(Medicare Claims Processing Manual)

 The availability of the appropriate specifications for providers and instructions for accessing these via the Internet or other cost effective means;    The availability  of the A/B MACs to provide  providers bulletins via the Internet and/or bulletin board system;    The availability of the A/B  MACs, and CEDI to provide EDI instructions or procedures via the Internet and/or bulletin board system;    The availability of the A/B MACs, and CEDI to provide free Medicare EMC software;    The availability of the A/B MACs free PC -Print software and the A/B  MACs, and CEDIs free Medicare Remit East Print (MREP) software for the printing of the Electronic Remittance Advice.    Login requirements;    Hours of operation, system and support;    Telecommunication options and requirements;    Procedures for updating submit ters with any billing changes;    EDI formats required for input to the A/B MACs and CEDI system.  These specifications must be in sufficient detail for the submitters use, and must include information regarding code, record length(s), field positioning within record(s), labeling and any other conventions necessary for compatibility with the A/B MACs or CEDI system;    All acceptance and rejection formats and content for output from the A/B MACs, or CEDI;     Availability of online claim entry, claim correction (A/B MAC (A) only), claim status check, eligibility verification, claim development via DDE or otherwise, and the procedure for accessing these transactions;    Availability of claim status check and eligibility verification and the procedure for accessing these transactions (A/B MACs only);    Specifications of the A/B MACs, and CEDIs front -end editing process (except in those cases when disclosure of specific edits is related to medical Review or another sensitive area for which disclosure is not a dvisable) with complete list of error codes and resolution, including those conditions that will result in the rejection of entire EDI transmissions/batches;   Conventions for acknowledging claims received and for recovering data known to be lost;    Instruct ions for submitters to notify their A/B MACs and CEDIs changes to the submitter profile in regard to use of clearinghouses, billing agents, EDI transactions and software for submission/receipt of those transactions;    A/B MACs and CEDI listings of vendors a nd clearinghouses that are approved for production;    Data requirements for reporting third party Medigap payers,    Frequently asked questions and answers about EDI.   DME MACs  must make information available to potential users (preferably via their web page  or the Internet) of each EDI transaction supported by Medicare with detailed information on:    How to contact CEDI to:   o Get started with electronic billing and other EDI transactions; and  o Obtain on- going support for electronic transactions.   The availability of DME MACs  provider bulletins via the Internet and/or bulletin board system;    The availability of CEDIs free Medicare EMC software    The availability of the CEDI free Medicare Remit East Print (MREP) software for the printing of the Electronic Remittance Advice.    Special instructions related to specific diagnosis or procedure codes, i.e., the necessity for attachments or modifiers and appropriate placement within the electronic record and;    Data requirements for reporting third party payers, i.e., Medigap, crossover, Medical Assistance and private insurance.   40.2.4.2 - Technical Assistance to EDI Trading Partners  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs and CEDI will provide help desk support to a ssist submitters and receivers with inquiries related to file transmission and acknowledgment, file retrieval, transaction requirements/specifications and the use of free software.  Help desk support will be available during normal business hours at a mini mum.  Time zone differences at the providers location should be accommodated if possible.  Help desk activities are to be controlled and monitored through an automated call management system that provides the following functions:    Control (login) of all incoming calls: identification of caller, reason for call, date and time;   Track activities related to the call to the final resolution of the call: identification of routing, callbacks, issues(reason for call), resolution, date and time;    Workload distribution of open items;    Classification of call types for resource planning, provider education, management reporting; and    Storage of caller -specific audit trails.   In addition to an automated call system, A/B MACs and CEDI must provide for receipt of e-mail or voice mail when the help desk is not available.  Receipt of customer service inquiries must be acknowledged within one business day, or attempts to acknowledge the inquiry within this time must be documented if contact has not been made successfully.   Where transmission, retrieval or file problems are reported, a plan of action to resolve the issue must be provided to the inquirer within three (3) business days. This plan should include one or more of the following:    An indication that the A/B MACs or CEDI looked into the issue and did not identify a problem;    The submission of a new corrected file (A/B MAC or CEDI only);    An explanation which either solves the problem or indicates action which the submitter or receiver can take to resolve the problem;    An indication of the need for further investigation, with an estimated time frame for responding with more information and or a resolution;    An indication that resolution requires A/B MACs or CEDI action, and a description of the plan for resolution and estimated completion date.   Where the problem affects multiple submitters the A/B MAC or CEDI makes information on the issue available to all affected submitters.   40.2.4.3 - Training Content and Frequency  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09 -17-13)  See the CMS Provider Education and Training (PET) manual for the definitive provider outreach and training requirements.  