUTH_NO_3 CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS

Varchar Integer

New New New New New New New New New

30 30 30 20

Varchar Varchar Varchar Varchar Timestamp

20

Varchar Timestamp

Appendix A: Database Changes

47

TABLE NAME CLMADJS CLMADJWK CLMERAWK

DESCRIPTION altered table for ERAs to alter field length altered table for ERAs to alter field length altered table for ERAs to alter field length

COLUMN NAME PAYER_INT_CNTL_NUM PAYER_INT_CNTL_NUM REFERENCE PAYER_INT_CNTL_NUM

LENGTH / PRECISSION 50 50 50 50 50 50 50 50 20 20 50 50 50

SQL TYPE Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar

NEW / ALTERED Altered Altered Altered Altered Altered Altered Altered Altered Altered Altered New Altered Altered

DETERA_ DETERAWK DETADJS DADJSWK EDIT92_4_ ( ED92HIST4 EMC1500 ERACLAIM

altered table for ERAs to alter field length altered table for ERAs to alter field length altered table for ERAs to alter field length altered table for ERAs to alter field length altered table to alter column length altered table to alter column length altered table to add column for Payer Claim Control Number altered table for ERAs to alter field length

PAYER_INT_CNTL_NUM PAYER_INT_CNTL_NUM PAYER_INT_CNTL_NUM PAYER_INT_CNTL_NUM TREAT_AUTH TREAT_AUTH PAYER_CLM_CTRL_NBR REFERENCE PAYER_INT_CNTL_NUM

48

Appendix A: Database Changes

TABLE NAME ERAPMTCODE

DESCRIPTION Added new table for ERA Payment Type Cross Reference screen

COLUMN NAME LRN FIN_CLASS PAYER_CODE PATIENT_TYPE CLAIM_TYPE NPI PAYMENT_TYPE OUTLIER_PAYMENT_TYPE CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS

LENGTH / PRECISSION 4 2 4 2 1 30 2 2 20 10 20 10 50 50

SQL TYPE Integer Varchar Varchar SmallInt Character Varchar SmallInt SmallInt Varchar Timestamp Varchar Timestamp Varchar Varchar Integer Integer Small Int

NEW / ALTERED New New New New New New New New New New New New New New New New New New New New New New New New

INS1500 NEW1500 PPMCLMNT

altered table to add column for Payer Claim Control Number altered table to add column for Payer Claim Control Number added table for billing/claim notes

PAYER_CLM_CTRL_NBR PAYER_CLM_CTRL_NBR LRN TICKET_NO CLAIM_TYPE (1 = 1500, 2 = UB) NOTE_REFERENCE_CODE NOTE_DESCRIPTION CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS

3 80 20

Varchar Varchar Varchar Timestamp

20

Varchar Timestamp Integer

PPMCLNTH

added table for billing/claim note hist

LRN

Appendix A: Database Changes

49

TABLE NAME

DESCRIPTION

COLUMN NAME TICKET_NO CLAIM_TYPE (1 = 1500, 2 = UB) NOTE_REFERENCE_CODE NOTE_DESCRIPTION CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS

LENGTH / PRECISSION

SQL TYPE Integer Small Int

NEW / ALTERED New New New New New New New New New New

3 80 20

Varchar Varchar Varchar Timestamp

20

Varchar Timestamp Date Date

TKTDATES

altered to add columns for Edit Ticket

INITIAL_TREAT_DATE DATE_LAST_SEEN

DATA TABLES (Hospital) AMBULANCE_LOCATION added table for ambulance billing LRN VISIT_ID SEQ_NO DROPOFF_PICKUP_ID SERVICE_LOCATION ADDRESS_1 ADDRESS_2 CITY STATE ZIP_CODE COUNTRY_CODE CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS 20 1 55 55 55 30 2 10 3 20 Integer Integer Small Int Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Timestamp Varchar Timestamp New New New New New New New New New New New New New New New

50

Appendix A: Database Changes

TABLE NAME

DESCRIPTION

COLUMN NAME

LENGTH / PRECISSION

SQL TYPE

NEW / ALTERED

ADMRELDT

altered to add new fields

INITIAL_TREAT_DATE DATE_LAST_SEEN

4 4 2 20 50 50

Date Date Varchar Varchar Varchar Varchar

New New Altered Altered New New Altered

CAREGIVERROLE

altered to add new caregiver roles

CAREGIVER_ROLE_CODE CAREGIVER_ROLE_CODE_DESC

EDIT0315 EDIT_HIST0315 ERRMESS

altered table to add new column altered table to add new column Altered to add new records for patient status and type of admit error messages

