Managed Data Systems

EDI Update Bulletin!

February 2001 Edition

Payer changes                                                

The following changes are effective February 7. New payers listed will be added automatically to your Per-Se payer database. Be sure to match the spelling of each payer with those produced in your billing system. If you scan on the payer number instead of the payer name, those numbers are also included.

New medical payer                                      Payer number  

EMPLOYEE BENEFIT MGMT EBMS                    (“ 30607”)

New hospital payers                                    Payer numbers  

MANAGED CARE SVCS HOS                               (“5009978”)

CORESOURCE OF NC HOS                                    (“5009979”)

ERIN GROUP ADMIN HOS                                                    (“5009980”)

New EDI claim level rejection edits

(Payer IDs “1371001”, “1371002”, “ 241001” and  “ 241002”) 

Medicare PA/NJ has announced that effective with claims sub-mitted after 4:00 p.m. on February 16, 2001, a claim level rejection will occur:

1.       when procedure code Q0188 (echo-cardiography contrast agents) is reported without the corresponding referring/ordering physician name and UPIN number information.

2.       on all assigned physical and occupational therapy claims if the date last seen is not reported. If you transmit a print image file to Per-Se, the date last seen should be supplied in Box 15. If you transmit your claims to Per-Se in an (H)NSF, or NSF 2.0 or 3.0 format, the date last seen should be supplied in EA0 record Position 267.

3.       when the 2^nd through 5^th positions of the procedure code is missing or non-numeric.

Blue Cross Blue Shield Michigan

(Payer ID = “ 630000” and “ 630001”)

The following information was taken verbatim from the BCBSMI EDI Newsletter. Because we have not sent these types of claims previously, please contact our customer support department for testing purposes.

“As of 12/01/2000, all freestanding facilities (Physical Therapy, ESRD/Hemodialysis, Skilled Nursing, Substance Abuse and Hospice) can submit most claims electronically to Blue Cross Blue Shield of Michigan. The following claim types are excluded at this time for these freestanding facilities:

·         Claims with attachments

·         COB claims

·         FEP claims

·         Medicare Supplemental Substance Abuse claims”

Humana Bulletin on Medicare B data (Payer ID = “1359000”)

The Balanced Budget Act (BBA) of 1997 required the Health Care Financing Administration (HCFA) to establish a risk adjustment payment methodology for Medicare+Choice Organizations (M+COs). As part of this process, M+COs (such as Humana) must collect and submit to HCFA claim/encounter data on all Medicare Part B physician services beginning with date of service 10/1/2000.

This notification does not change the manner in which data is submitted, but requests additional elements be submitted on each claim/encounter.  Humana's request for additional data is consistent with Medicare's fee-for-service coding guidelines.  Providers should continue to submit to Humana claim/encounter data using the HCFA 1500 Form or the HCFA 1500 National Standard Format (NSF) record (if submitting electronically). Providers participating in Humana's commercial plans may also submit claim/encounter data using the HCFA's 1500 or NSF record.

For additional information regarding these federal requirements, please see HCFA's website, www.hcfa.gov. 

The following mapping guide provides specific field requirement explanations and the location in the Halley NSF record layout.

Per-Se Exchange

(HNSF FORMAT)

 Per-Se reiterates that Humana Health Plans accepts professional/medical claims through the Per-Se Exchange using Payer ID 1359000.  If you have any questions regarding this bulletin, please contact the Per-Se Exchange Support Department at (847) 608-7000.

Humana requires the following information be submitted:

 DESCRIPTION                            COMMENT                                          HCFA 1500                            RT/FLD                                 

Provider Commercial              The Humana assigned                             Box 33                                     BA0-2

Number (Group level              Provider ID

Provider Number)

___________________________________________________________________________________________________________

Humana wants the following information on specialist claims.  This in not a required field, but will help facilitate claims payment.

Referring Provider                   Authorization number for                       Box 23                                     DA0-14

Authorization Number           services rendered.                   

___________________________________________________________________________________________________________

Humana requires the following information also be submitted on Medicare members:

Care Plan Oversight                Medicare Provider ID                             Box 19                                     EA0-56

(CPO)                                     for Home Health or Hospice.                                

Rendering Provider Name                                                                       Box 31                                     FB1-14, 15

Rendering Provider State                                                                        Box 32                                     FB2-9

Rendering Provider Zip                                                                          Box 32                                     FB2-10

Rendering Provider UPIN                                                                       Box 24K                                  FB1-17

Modifier 1                                                                                               Box 24D                                  FA0-10

Modifier 2                                                                                                                                               FA0-11

Diagnosis Pointer                                                                                    Box 24E                                  FA0-14