Provider training is included in the CMS contractor PET budget and although EDI information must be included in those training efforts as appropriate, the PET requirements contain specific activities that must be completed by A/B MACs, DME MACs and CEDI.  When possible, EDI training should be conducted in conjunction with non- EDI training to share training room and trainers expenses.  This EDI-related training information is included in Chapter 24 for reference purposes only.  When appropriate, A/B MACs, DME MACs and CEDI may develop user groups for general EDI users and free software users. A/B MACs, DME MACs  and CEDI  are not required to support or train providers on the use of software provided by commercial vendors/trading partners, on ASC X12 format structure or coding, the use of PCs, or other subjects non- specific to Medicare EDI.  On an ongoing basis, A/ B MACs, DME MACs and CEDI should assess the need for additional training based on:    Periodic identification and evaluation of common electronic billing errors;  New software release; or   The introduction of new EDI functions or changes to existing functions.   40.2.4.4 - Prohibition Against Requiring Use of Proprietary Software or DDE  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs, DME MACs and CEDI will accept and process HIPAA EDI transactions created from any software as long as the transactions comply with the TR3 requirements standards adopted under HIPAA and CMS business requirements.  A/B MACs, DME MACs and CEDI are prohibited from requiring that submitters of HIPAA EDI transactions use proprietary billing software  or specific hardware.  A/B MACs, DME MACs and CEDI may not charge providers that use their own software, hardware, modems, and telecommunication lines to submit and/or receive EDI electronic transactions in a HIPAA -compliant format.   DDE screens generally  involve the use of dumb terminals programmed for specific uses, or of PCs that use software issued by a payer to emulate a dumb terminal to permit providers to individually enter claim data and correct claims errors (applies to Medicare institutional claims only), verify beneficiary eligibility (A/B MACs (A) and some A/B MACs (B)), obtain claims status (A/B MACs (A)  and some A/B MACs (B)), or possibly perform another function.  A/B MACs and DME MACs incur additional costs to maintain DDE functionality and support, they are allowed to recoup those costs from users and are permitted to charge a reasonable amount for its use A/B MACs, and DME MACs may not require use of DDE, or refuse to accept or discourage submissions of HIPAA EDI transactions.   40.2.4.5 - Free Claim Submission Software  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs, and CEDI will provide free/at cost software for their providers to use on a Windows -based PC for electronic submission of HIPAA -compliant  claims to Medicare.  At a minimum, this basic software must contain the following:    Edits to prevent incomplete and inaccurate claims from entering the system;  User friendly qualities including:   o A low initial investment, as well as low -cost upgrades, on the part of the submitter;  o Minimal effort for both the software installation and training for the submitter; and  o Clear and understandable software documentation, including information about where to receive additional help.  This software must also be able to identify when Medicare is a secondary payer and to collect data elements concerning a primary payers payment, standard claim adjustment reason codes and adjustment amounts made by a primary payer prior to submission of a claim to Medicare for seco ndary payment.   A/B MACs and CEDI are not funded to issue free/at cost software for other than submissions of ASC X12 837 claim inbound transaction.  NCPDP has indicated software for billing NCPDP formatted claims was already in widespread use by retail ph armacies and there was not a need for Medicare to fund development of free billing software for retail pharmacies.   The software is free/at cost but A/B MACs and CEDI may charge a fee up to $25.00 per request to recoup their postage, reproduction, and handling expenses when a provider requests the software be sent via diskette, CD, or other medium, rather than downloade d by a provider from the Medicare contractors web page (if not precluded by a software copyright or licensing agreement).  A/B MACs and CEDI are to complete upgrades to their free/at cost billing software to correspond to the requirements of the current X 12 version of the transactions.  Prior to distributing the initial or updated versions, A/B MACs and CEDI will scan the free/at cost billing software with a current anti- virus program.  Whenever A/B MACs and CEDI issue a new version of their free/at cost billing software, they shall notify providers to terminate use of the earlier version of the Medicare free/at cost billing software within 90 -days of release of the updated software.   NOTE:  The free -billing software distributed by A/B MACs (A) is maintained  by the shared system maintainer.  A/B MACs (A) are responsible for testing and distribution of that software only.  There is not a similar common source of free billing software or maintenance for the A/B MACs (A) or A/B MACs (B) . A/B MACS or A/B MACs (B)   are encouraged to obtain and license for distribution Medicare Part B billing software.  This software is available to A/B MACS and A/B MACs (B)  for purchase and licensing from software companies.   40.2.4.6 - Newsletters/Bulletin Board/Internet Publicat ion of EDI Information  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  To educate providers and encourage the use of EDI A/B MACs, DME MACs, and CEDI must periodically include information about use of EDI in their newsletters and on their Web site.  Their newsletter and Web site shall:   1. Announce upcoming EDI changes;  2. Point out common EDI billing errors and provide guidelines to eliminate errors; and 3. Promote use of each of the Medicare -supported HIPAA EDI transactions.