HIPAA

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HIPAA EDI OUR EXPERIENCE
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BACKGROUND

• UWHC is a 500 bed complex academic medical
  center.
• gt 600,000 ambulatory encounters and 20,000
  admissions annually
• Siemans Invision mainframe HIS platform Cirius
  claims scrubber
• Live with 837-4010A format direct to 8
  payerstesting with 7 additional payers and 1
  clearinghouse.

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TOPICS OF DISCUSSION

• Your Trading Partners
• Testing services and certification
• Companion Documents
• Getting started How we dealt with some problems
• How much testing is enough
• Moving to Production
• The 835
• Wrap Up

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YOUR TRADING PARTNERS

• Create a priority list of your partners Which
  payers represent highest volume of claims? Which
  transactions are most important with which
  partners?
• Establish an EDI contact with each of your
  Trading Partners
• Create a checklist with each partner

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TRADING PARTNER CHECKLIST

• Contact name your new best friend until October
  16th!
• Your own internal identifiers for this payer
• Mode of transmission agreed upon (FTP modem,
  Bulletin Board, Internet etc)
• Logins and passwords
• Encryption

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CHECKLIST (CONT)

• Timetable for transmission and acceptance reports
• Create a log for transmission, acceptance and
  comments pertaining to this payer. The more best
  friends you have, the more important this
  becomes to keep everyone straight.

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TESTING AND CERTIFICATION

• Subscribe to a nationally recognized Testing
  Agency. (We use Claredi) This provides you with
  credibility and identifies issues within your own
  data and its cheap!
• Prepare test files using production data in a
  test environment to submit to the testing service
• Dont send a test file to a payer until you are
  certified

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COMPANION DOCUMENTS

• Not all payers have companion documents. If not,
  they need to identify values they would like to
  see in the ISA and GS segments as well as any
  situational loops they require.
• Your testing agency will tell you if their
  requirements are compliant or not.

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Problems/Solutions

• Loop 2400 SV2 too much information!
• Based on the revenue code if revenue code 0022,
  0023 or 0024 you must send a ZZ in SV202-1
• If you are passing a hcpc code, you must pass an
  HC in SV202-1
• If you are passing a modifier, there has to be a
  separator between the hcpc and modifier(s)

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PROBLEM

• Loop 2400 DTP
• If you are a Home Health Provider and sending a
  RAP claim to Medicare, they want to see the
  Assessment Date and not the service line date.
  
• Work with your HHA on how this date will be
  passed. Many will use the admission date field
  for this which can then be mapped to this loop.

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PROBLEM

• Where do you put those valuable remarks you want
  the payer to see so you dont have to fax or mail
  them something separately? (Remember this is an
  electronic solution)
• Use the 2300 Loop Billing Note and map form
  locator 84 to this loop so it is transparent to
  your billers but allows this information to pass.

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PROBLEM

• E M codes if you are a hospital based
  provider and billing revenue code 510 your file
  is non-compliant without a CPT code for this
  revenue code. The current CPT language for E M
  is defined for physician services.
• Send a letter of understanding to your trading
  partners that your are sending an E M that
  represents Facility services and not professional.

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HOW MUCH TESTING IS ENOUGH

• The larger the payer, the more testing you should
  do. Send each test file through your testing
  service prior to sending to the payer. The more
  you test, the greater likelihood of finding all
  those unique errors
• Dont fix the claim, fix the cause track the
  error back to the source data and find a way to
  prevent then from recurring

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MOVING TO PRODUCTION

• Only the payer can set this date. Many have to
  test your data in two capacities, first run it
  through a front end translator and then through
  their claims adjudication system
• Some payers will forward your files through their
  own testing service which is why you want to make
  sure it is clean!

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The 835

• Remember, you are helping the payer by giving
  them an 837, ask for an 835 in return. This
  translates into FTE for you in batching and
  keying cash transactions. Use this in
  prioritizing your trading partners.
• In addition to the 835 ask the payer to send the
  funds through EFT so you are not sitting on
  transactions while a check is being mailed.

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The 835 (cont)

• Research what steps you can build into the 835
  process that will help your facility. We post
  the cash, compare the contractual allowance to
  that posted at time of billing and correct if
  necessary, move the balance to the next payer,
  generate a secondary claim form and EOB and post
  the ansi codes as remarks to the account.

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The 835 (cont)

• Ask the payer to map their existing proprietary
  codes to the ansi codes. Knowing this up front
  will reduce calls back to the payer to translate
  after you are in production.
• Ask for the 835 test files to be of actual claims
  so you can look at production data for a
  comparison.

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WRAP UP

• What have we learned? The IGs have to be read
  and not used to cure insomnia.
• I/S cannot own this it is about claims and
  adjudication, not programming.
• Get certified without this, you have no
  credibility with it you have an internal testing
  resource
• Keep it simple! This is a solution, not a problem

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Facts

• Trading partners really are partners work to
  benefit both sides dont agree to processes that
  require manual intervention this is an
  electronic solution!
• Your vendor will not make you compliant!
• Your clearinghouse will not make you compliant!

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CLOSING

• If you havent already done so, schedule a
  vacation starting October 17th. Dont tell
  anyone where you are going! Computers and phones
  not allowed on this vacation!
• Good Luck!