HIPAA 5010 Webinar Questions and Answer Session

1 HIPAA 5010 webinar questions and answer session Q: After Jan 2012, do the providers who bill on paper have to worry about 5010? A: No. Q: What if a provider submits all claims via paper? Do the new 5010 guidelines require all providers to switch to electronic claims processing? A: No. Q: If I currently submit one half of my claims using paper HCFA forms, will those be affected by 5010? A: No. Q: What if you submit and electronic primary claim and a paper secondary claim? A: Your electronic claims will need to comply with 5010 in content and format. Q: Will the HCFA/CMS Paper Form need to be altered or changed for 5010? We use the CMS 1500 form. A: No. Q: Will they change the red CMS Health Insurance Claim Form 1500 CMS 1500 (08 05) for paper claims? The last update was to include the NPI, so will 5010 make any changes there? A: No. Q: My system prints paper claims which I then key into NaviNet. Does my PM vendor therefore need to be compliant with 5010 requirements for keying into either NaviNet?

2 A: No. Q: For paper claims, can the mailing address for those claims be a PO Box, or do these addresses also have to be a street address? A: There should be no change to paper claims. Q: On paper claims do we enter the pay to provider address as a street address? Is this the only address that needs to be a street address or does the insurance carrier as well as referring physician need to be street addresses also? A: For all claim types: the billing provider address can no longer be a Box or a lock box, but must instead be a physical address associated with the NPI and must have a 9 digit zip code. (Box 33, CMS 1500 ) If you still want to report a Box you must do so in the Pay To Address. Q: We use the Medisoft Network Professional version 12 SP 2 for our practice management software and submit claims electronically via Capario clearing house. Everything works fine now with no problems. If nothing changes on the paper claim submissions why would I have to update my practice management software?

3 A: Practice management and / or your electronic claims clearinghouses must be able to produce and transmit a HIPAA 5010 compliant version of the 837P or 837I. Q: I use a provider group NPI as billing provider and individual NPI rendering for Medicare claims only. Do I now have to bill that way for all my payers? A: As long as the proper NPIs are on file with the payers, there is no change mandated. Q: Can you explain again where EOB's and correspondence needs to be sent PO Box vs physical address? A: For all claim types: the billing provider address can no longer be a Box or a lock box, but must instead be a physical address associated with the NPI and must have a 9 digit zip code. (Box 33, CMS 1500 ). If you still want to report a Box you must do so in the Pay To Address. Q: Are IBC and KHPE ready to accept 837s now? A: Yes Q: For the eligibility and benefits info, is that what is shown on the patient's card? A: The patient's card usually contains the subscriber or member ID required to access E&B information on NaviNet.

4 The benefits that are returned on the screen may be more comprehensive under 5010. Q: What if the last 4 digits are not the same? If payers have different ones how do you know which one to use? Will the zip code need to be 9 digits for all patient demographics or just the billing provider? A: 5010 specifies that provider (not patient) addresses used on the claim form all have the full zip code, including the 4 digit extension. However, it is unclear whether all payers will validate this information when they receive it. Q: I am a private practitioner and use NaviNet online (my laptop) to submit claims for Aetna. Is there anything I need to do to be 5010 compliant? A: You can continue to use the NaviNet system as you do today. If you are submitting claims online, we will assure that the 5010 formats are created. Q: Are there any changes that are specific to Behavioral Health or other Mental Health Providers? Q: Will anything change for a routine eye exam?

5 Q: Will there be changes specific to a chiropractic practice? Q: Will there be any changes for optometrists? Q: Will anything change for Podiatry? A: 5010 standards apply to all specialties and really only affect the transactions you conduct electronically. Where you will see improvements is in eligibility and benefits, where more information may be provided for certain types of services ( co pays / limitations) Q: When submitting claims, is it required to enter the Subscriber date of birth if he/she is not the patient? A: In 5010, the ONLY time the subscriber address, date of birth and gender should be reported is if the subscriber IS the patient. Q: Will the monetary amount that patients are required to pay be based only on the plan or will specific fee schedule information be available? A: Some payers on NaviNet make a transaction available for you to look up your fee schedule. The fee schedule is NOT available through the eligibility and benefits transaction.

