(Medicare Claims Processing Manual)

For more information on EFT see IOM Pub 100- 08 Chapter 10.   60.5.4 - Tri-Partite Bank Agreement  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs and DME MACs  must ensure that Tri -partite bank agreements (three- party agreements between the contractor, the bank, and the provider) include wording that allows funding of the letter of credit to include EFT as well as paper checks.  The agreement must clearly state that all references to checks in the agreement include checks and/or electronic funds transfer.   For more information, refer to the Medicare Financial Management Manual, Pub. 100- 06, Chapter 5.   60.6 - Health Care Provider Taxonomy Code (HPTC) Requirements  (Rev. 10236, Issu ed: 07 -31-2020, Effective: 08- 31-2020, Implementation: 08- 31-2020)   Health Care Provider Taxonomy Codes (HPTC) are also called Specialty Codes. HPTCs are 9 -digit identifiers assigned by the National Uniform Claim Committee (NUCC) to be used in HIPAA transa ctions.  Contractors are required to validate the incoming HPTC against the most recent taxonomy code list. CMS will notify A/B MACs, their shared system maintainers, and CEDI (via Recurring Update Notification) to load the most recent HPTC code list into a contractor -controlled table.  HPTCs may not be hard coded by the shared system maintainers.  Contractor -controlled tables minimize the impact of future system updates.   HPTCs are updated twice a year (tentatively October and April) by the NUCC and the updates are available for download in a portable document format (PDF) from the official Washington Publishing Company (WPC) website for no charge or an electronic representation of the list, which could facilitate loading of the codes, may be purchased from  WPC on a subscription basis.  Contractors are to use the most cost effective means to obtain the list for validation programming and updating purposes.    70 - CMS Defined File Formats  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  70.1 - General HIPAA EDI Requirements  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  As described in section 40.1.1, the A/B MACs, DME MACs and CEDI shall support the current versions adopted under HIPAA of the following transactions and their implementation guides for the electronic exchange of data with Medicare providers/submitters/receivers/COB trading partners. Electronic transactions that do not fully comply with the implementation guide requirements for th ese formats will be rejected.   ASC X12 837 claim, institutional and professional    NCPDP telecommunication and equivalent batch standard for retail prescription drug claims ( applicable for CEDI and  DME MACs only) and COB (see  40.1 of this chapter for addi tional information);   ASC X12 835 remittance advice (see chapter 22 for additional information); and    ASC X12 276/277 claim status request and response (see chapter 31 for additional information).   Links to sources of implementation guides for these standards are available at    www.cms.hhs.gov/ElectronicBillingEDITrans   Although not mandated by HIPAA, as noted in  40.1.2, CM S also requires that A/B MACs and CEDI issue an ASC X12 999 implementation acknowledgment transaction to electronic claim submitters to acknowledge receipt of claims (except where waived by a submitter) and to report syntax errors related to any ASC X12 transactions submitted to Medicare.   See Pub.100-09, the Medicare Contractor Beneficiary and Provider Communications Manual, regarding contractor requirements for furnishing Medicare claim remittance advice print software updates information to providers via the Internet and alternate methods to be used to furnish information to those providers that lack Internet access.  An overview of any changes to existing specifications, including effective dates will be issued to providers via A/B MACs and CEDI bulletins, on contractor Web pages, and will also be available via the Internet as Manual transmittals which can be viewed via a link from www.cms.hhs.gov/ElectronicBillingEDITrans/01_Overview.asp to the separate page for each EDI transaction format supported by Medicare fee- for-service plans.   70.2 - National Council for Prescription Drug Program (NCPDP) Claim Requirements  (Rev. 2803, Issued : 10-28-13, Effective: 09-17-13, Implementation: 09-17-13)  A. NCPDP Batch Transaction  The NCPDP batch transaction format is intended to provide a file transmission standard for submission in a non- real-time mode of the telecommunications standard transaction for drug claims from retail pharmacies. CEDI will not accept retail pharmacy drug claims that are not submitted as batch transactions.  NCPDP users are required to transmit National Drug Codes (NDCs) in the NCPDP standard for identification of prescription drugs dispensed through a retail pharmacy. NDCs replace the drug HCPCS codes for retail pharmacy drug transactions submitted to CEDI and delivered to the DME MACs via the NCPDP standard. The DME MAC shared system (VMS) will convert NDCs to HCPCS codes for internal claim processing. The CMS will provide the HCPCS codes for these drugs and an NDC to HCPCS crosswalk for use by VMS and the DME MACs.  B. Generating a Batch NCPDP Response   CEDI will return the NCPDP batch response for all NCPDP transmissions received. The NCPDP term transaction is equivalent to a Medicare service or line item and the NCPDP term transmission is equivalent to a Medicare claim. The NCPDP implementation guid e allows for up to 4 transactions (line items) per transmission (claim). This means that each claim can have up to 4 line items. Therefore, if one transaction (line item) rejects, the entire transmission (claim) will be returned. All transactions (up to 4)  in the transmission will be treated as one claim, and each transmission in a batch will be treated as a separate claim. For a transmission (claim) where one or more claim transactions (lines) have errors, the following will occur:   1. CEDI will reject all claim transactions (line items) in the transmission (claim) if any one claim (transmission) has detail errors.   