The January 1, 2012 deadline for a mandatory transition to the new HIPPA X12 version 5010 is fast approaching! In just two short months, CEDI will reject 837 and NCPDP (pharmacy drug) claims that are not submitted using 5010 standards.

Prior to the start of next year, your clearinghouses and software vendors will need to successfully complete testing with National Government Services, the CEDI contractor, and become approved to transmit claims in the new 5010 format. To find out whether your vendor is currently approved to transmit your Medicare claims in 5010, visit http://www.ngscedi.com/outreach_materials/outreachindex.htm and look for the “5010/D.0 Approved Entities List” (last updated 11/01/11).

If your vendor has not yet completed testing with CEDI, you may wish to let them know about a special teleconference the contractor will be holding on November 9, 2011 to help software vendors and clearinghouses work though any issues that may be preventing  them from successfully making the transition. Registration information is available here.

All current systems used to submit claims, receive electronic remittances and exchange claim status inquiries will be affected by the switch to the new 5010 standards. When talking with your vendor, be sure to find out:

1. When your system will be upgraded,
2. If you will be charged for the upgrade, and
3. Whether you will be required to buy any new hardware or software.

If you currently use PC-ACE Pro32 or Medicare Remit Easy Print (MERP) software to transmit your claims and receive EOBs, both software systems will be able to support 5010.

By: Andrea Stark, DMEPOS Consultant, MiraVista LLC

There may soon be an increased cost to submit claims to Medicare. Suppliers, clearinghouses, third party billers and software vendors are currently able to connect and transmit information directly to Medicare via several free modem and FTP network connections.  However, during a vendor call on September 8, 2010, CEDI announced that all direct connections to their gateway will be shut down over the next several months, and all electronic Medicare transactions will need to be transmitted through one of six select network service vendors: ECC Technologies, IVANS, McKesson CareBridge, MedXpress, VisionShare or Nebo Systems, Inc. 

Effective November 1, 2010, all new vendors and suppliers who aren’t actively submitting claims to CEDI will need to go through one of the above network service vendors, or through a clearinghouse that provides this service. All free connections to CEDI will be shut down for everyone else effective April 30, 2011.

The premise behind the service change is driven by CMS’ security concerns. National Government Services currently operates the Common Electronic Data Interchange (CEDI) contract, which is the entity responsible for the front-end editing of all claims traffic and transactions with the DME MAC contractors. NGS is closing all free modem and FTP connections to the CEDI gateway in order to meet requirements put forth in the Medicare Claims Processing Manual, Chapter 24 and the Internet Only Manual, Pub 100-17.  The six network vendors mentioned above will be the only vendors allowed to transmit data between suppliers and CEDI via secure AT&T Global Network Service (AGNS) lines.

If you connect directly to the CEDI gateway to upload your claims, retrieve response reports, download Medicare ERNs or send claim status inquiries, you will likely be affected by the upcoming change in service. However, if you are already transmitting claims and other transactions to Medicare through a clearinghouse or one of the network service vendors above, you may not be affected by the transition.  Suppliers who are currently using free network connections can typically expect to pay a per claim fee to a clearinghouse, or pay monthly fees for bandwidth time through one of the approved network service vendors once the transition takes place.

It will still be possible to secure a direct line to CEDI by becoming a direct network service vendor, but this option will be cost prohibitive for most.  IVANS and McKesson also serve as CMS’ authorized AT&T resellers. 

On September 9, 2010, CEDI released a list serve announcement confirming the coming transition. A copy of the announcement and a list of vendor FAQs is available at: http://www.ngscedi.com/news/newsindex.htm. Contact information for CEDI’s select network vendors is available at: http://www.ngscedi.com/telecomm/teleindex.htm.

By: Andrea Stark 

New front-end edits by CEDI now require DME providers to check their GEN Reports for Medicare rejections. As of January 10, 2009, almost all rejected claims are being returned via GenResponse Reports. Any claims rejected on these reports must be corrected and resubmitted to CEDI.

The second level reports that come back from Medicare will only list claims that were accepted and pushed through by CEDI. There should be a dramatic, if not complete reduction of rejected claims on second level reports. So if you don’t catch claim rejections on the GEN report, you could lose out on a lot of money.

CMN rejections have not been affected by this round of edits and should still be looked for on the 2nd level RPT/VMS report from Medicare.