June 02, 2010
Implementation of the new Health Insurance Portability and Accountability Act Formats for all Durable Medical Equipment Medicare Administrative Contractor Electronic Trading Partners
Are you prepared for the conversion to the new Health Insurance Portability and Accountability Act (HIPAA) formats? Will your software be ready in time? The Centers for Medicare & Medicaid Services (CMS) has mandated the industry upgrade to X12 version 5010 and National Council for Prescription Drug Programs (NCPDP) version D.0 (the NCPDP D.0 format is used by retail pharmacies) by January 1, 2012. Even though this deadline seems far away, now is the time to start preparing for these changes.
The Common Electronic Data Interchange (CEDI) will be fully compliant with ANSI X12 version 5010 and NCPDP version D.0 code sets according to the timelines established by the U.S. Department of Health and Human Services (HHS).
- Timelines
January 1, 2011 The Common Electronic Data Interchange (CEDI) will open testing of the new HIPAA formats to all software vendors or suppliers with proprietary systems. Once a software vendor is approved, they can begin moving their customers into production.
January 1, 2012 CEDI will only accept and return the new HIPAA formats (ANSI X12 5010 and NCPDP D.0). All DME MAC electronic trading partners must be in production with the new HIPAA formats by this date.
Note: Electronic trading partners can move into production any time on or after January 1, 2011 as long as their software has been approved for the new HIPAA format(s) (ANSI X12 5010 and/or NCPDP D.0).
- Front-end Reports
The current X12 version 4010A1 electronic claims front-end reports created and produced by the Common Electronic Data Interchange (CEDI) (997, TRN and GenResponse) will be replaced with the 999 and 277CA transactions once an electronic trading partner begins using the new X12 version 5010 format. The 999 and 277CA transactions will not be readable without translation, so suppliers will have to get these new reports read by their software. The 999 and 277CA transactions are not HIPAA mandated; however, CMS is requiring these transactions for all Medicare business. Note: The TA1 produced by CEDI and the Certificate of Medical Necessity (CMN) rejection report produced by the durable medical equipment Medicare administrative contractors (DME MACs) and delivered by CEDI will continue to be produced for X12 version 5010 transactions.
The current NCPDP version 5.1 front-end report created and produced by CEDI will be replaced with an NCPDP formatted transmission response report for NCPDP version D.0 claims. The version D.0 NCPDP transmission response report will not be readable with out translation, so suppliers will need to have these reports read by their software.
- PC-ACE Pro32 Users
The PC-ACE Pro32 software will be updated for the new HIPAA X12 version 5010 claims format and made available in 2011. CEDI will provide notification via the CEDI Listserv and Web site as soon as the X12 version 5010 of the PC-ACE Pro32 software is available.
- Express Plus Users
The Common Electronic Data Interchange no longer supports the Express Plus software; therefore it will not be updated for the new HIPAA X12 version 5010 format. All suppliers using Express Plus should have converted to PC-ACE Pro32 or another software program as of April 1, 2010.
- What You Need to Do
All DME MAC electronic trading partners need to make sure their software programs will be ready for the new X12 version 5010 and/or NCPDP version D.0 standards according to the timelines listed above. National Government Services CEDI suggests you contact your software vendor, billing service or clearinghouse to make sure they are aware of the changes to the new HIPAA formats.
- A list of questions to ask your software vendor, billing service, or clearinghouse:
- Will you be upgrading my current system to accommodate the ANSI X12 5010 and/or NCPDP D.0 transactions?
- Does my contract include an update to the ANSI X12 5010 and/or NCPDP D.0 standards or will I be required to pay for this upgrade? If so, how much will it cost?
- When will my system be upgraded with the ANSI X12 5010 and/or NCPDP D.0 standards?
- When will the installation to my system be completed?
- Will I need to purchase any new hardware?
- Will you be increasing your fees to cover the cost of the ANSI X12 5010 and/or NCPDP D.0 implementation?
- Will you have any testing and validation phases with me directly so I can see if any problems occur when submitting claims?
- Who should I call if we have problems submitting claims with the ANSI X12 5010 and/or NCPDP D.0 formats?
- Will the ANSI X12 5010 upgrade include a way to translate the 277 claims acknowledgement (277CA) electronic transaction into a format to show me if there was an error in the claim?
- Will the ANSI X12 5010 upgrade include a way to translate the Functional Transaction 999 into a format to show me the file was accepted by the Medicare contractor?
- Will the NCPDP D.0 upgrade include a way to translate the NCPDP front-end transmission response report into a readable format to show me if the claim was accepted by the Medicare contractor or if there was an error on the claim?
- Will this require any additional training by my staff? If so, where can I obtain this training and will there be additional costs for this training?
Important: It is up to you as the health care provider to ensure your transactions are conducted in compliance with HIPAA regulations-whether or not you contract with a software vendor, billing services, or clearinghouse.
Additionally, The Administrative Simplification Compliance Act (ASCA) requires the use of electronic claims (except for certain rare exceptions) in order for suppliers to receive Medicare payment. Therefore, effective January 1, 2012, you must be ready to submit your claims electronically using the X12 version 5010 and/or NCPDP version D.0 standards.
Remember, the X12 version 5010 and version D.0 HIPAA standards are national standards and apply to your electronic transactions with all payers, not just with fee-for-service (FFS) Medicare. Therefore, you must be prepared to implement these transactions with regard to your non-FFS Medicare business as well.
- Additional Information/Resources
The Centers for Medicare & Medicaid Services has created an entire section of their Web site devoted to the new HIPAA formats, including a Medicare comparison of the current and new formats
The Centers for Medicare & Medicaid Services Web site for industry-wide information, including upcoming free educational seminars