Healthcare: Is Your Billing System Ready for 5010 and eMedNY Front End Edits?
7/14/2011
The eMedNY production system will begin processing 5010 and D.0 transactions on July 21, 2011. This implementation will drastically impact technical and business processes for medical billing systems.
The following is a summary* of some of the business and technical changes to be expected as of July 21, 2011:
- The 835 Supplemental Remittance file sent with electronic remittances will no longer contain paid or denied claims; only pended claims will be reported in the Supplemental file. 4010 EFT remittances will continue to be submitted to providers upon receipt of a 4010 transaction file. 5010 EFT remittances will only be submitted to providers upon completion of a request form to Computer Sciences Corporation. Effective January 1, 2012, all providers will receive the 5010 EFT remittances.
- eMedNY will improve the acknowledgment files process. Claims rejected by the front-end process will not be reported in the Remittance Advice; instead they will be returned in outbound responses to claim submissions, 277CA for 5010 submissions and U277 for 4010 submissions. Claims that have passed all “pre-adjudication” edits and do not have errors indicated will be reported on a future remittance advice.
- 278 Service Authorization transactions will be eliminated.
- Eligibility Response (271) transactions will require major technical changes. The response will provide “at limit” information for any applicable Service Categories coupled with the Service Type identifying which category is “at limits.” Utilization Threshold units will be counted at the time of adjudication not reservation. If the patient is “at limits” when the claim is processed, the claim will pay if an eligibility response is on file and indicates service units were available for the date of service. The claim will pay only if the provider number in the eligibility request is equivalent to the billing provider on the claim.
- The 278 Prior Approval transactions will provide the ability to request changes for existing authorizations:
- Request extensions for a previously approved service;
- Cancel an entire approval; or
- Revise/cancel a previously approved service line.
- Point of Service devices will require a new software version. Implementation of the download has been scheduled from July 20, 2011 at 6:00 p.m. through July 21, 2011 at 8:00 a.m.
- ePACES screens will change.
- Processing time from file submission to acknowledgement is anticipated to be greatly reduced.
- Online dashboards will now be available; Enhanced Batch File Tracking will be introduced to allow submitters to track ALL batch files throughout the adjudication process. The new “dashboard” will be available to track files submitted via eXchange, FTP, or VPN.
Your technical staff and/or vendor must ensure systems and business process changes resulting from this implementation do not impact your Medicaid payments.
It is also imperative to have efficient work flows in place to track receipt of the 277CA or U277 that reference back to each claim submission and to ensure your billing staff is provided with a report of the responses returned in the 277CA or U277 so they can identify and correct pre-adjudicated denied claims.
A list of pre-adjudication edits and associated claim status codes are available at http://www.swiftpage3.com/SpeClicks.aspx?X=2V0NISRXE696HP0T05Y9WW, under “eMedNY HIPAA Support.” Then, click on “5010 Crosswalks.”
For further information about this or other issues that may impact your business, please contact Peter R. Epp, managing director of J.H. Cohn’s Healthcare Industry Practice, at pepp@jhcohn.com or 646-254-7411; Dolores DiRe, manager, at ddire@jhcohn.com or 646-625-5703; or your J.H. Cohn engagement partner at 877-704-3500.
Note: Providers may continue to submit 4010 transactions until December 31, 2011. Effective January 1, 2012, providers must be ready to submit, receive and process all 5010 transactions. The changes noted above affect 4010 and 5010 submission transactions as of July 21, 2011.
*Sources: Medicaid Update, February 2011-Special Edition and www.emedny.org