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Part B Vendor Gazette
Tennessee - Summer 2002

HIPAA Legislation Implementation Is Here

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 implementation of electronic transaction sets is fast approaching. The final guidelines governing this process have been released. HIPAA requires all information such as health care claims, health care payments, health care status, to be transmitted via a single EDI standard, as of October 16, 2002. If you have or plan to file for an extension, the implementation date will become October 16, 2003. This implementation will affect all payers, providers, vendors and clearinghouses. Visit the HIPAA section of the CINGA Medicare Web site and look for the "What's New" section for more information.

Updated Implementation Dates for HIPAA

CIGNA Government Services has received instructions from the Centers for Medicare & Medicaid Services (CMS) that update timeframes associated with the implementation of HIPAA transactions. Of particular note is the final implementation date, which moves from October 16, 2002 to October 16, 2003. * This extension is a result of the Administrative Simplification Compliance Act (H.R. 3323), which requires, among other things, that a waiver process be followed to obtain the one-year delay. It is important to note that the extension is not global.

There are specific steps the submitter must take to receive approval to delay. Please view the CMS web site, www.cms.gov/hipaa/hipaa2/ASCAForm.asp for more information about the extension and the waiver.

In addition to the final implementation date, the following HIPAA implementation dates have been updated. Please make note of these changes and notify your staff of the revised dates.

Health Care Claim (X12N 837)

Submitter testing opened by May 1, 2002. Testing instructions for the Medicare Part B may be found at www.cignamedicare.com/hipaa. All requested testing must be completed by October 16, 2003. * Testing must begin by April 1, 2003.

Electronic Remittance Notice (X12N 835)

ANSI 835 testing will be available to submitters that request testing by May 16, 2002. All requested submitter testing must be completed by October 16, 2003.* Testing of this transaction set is not mandatory.

Claim Status Inquiry (X12N 276/277)

Submitter testing is not required on this transaction, however, it may be requested. CIGNA Government Services will be ready to accept tests for this transaction by July 16, 2002.

Beneficiary Eligibility (X12N 270/271)

CMS has not provided final instructions on the implementation date for the ANSI 270/271 transaction. However, all the mentioned transaction sets, including 270/271, will be implemented by the final implementation date of October 16, 2003.*

Free Billing Software

Currently, CIGNA Healthcare Medicare Part B offers (BMACS), a free billing software product for Part B Medicare. BMACS is programmed for the current NSF 3.01 format. CMS has instructed CIGNA Government Services to issue a HIPAA-compliant Medicare free billing software product for providers who wish to use such a program to comply with HIPAA. The new HIPAA-compliant software will be available for distribution by December 3, 2002. Please note that CMS' announcement regarding the elimination of the free billing software remains effective for FY 2004 (October 2003). Furthermore, all providers who use the current BMACS software will need to file for the Compliance Extension by no later than October 15, 2002.

New EDI Submitters

Providers who are planning to begin billing electronically to CIGNA Government Services Part B should begin with the HIPAA format (ANSI X12N v.4010), rather than test and transmit production claims in the NSF 3.01 format. If a new submitter is unable to begin transmitting with the HIPAA format, CIGNA Government Services Part B will accept new EDI submitters using the NSF 3.01 format until October 1, 2002, but we will provide no testing support for any format other than ANSI 4010. After October 1, 2002, new EDI submitters must begin using the HIPAA format, ANSI X12N v. 4010.

EDI submitters should be updating their billing systems with the applicable HIPAA transactions to avoid last minute testing concerns. For the most up-to-date information regarding CIGNA Government Services Part B HIPAA implementation, please visit www.cignamedicare.com/hipaa.

*The October 16, 2003 date applies only if a waiver has been requested from the US Department of Health and Human Services (DHHS). Otherwise, October 16, 2002 will still remain as the final implementation date. Instructions on the waiver may be found at www.cms.gov/hipaa/hipaa2/ASCAForm.asp.

ANSI: What More Will It Take?

Prepare yourselves by testing and updating your customers with your preparedness as soon as possible. Will you be ready? Will they need to file for an extension? For more information, please visit the following Web sites and join our e-mail list for up to date information:

• www.wpc-edi.com/hipaa - this site allows you to download the ANSI Implementation Guide
• www.cignamedicare.com - this site provides the Transaction Testing Instructions and you can join our e-mail list for updates on ANSI
• www.hcfa.gov - this site provides general information about HIPAA Administration Simplification.
• www.cms.hhs.gov/hipaa - this site allows you to review and file an electronic extension plan request.

MSP: How to File the OTAF

Effective October 16, 2002, Part B physicians must submit all electronic MSP (Medicare as Secondary Payer) claims to CIGNA Government Services using the ANSI X12N 4010 837 unless they request a one year extension to comply with HIPAA under the provisions of the Administrative Simplification Compliance Act. The ANSI X12N 4010 837 is the electronic claim format which has been specified for use under HIPAA.