6 Patient responsibility is generally calculated by the payer based on the patient's benefit plan and the amount allowed under the fee schedule. Q: How will 5010 impact the out of state Blues benefit pages? A: 5010 changes have already been implemented for all out of state (Blue Exchange) transactions on NaviNet. You should not see any difference in how they work. Q: If I only submit electronic claims via NaviNet and other portals, do I need my PM vendor to be 5010 compliant? A: If you are not relying on your Practice management system to produce any electronic transactions, then you need not be concerned about 5010 compliance. Q: We are not yet ready for 5010. How can we get our Aetna remits in 4010? A: Aetna makes several channels (including NaviNet) available to receive remittance. We would advise contacting their provider relations department to address your options. Q: My doctor is using an outdated version of software for claims submission.

7 How critical is it to have updated software for 5010? A: If you rely on this system to produce electronic claims, it is critical for you to contact the vendor for an upgrade or look at options for switching to a compliant product. Q: What is 5010 really? Is this just for EMR or is it for everyone to get ready for 2012? A: 5010 is mandated to address known deficiencies with the 4010 version for electronic transactions, AND positions the industry to switch to the new ICD 10 code sets in 2013. Q: Does Medicare only accept EDI claims? A: Yes, Medicare mandates the use of electronic claims. You can contact your local Medicare Administrative Contractor (MAC) to explore options. Q: Will each insurance plan on NaviNet be required to show 'payment estimator' style responses, like Aetna's via your site, showing a patient's co pay and other payment responsibility when diagnosis and CPT codes are provided? A: The use of estimators is not mandated under 5010, but we are encouraging payers to make them available on NaviNet.

8 Q: You mention there will be an area to include the Web address in which we used to obtain patient balance etc. Please tell me how this is done again and where this reflects? A: The web address has been added to remittance advice (835) transactions. The PAYER will have the option to use it to provide more information to you about how a claim was priced and adjudicated (beyond the standard remark and adjustment codes). Q: What kinds of problems have you seen during this transition year? A: Many vendors have realized that 5010 upgrades are costly and complex and some have chosen not to update systems. This is a trend we are seeing in the market. Q: Can pay to be PO Box? A: Yes. Q: How does the secondary payer know what the primary payer paid on the claim? A: Most payers will require the explanation of benefits from the primary carrier be sent with the claim as an attachment. If we have a PO Box, what form do we need to complete to have a pay to address changed?

9 You should not need to change the Pay To address if it is a Box, only the Billing Provider address on your electronic submissions. If we have a P. O. Box, where are the "pay to provider" name and address fields on the HCFA forms? The Pay To address is specific to electronic submissions and should be included in the Pay To Address loop (2010AB Loop) Q: Will the PO Box affect the payments that come via EFT? A: EFT payments should not be affected as they are deposited to the account you have specified with the payer. Q: Under 5010 rules, will allowable amounts have to be reported under Eligibility and Benefits? Currently, (I am not a participating provider with the insurance plans), I only get percentages . if they are applying these to usual and customary, it covers my fee if they are using an "allowable amount" I cannot predict how much the patient will have to pay. A: The only difference you should see in the process you use today is that you MAY receive more specific co pay or co insurance percentages specified by benefit type in 5010.

10 Q: We were recently informed that the 4 digit code is only required for payers not for patients. Can you please direct me to the documentation that states it is required for patients so that I can share this within my organization? A: Just to be providers, patients and insurance payers need to have their Zip +4 entered into our EMR software? I was only aware of the provider information needing the Zip + 4. Q: What if the patient does not know their 4 digit zip code extension? A: Zip code extensions apply to the PROVIDER and FACILITY addresses. You do not need to submit them for patient addresses. CMS has stated they will reject claims with missing 4 digit extensions for provider addresses. Q: Will specialists, specifically chiropractors, need to use taxonomy codes in all claims? If so, how do we know which code to use? A: Yes. The taxonomy codes should match what the payer has on file for your NPI and should be specified in the following fields: ADA J400 Field 56A UB 04 Form locator 81 CMS 1500 Fields 17A, 24I, 32B and 33B Q: If we are billing exclusively through NaviNet, does that mean that we don't have to do any upgrades for 5010?