Billing/Financial Considerations

Please be aware that CMS will be converting to a new electronic version for claims processing.  Currently your 837 electronic institutional claim is in a (ASC) X12 version 4010A1 format, and they will be updating to a (ASC) X12 version 125.

This new formatting will be the responsibility of your software vendors to update your software systems to accommodate the version changes.  However, Harmony recommends that you always make sure that they are aware of these type of changes and deadlines. (Feel free to send this document on to them for reference.)

The timeline for the new 5010 version is as follows:

·        Effective Date of the regulation: March 17, 2009

·        Level I Compliance by: December 31, 2010

·        Level II Compliance by: December 31, 2011

·        All covered entities have to be fully compliant on: January 1, 2012

Level I compliance means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."

Level II compliance means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards."

HHS permits dual use of existing standards (4010A1 and 5.1) and the new standards (5010 and D.0) from the March 17, 2009, effective date until the January 1, 2012 compliance date to facilitate testing subject to trading partner agreement.

As part of the new formatting to version 5010, CMS has finally developed a way to both indicate and send additional documents required for claims processing.  There is a certain loop or segment in your electronic claim that will include an indicator that additional documentation required for processing of the claim will be forthcoming.  The submission of the extra field indicating that there will be follow-up additional documentation and the (necessity to send the documentation) will go into effect in April 2011.

Again, it will be the responsibility of your software vendors to include this segment in the electronic claim, and also to indicate to you how and where in the software you will access it, for use when necessary.

Unfortunately, there is still no direct electronic way to include the documents yet, so they must be faxed or mailed to CMS. However, CMS has set guidelines and deadlines for their transmission. They have also developed a face-sheet to accompany the additional documentation, and it must be completed both timely and exactly as CMS wants it or they will deny the additional documentation, and process the claims without considering it.

Harmony has a Financial Consultant dedicated to providing facilities with this and additional information. Sue Lounsbury, Billing/Financial Consultant, provides unique consulting visits to address all your Payable and Receivable needs.  Sue will be presenting several Webinars discussing billing for MDS 3.0 and RUG-IV this Fall. 

MDS 3.0 RAI Manual https://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.asp