Currently, there are fields to identify the other payer's allowed and paid amount on the 837, but there is no field on the 837 to specifically identify the OTAF amount. The OTAF (Obligated To Accept in Full) amount is a payment (which is usually less than your charges) that you are obligated to accept or agreed to accept as payment in full satisfaction of the patient's payment obligation. On most claims, the OTAF amount is greater than the amount the primary payer actually paid on the claim. The Medicare program uses the OTAF amount(s) when calculating its secondary liability on such claims when services are paid on other than a reasonable charge basis.

When you migrate to the X12N 4010 837, you must use the Contract Information (CN1) segment to report the OTAF. Report the OTAF in CN102 (Contract Amount) with a qualifier of "09" (Other) in CN101. If MSP data is received at the claim level, report the OTAF in 2300 CN102. If MSP data is received at the line level, report the OTAF in 2400 CN102. The X12N 4010 837 Professional Implementation Guide allows for claim level OTAF reporting using the CN1 segment as described above, as well as line level reporting using the line level CN1 segment. Furnish line level primary payer data, including the OTAF amount, when available.

The chart below identifies the segments and data elements that you must use to report: (1) the submitted charges, (2) the primary payer paid amount, (3) the primary payer allowed amount, and (4) the OTAF amount at the claim and the service line levels.

If you have any questions please call the EDI Technical Helpdesk at 866.520.4023.

Trading Partner Testing Process on the ANSI 4010 format (837 - Health Care Claim Professional)

1. Please call the TN/ID EDI Tech line (866-520-4023) when you are ready to test the 837 inbound claim with CIGNA Government Services. If a provider/billing service/clearinghouse is using vendor software that has been approved, they are not required to test individually.
2. We will have an option on the tech line that will be specifically for requests to test. We hope to have it operational in the near future
3. The HIPAA Testing and Reporting Coordinator will send the testing documentation to the tester to begin testing. The Part B Test Packet and Companion Document/Trading Partner Agreement can be downloaded from: http://www.cignamedicare.com/HIPAA/code_sets.html
4. Once the Testing Coordinator receives the testing documentation back, the internal set up is processed to get ready for the test. A test Stratus ID and a test submitter ID are assigned and the tester is assigned to an EDI tech.
5. The tester has by now created their specific business scenarios (at least ten claims) in the ANSI 4010 837 Professional format. The tester can use the CMS-1500 test claims downloaded from the cignamedicare.com web site.
6. The tester uploads the file to the Stratus Network (SEND_ANSITEST data type). Approximately two hours after the upload, the tester should be able to download the 997 Functional Acknowledgement (RECEIVE_ACK data type). If the 997 has X12 syntax errors, then the tester corrects the errors and resubmits. If the tester has an error report (containing an Implementation Guide level error/VMS level error/Part B business level error) they will need to correct the error and resubmit. To download the error report, please use the RECEIVE_ANSITEST data type option.
7. Once the claims meet all the test criteria, a letter indicating approval for production will be sent to the tester.

Stratus Network Mailbox Facility to Change for HIPAA Transactions

Currently, the interface of the Stratus Network is designed around the National Standard Format. As the HIPAA Transactions and Code Set rule mandates use of the ANSI 4010 format, we have designed a system that will work in an efficient manner to support both current production formats and preparations for the HIPAA transactions.

We have already begun testing the HIPAA compliant 4010 837 transaction set. The Stratus Network changes are designed to allow you to continue sending and receiving NSF files while preparing your 4010 transactions.

For those already familiar with the Stratus environment, there will be little difference in how the mailbox system works. The only real changes will be that CIGNA Government Services will assign the user a new ID, and the data type menu will now contain entries for ANSI file transmissions, as well as for your current NSF entries (See new menu picks below). Keep in mind, though, that the NSF entries will be going away when the HIPAA Transaction and Code sets are fully enacted in October 2003.

E-Mail may be used for inquiries to the EDI Department

CIGNA Government Services currently has four EDI Technical Analysts. Each representative has an individual e-mail address.

Technical Analyst E-Mail Addresses

HIPAA Testing Coordinator

The CIGNA Government Services EDI Technical staff offers more information through e-mail. You can now request:

1. ANSI Testing Applications
2. Stratus User Manuals
3. Very generic questions (Do not include any specific data)

Please keep in mind, that when you send requests through e-mail you must adhere to the Privacy Act. Section 1106 of the Social Security Act prohibits disclosure of any file, record, or any information obtained by a federal agency, organization (e.g., carrier), or institution, or any of its officers or employees, in fulfillment of a contract or agreement with a federal agency.

Sending information protected by the Privacy Act over the Internet is prohibited. Please do not send patient, provider or submitter specific information via e-mail.

Special Reminder:

Please send us any changes to your physical address, corporate name changes, contacts, telephone numbers, billing services, clearinghouse, etc. We want to ensure that you receive prompt notification of any changes in the electronic Medicare claim protocols.