PAYER_CLM_CTRL_NBR PAYER_CLM_CTRL_NBR MESSAGE_CODE

ERROR_NUMBER MESSAGE_DESC FIX_DESC EV270EQLOOP altered table to add new columns DIAGNOSIS_CODE_POINTER_1 DIAGNOSIS_CODE_POINTER_2 DIAGNOSIS_CODE_POINTER_3 DIAGNOSIS_CODE_POINTER_4 EV270HI new table to hold 5010 segment info EV270_ID LOOP_LEVEL LOOP_SEQUENCE INDUSTRY_CODE INDUSTRY_CODE_QUALIFIER EV271 altered table to add new columns RECEIVER_ADDR1 RECEIVER_ADDR2 RECEIVER_CITY RECEIVER_STATE RECEIVER_ZIP 2 2 2 2 13,0 2 2,0 30 3 55 55 30 2 15 Small Int Small Int Small Int Small Int Decimal Varchar Decimal Varchar Varchar Varchar Varchar Varchar Varchar Varchar

Altered Altered Altered New New New New New New New New New New New New New New

Appendix A: Database Changes

51

TABLE NAME

DESCRIPTION

COLUMN NAME RECEIVER_COUNTRY

LENGTH / PRECISSION 3 48 2 2 2 2 2 13,0

SQL TYPE Varchar Varchar Small Int Small Int Small Int Small Int Varchar Decimal Timestamp

NEW / ALTERED New New New New New New New New New New New New New New New New New New New New New New New New New New

EV271EBLOOP

altered table to add new columns

PRODUCT_SERVICE_ID DIAGNOSIS_CODE_POINTER_1 DIAGNOSIS_CODE_POINTER_2 DIAGNOSIS_CODE_POINTER_3 DIAGNOSIS_CODE_POINTER_4 ENTITY_RELATIONSHIP_CODE

EV271HI

new table to hold 5010 segment info

EV270_ID EV271_TRANSMISSION_TS LOOP_LEVEL LOOP_SEQUENCE

2 2,0 13,0

Varchar Decimal Decimal Timestamp

EV271MPI

new table to hold 5010 segment info

EV270_ID EV271_TRANSMISSION_TS LOOP_LEVEL INFORMATION_STATUS EMPLOYMENT_STATUS GOVT_SERVICE_AFFILIATION_CODE DESCRIPTION MILITARY_SERVICE_RANK PERIOD_FORMAT_QUALIFIER DATE_TIME_PERIOD

2 1 2 1 80 2 3 35 2,0 264 13,0

Varchar Varchar Varchar Varchar Varchar Varchar Varchar Varchar Decimal Varchar Decimal Timestamp

EV271_III

altered table to add new columns

CODE_CATEGORY MESSAGE_TEXT

EV271PRV

added table of values returned in 271

EV270_ID EV271_TRANSMISSION_TS LOOP_LEVEL

Varchar

52

Appendix A: Database Changes

TABLE NAME

DESCRIPTION

COLUMN NAME PROVIDER_CODE PROVIDER_ID_QUALIFIER PROVIDER_ID

LENGTH / PRECISSION 3 3 30 256 256 256

SQL TYPE Varchar Varchar Varchar Varchar Varchar Varchar

NEW / ALTERED New New New Altered Altered Altered

EV271PER

altered table to increase field sizes

CONTACT_1_NUMBER CONTACT_2_NUMBER CONTACT_3_NUMBER

EVERRORS

altered table to add new records for Loop 2110C - Subscriber Eligibility or Benefit Inquiry & 2110D - Dependent Eligibility or Benefit Information error messages altered table to add new column added table for billing/claim note PAYER_CLM_CTRL_NBR LRN VISIT_ID CYCLE_NO CLAIM_FORM_TYPE (1 = UB, 2 = 1500) NOTE_REFERENCE_CODE NOTE_DESCRIPTION CREATED_BY CREATED_TS UPDATED_BY UPDATED_TS 20 3 80 20 50 Varchar Integer Integer Small Int Small Int Varchar Varchar Varchar Timestamp Varchar Timestamp 1 1 Varchar Varchar New New New New New New New New New New New New New

HIST0315 HSPCLMNT

SECPPMBI

altered table to add new columns

UB_BILL_CLAIM_NOTE 1500_BILL_CLAIM_NOTE