ediLive! Users Group

Electronic Claims Response Files

Electronic Claims Response Files

27S files are the files that ediLive! receives from THMP that tells us whether or not your claims have passed the final check and gotten accepted into Medicaid's adjudication system for payment.   TMS has learned that these 27S files are not required HIPAA files, Medicaid sends these files back for your convenience to let you know if claims were rejected or not. 

At this time insurance companies are not required to send back any response at all when rejecting claims electronically.  When they do send responses, they can basically send the response in any format that they prefer - regardless of how difficult they may be to interpret and attach back to the correct claims.  Because the files that we get back are not HIPAA compliant or Ansi 4010 formatted, they do not always get processed correctly.  This means that sometimes rejection information is not tied back to the claim correctly.

Some of you have reported having claims with an edi claim status of ACK or ACK-CH even months after the claims were filed.  When you check in CMEDS, you find that some of these claims have been paid and some have had no payment at all.  At this point, you call Medicaid (or whatever carrier is involved) and they tell you that they never received the claim.  This typically means that the claim was rejected at the carrier's "gateway" before it made it into the final checkpoint.  EdiLive! now has a report that you can run from Cmeds and upload that will change claim statuses in edi to PAID-PMS for all claims marked Primary Paid in Cmeds for more ease in doing followup on claims in EdiLive!.  Call your service representative to have this option added to your Cmeds menu! 

  EdiLive is currently working on a solution to ensure that claim statuses will not say ACC unless the claim have actually been passed through this final check and are actually accepted into the adjudication system.  We are also working on a solution to always process the rejections even though the 27S file is not a HIPAA compliant file. 

Regardless of the reports you do or do not get in ediLive!, it is essential for you to run follow-up reports in CMEDS on a regular basis.  For Medicaid especially, you should run lists of claims that still have a status of Pending Primary after 3 weeks have passed since they were filed

Tricare Electronic Claims

Since setting up a direct connection to Tricare, Texas Medical Systems has learned that only claims sent after our live date with Tricare will be accepted electronically. 

All Tricare claims submitted to ediLive! must have a date of service after November 1, 2004.  All dates of service prior to that date must be printed to paper and sent by mail.

Invalid Tax ID/SS# Mapping by THIN

Invalid Tax ID/Social Security
Number Mapping

(10/15/2004)

>From 10:15am on 10/4/2004 thru 4:00pm on 10/14/2004, the tax ID number on
some ANSI 837 Professional claims was incorrectly translated. If the
billing provider ID in Loop 2010AA NM109 was different than a billing
provider ID in Loop 2010AA, REF02, the billing provider ID in NM109 was
changed to agree with REF02. In most cases, we determined that the EIN tax
number was overlaid with a Social Security Number.

This resulted in some payers rejecting claims either thru the electronic
response notice or thru the Explanation of Benefits (EOB). Because this
overlay only affected some of the claims and not all payors reject claims
based on this information, unfortunately THIN is not able to determine
which claims should be corrected and resubmitted. If you received a payer
rejection for invalid tax ID or invalid provider number and you have
verified that the information was correct on your ANSI 837 claim format,
you can just resubmit those claims to THIN for processing.

Update on Erroneous Diagnosis Rejections

Date of Notification
October 15, 2004

Subject
Incorrect Diagnosis Code Rejections

Date Range of Issue
October 13, 2004

(Claims Submitted on this date)

Description Of Production Issue:
We have resolved the issue that caused the processing error that created invalid error messages for diagnosis codes.

ProxyMed will re-process these claims for you today, October 15th. These claims will be processed with a different trace number so they will be processed and valid rejects will be reflected in your .REC and clearinghouse reports.

We apologize for the delay in processing these claims.

Erroneous Rejections : Diagnosis

Date of Notification
October 14, 2004

Subject
Invalid Diagnosis Code Rejections

Date Range of Issue
October 13, 2004

(Claims Submitted on this date)

Description Of Production Issue:
We are assessing a processing error last night that created invalid error messages for diagnosis codes.

When you review your reports and see these types of errors, please do not resubmit the claims today. Once the error is corrected, we will reprocess these claims for you.

More updates to follow today

ediLive! cliams error

All claims submitted to ediLive on Friday September 17th had to be reprocessed on Monday September 20th due to technical problems. Clients may get EOBs stating that there is no rendering provider on these claims. These claims should not be resubmitted from your practice management software, as they have been corrected and resubmitted by TMS.

Laurie

Medicare Duplicate EOBs

If you submitted claims electronically on 8/19/2004, there is a chance that you will recieve an EOB dated 8/20/2004 stating that your claims were all duplicates. TMS has called Medicare on this - It was a mistake on their part - claims submitted on 8/19/2004 were inadvertently marked as duplicate. You can call Medicare at 866-211-5708 to verify this information if you've received these eob messages.

THIN Response Delays

THIN is experiencing some communication problems and has stated that responses may take up to 24 hours to process. If you have any questions, please contact Laurie @ 866-349-9220.

Medigap Payer IDs

Texas Medical Systems has received a fax memo from Trailblazer regarding Medigap Payer ID numbers. Starting on August 16th, they will start marking claims with a WARNING message when a Medigap policy number reads 99999, OTHER, NONE or is left blank, and on September 20th, they will start rejecting them. There will be a Trailblazer Medigap Newsletter No. 04/045 that will be distributed to the provider community on August 16th with a list of Medigap Payer IDs, or just follow this link: http://www.trailblazerhealth.com/tools/Medigap.asp

Medicare News

Medicare Part B
***************************************
Nurse Practitioners as Attending Physicians
This change request implements Section 408 of the Medicare Prescription
Drug, Improvement and Modernization Act of 2003 (MMA), which amends the
Social Security Act (Section 1861(dd)(3)(B) and Section 1814(a)(7)) to
include nurse practitioners in the definition of an attending physician
for beneficiaries who have elected the hospice benefit.
http://trailblazerhealthqa/notices.asp?action=detail&id=2234

New Food and Drug Administration-Approved Drug
Effective immediately, the following drugs have been approved by the Food
and Drug Administration (FDA).

Risperdal Consta (Risperidone®)
Alimta (Pemetrexed®)
Abarelix (Plenaxis™)
http://trailblazerhealthqa/notices.asp?action=detail&id=2233


Billing for Immune Globulin
If a drug can be matched to an appropriate Healthcare Common Procedure
Coding System (HCPCS) code that best describes the drug and dosage given,
pricing will be determined from that specific HCPCS code. Medicare would
not expect to see HCPCS code J1564 billed with a large quantity-billed
amount when J1563 would be the appropriate code to use. It would be
inaccurate to use HCPCS code J1564 with a quantity billed amount of 100 to
increase the reimbursement rate.
http://trailblazerhealthqa/notices.asp?action=detail&id=2232