Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth All Provider Bulletin 213 September 2011 TO: All Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Testing Readiness for CMS 5010 Mandate Background The Centers for Medicare & Medicaid Services (CMS) has mandated that on January 1, 2012, the standards for electronic health care transactions must change from version 4010/4010A1 to version 5010. MassHealth is actively working toward this January 1, 2012, implementation date. All electronic health care transactions currently submitted to, or returned from, MassHealth in the 4010A1 version are affected. Please see All Provider Bulletin 205 for a list of the impacted transactions. Testing Readiness MassHealth will conduct testing with active submitters (those who have submitted electronic claims within the past year) before the January 1, 2012, implementation date. Testing will be executed in the following three phases. Beta Testing Phase Who Is Involved In this Testing Phase? Limited number of select submitters that represent a cross-section of the MassHealth submitter population What Is Being Tested? * Batch transactions * Direct data entry (DDE) * Paper claims Time Period July – September 2011 Phase I – 7/5 – 8/12 Phase II – 8/15 – 9/30 Vendor Testing Phase Who Is Involved In this Testing Phase? All software vendors, clearing houses, and commercial billing intermediaries What Is Being Tested? Batch transactions Time Period September – October 2011 Early adopters began testing in mid-August. Trading Partner Testing Phase Who Is Involved In this Testing Phase? All other trading partners What Is Being Tested? Batch transactions Time Period October – December 2011 Testing Readiness (cont.) MassHealth started beta testing on July 5, 2011, with 16 trading partners that represent MassHealth providers and vendors. During phase I of beta testing, the testers will actively test DDE, batch 837P, and 270/271 transactions. Phase II of beta testing began on August 15, 2011, and, in addition to phase I functionality, includes the 837I, 276/277, and 835 transactions. Phase II also includes paper claims testing, DDE, and HTS (healthcare transaction services) submission methods. Currently, the HIPAA 5010 EDI team is actively outreaching to MassHealth vendors, billing intermediaries, and clearing houses to confirm when they will submit their first test file to MassHealth. Vendor testing is slated to begin on September 1, 2011. However, vendors who were ready before September 1st began testing in August. A vendor testing overview session was conducted on August, 16, 2011, with all impacted entities. Providers who submit electronic claims to MassHealth through a vendor should contact their software vendor or billing intermediary to ensure they are prepared for 5010. It is critical that your vendor is ready to support testing with MassHealth in the designated time frames. Failure to do so could impact your ability to submit electronic claims to MassHealth starting January 2012. Additionally, MassHealth will publish the testing status of every vendor on its 5010 Web page. This will allow providers to measure each vendor’s readiness and coordinate implementation plans accordingly. The HIPAA EDI team will be contacting all providers who currently submit electronic claims directly to MassHealth to schedule testing that will begin in October 2011. To prepare for 5010 testing, please contact your software vendor to determine when your software will be ready for testing with MassHealth. Confirm with your vendor that your software will support all applicable 5010 changes, including the ability to use void and replace capabilities as well as coordination of benefits functionality, if applicable. When the HIPAA EDI team contacts your organization, they will validate that your current contact information is on file, validate your software vendor’s readiness, and schedule a time to test your file. Testing Readiness (cont.) If you have not defined your testing timelines yet, please be sure to review the 5010 preparation readiness activities that MassHealth outlined in All Provider Bulletin 210 for guidance. Testing with managed care organizations (MCO) is now underway. Currently, MassHealth is actively testing the 820 transaction with 16 trading partners and will start 834 outbound transaction testing with MCOs in September. Training MassHealth has posted a number of POSC DDE job aids on its 5010 Web page. These job aids have been updated to reflect the changes that were made to accommodate 5010. Providers may use these job aids as needed to assist them with 5010 claim submission. Additionally, MassHealth will initiate 5010 DDE training this fall. In an effort to maintain efficiency, MassHealth will integrate the 5010 DDE training into other agency training initiatives, and will leverage the standard provider association meetings and other forums to train and communicate with providers. Please check the MassHealth 5010 Web page for further information on the training activities at www.mass.gov/masshealth/5010. Additional 5010 In an effort to keep providers informed of important 5010 key concepts, Key Concepts MassHealth posted key concepts on the 5010 Web page. While these concepts are included in the updated billing instruction and companion guide documentation, posted on www.mass.gov/masshealth, MassHealth has recently identified a number of key concepts that are distinct enough that it is important to ensure that everyone is aware of them. KEY CONCEPTS Anesthesia Units - Anesthesia services billed with service codes that do not have a specific time period defined in the description of the code must be reported using minutes. Anesthesia services reported in units will no longer be accepted. Details about this change can be found in Physician Bulletin 91. 