2. The response status for all transactions will equal R (rejected).   3. CEDI will send up to 5 reject codes for claim transactions (line items) that ha ve detail errors.   4. No transaction level reject code will be reflected for the line item with no error.  Instead, the 504- F4 response message field at the header level is being used to denote acceptance or rejection of the entire claim.   C. NCPDP Implementat ion Guide (IG) Edits   CEDI shall allow segments to be submitted in any order including AM07, AM03 and AM11 as permitted by the NCPDP standard.  CEDI must create the NCPDP flat file segments in numeric order for receipt by the DME MACs shared system maintai ner.  D. Misdirected Claims   With the implementation of CEDI, there are no longer mis -directed claims.  CEDI receives all DME ASC X12 and NCPDP claims, performs all front end editing and translation.  Claims accepted by CEDI are assigned the Claim Contro l Number and delivered to the appropriate DME MAC based on the beneficiary state code submitted on the claim.   80 - Electronic Data Interchange (EDI) Reporting Requirements  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Contractors are required to participate in the following EDI reporting efforts as appropriate for their line of business. Each reporting effort has its own defined content and reporting frequency.   80.1  Contractor  Monthly Status  Reporting  (Rev. 10319, Issued: 08 -28-2020, Effective: 09- 29-2020, Implementation: 09- 29-2020)   The CMS Data Exchange (MDX) portal is a system that provides CMS automated capabilities for monitoring and analyzing data relating to the Medicare contractors on -going operational act ivities. A/B MACs are required to input their Electronic Data Interchange (EDI) workload statistics into MDX using the Monthly Status Report in Excel (MSRE) format. Contractors must prepare and submit to CMS the Medicare MSRE showing their EDI and manual t ransactions workload under the health insurance program. A separate report is required for each office assigned a separate contractor number.   The MSRE EDI claims processing data for PART A, Part B, and Home Health/Hospice (HHH) includes:   ACCEPTED CLAIM ST ATUS REQUESTS (276 - Electronic)   RESPONSES TO CLAIMS STATUS INQUIRIES (277 - Electronic)   REMITTANCE ADVICES -  NUMBER SENT (5010) -  835/ERA   REMITTANCE ADVICES -  NUMBER SENT (5010) -  SPR   REMITTANCE ADVICES -  NUMBER SENT (5010) -  Internet/Portal  NUMBER OF PAYME NTS TO PROVIDERS OR SUPPLIERS -  EFT   NUMBER OF PAYMENTS TO PROVIDERS OR SUPPLIERS -  Paper Checks   DOLLAR AMOUNTS ASSOCIATED W/PAYMENTS (5010) -  EFT   DOLLAR AMOUNTS ASSOCIATED W/PAYMENTS (5010) -  Paper Checks   ELECTRONIC CLAIMS PROCESSED (5010) - Electronic   ELEC TRONIC CLAIMS PROCESSED (5010) - DDE   DDE CLAIM ADJUSTMENTS REC'D -  DDE   DDE CLAIM STATUS RESPONSES -  DDE   PAPER CLAIMS PROCESSED   NCPDP RETAIL PHARMACY DRUG CLAIMS   Contractors shall reference Change Request (CR)10870 (Transmittal R21390TN, 9/17/18) for details on MDX reporting.   80.2 - Common Edits and Enhancement Module (CEM) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  A/B MACs are required to support a vigorous reporting system which will provide a full range  of routine and ad hoc workload reports and operational reports regarding Electronic Data Interchange (EDI) activities. The types of reports which are required include but are not limited to daily EDI workload statistics, edit exceptions, receipt- control -balancing, provider and submitter transaction version utilization data, transmission and receipt problems, etc.   A/B MACs will utilize the reporting functionality in the CEM to provide CMS with their EDI operational reports.   80.3 - Common Electronic Data I nterchange (CEDI) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  CEDI is required to support a vigorous reporting system which will provide a full range of routine and ad hoc workload reports and operational reports  regarding Electronic Data Interchange (EDI) activities. The types of reports which are required include but are not limited to daily EDI workload statistics, edit exceptions, receipt- control -balancing, provider and submitter transaction version utilization data, transmission and receipt problems, etc.   DME MACs will utilize the reporting functionality in the CEDI to provide CMS with their EDI operational reports.  80.4 - HIPAA Transition Reporting (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implemen tation: 09 -17-13)  As new HIPAA versions are named, contractors are required to report their implementation progress to CMS via transition reporting. Data collection will be achieved via an external, secure web -based reporting tool designed to support long  term, short term, and ad- hoc data gathering efforts, such as Electronic Data Interchange statistics and performance metrics.   The contractor shall obtain access to the web -based reporting tool via self enrollment  contingent on CMS approval. Current reports vary in frequency from weekly to monthly; however, any future efforts will reflect the most appropriate time period. Contractors will always be notified via Technical Direction Letter (TDL) on the required start ing date of any transition reporting, the content of the transition data, and the frequency of the reporting effort.   Contractors will utilize the reporting functionality in their front end systems, in CEM, in the Shared System Maintainer, and/or in CEDI t o provide CMS with their EDI HIPAA transition reports.  80.5 - Administrative Simplification and Compliance Act (ASCA) Reporting  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)