837P CMS-1500 Diagnosis Codes - All MassHealth providers must use the ICD-9-CM diagnosis codes or, if applicable, use diagnosis codes from the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision). This change also impacts MassHealth providers who are not currently required to submit diagnosis codes with their claim submissions. This new requirement does not apply to dental providers submitting claims on the ADA (American Dental Association) claim form. 837P 837I UB-04 CMS-1500 Patient-Paid Amount - The 2300/AMT segment with F5 qualifier (patient-paid amount) has been deleted. All providers must now submit the FC value code (claim/value information) with patient-paid amount as the value code amount on claim submissions. 837I UB-04 Patient Reason for Visit - Acute outpatient hospitals, chronic disease and rehabilitation outpatient hospitals, psychiatric outpatient hospitals, substance abuse outpatient hospitals, and hospital-licensed health centers are required to include the “patient reason for visit” ICD-9-CM diagnosis code on all out-patient claims in order to comply with the HIPAA Implementation Guide. All relevant outpatient UB-04 paper claims must also contain this information. MassHealth will not enforce any additional requirements to accommodate this new data element 837I UB-04 Prior Authorization (PA) - If any service on a claim requires a PA, the PA is now required to be entered at the header level for the entire claim. It should be entered at the service line only when the PA is different than the one entered at the header level. 837P 837I Referrals - If any service on a claim requires a referral, the referral must now be entered at the header level for the entire claim. It should be entered at the service line only when the referral is different than the one entered at the header level. 837P 837I Please ensure that impacted staff within your organization are aware of this change, and that they are modifying your systems and billing practices accordingly to support this change. If you have a billing intermediary that conducts business on your behalf, or a software vendor who provides you with your 5010 software, please contact them to ensure that they are making the necessary modifications to support this change. The complete set of 5010 key concepts listed here is available on the MassHealth 5010 Web page at www.mass.gov/masshealth/5010. Direct Data Entry Demonstration In September, MassHealth will conduct a demonstration of the 5010 DDE functionality to a select group of MassHealth providers. This group of providers will have the opportunity to use the application in a secure environment. Providers will be able to use their own set of claims to test the functionality and provide important feedback to MassHealth. MassHealth staff will be available to provide guidance to testers and answer any questions that arise. In addition to the standard DDE functionality, providers will have an opportunity to use the new eligibility verification system PC (EVSPC) functional. Providers will be required to download the software and instructions before the demonstration and provide feedback to MassHealth on ease of use and any issues they have identified. Important MassHealth Reminders Paper Reduction MassHealth is moving toward an all-electronic claims submission policy to achieve greater efficiency. As of January 1, 2012, MassHealth intends to require electronic claim submission, unless the provider has received an approved electronic claim submission waiver. The related changes to MassHealth regulations will be issued via a future provider transmittal letter. Coordination of Benefits In accordance with the paper reduction initiative, it is crucial that providers transition from paper COB claim submissions to using either COB Direct Data Entry (DDE) or batch transactions. If you currently submit paper COB billing, please be aware that MassHealth supports the following. * 837P and 837I COB * DDE of COB through the POSC Please take advantage of these submission methods. If you are interested in submitting 837P or 837I COB batch transactions, please contact MassHealth and specify this when you schedule your 5010 trading partner testing, or contact EDI@mahealth.net. Questions We are committed to working closely with you, your software vendors, and billing intermediaries through this testing process. Our team is dedicated to providing you with the resources and support necessary to successfully transition to the 5010 standards. If you have any questions about the information in this bulletin, please contact the EDI test team by e-mailing your inquiry to EDI@mahealth.net, or contact us at 855-253-7717.