Implementing the ERA and EFT Operating Rules

In earlier articles, we talked about the upcoming implementation of the ACA-mandated EFT and ERA Operating rules that will require payers to make available to providers ANSI 835 electronic remittances and EFT procedures for payment processing.  We talked about the benefits of implementing these processes into your revenue cycle workflow to address the problems associated with paper remittances and checks.

Now that this deadline is approaching, providers should be developing a strategy for implementing these processes with payers who currently conduct these transactions on paper.  This begins with getting a list all health plans you do business with and importing this data into a spreadsheet.  Record which ones use paper or electronic remittances and which ones use EFT or checks.  Your goal should be to get everyone switched to the electronic alternative for each transaction. Continue reading

MEDTranDirect Introduces Roster Billing

It’s that time of the year again.  I’m not talking about turkey dinners or holiday shopping, flu season is coming.  Many healthcare providers, retail organizations, and employers are offering flu shots to their consumers and employees.  Unless these shots are exchanged for cash payments or distributed at no charge, these organizations may encounter problems with insured participants. As they must be billed through their individual payers for these services using new claims for each patient served.

Many organizations don’t provide this service because of the administrative cost associated with insurance billing.  At MEDTranDirect, we have modified our billing product 837Direct to handle these “roster bills” in a fraction of the time it would take to create them individually. Continue reading

Using HIPAA Transactions for Revenue Cycle Management

HIPAA transactions were developed with the intent to reduce overall administrative costs for the healthcare industry.  This is accomplished in two ways, by developing a standard that can be used to conduct these transactions consistently under all similar conditions and trading partners to create transactions that automate previously manual or semi-manual processes.

This article will discuss how these transactions can be used to support the processing and follow up of claims.

The first step in claims processing is the creation of the claim file itself, the 837i (institutional) and the 837p (professional).  These files must contain all recently produced claims of each type that are destined for a specific entity.  At our company, we use the term receiver to represent the target of these files.  Receiver is distinguished from payer in that a receiver may receive claims for multiple payers in a single file.  For example, a clearinghouse like Emdeon or Availity.  In other cases, the receiver may represent a single payer, or even a sub-classification of a payer, like Medicare Part A and Medicare Part B. Continue reading

The Government Shutdown and Healthcare Claim Processing

CMS has instructed all Medicare Contractors (MACs) to perform all claim processing functions during the government shutdown.  This includes the processing of claim files and the creation of response files (835, 999, 277CA).  Based on our internal operations regarding these processes, we have seen no impact on these activities from any contractor.  Medicare and Medicaid payments should not be delayed.

However, the shutdown will have an impact on other administrative activities that may impact reimbursement in the long run.  All activities related to surveys and certifications have been suspended.  This includes the authorization of new agencies to conduct these transactions or obtain Medicare certification and the termination of certification for organizations under investigation.  Continue reading

My DDE is not working!

As some of you know, CMS is transitioning their DDE connectivity to support a new security standard.  I discussed this topic in a previous article, “Direct Data Entry (DDE) Security Upgrade Requirement” on 9/16.  In this article, I mentioned that this upgrade might cause certain provider systems to fail when they attempt to connect to DDE after the transition.  CMS has two separate systems that provide this service, one is managed by HP (Hewlett-Packard) and one is managed by CDS (Companion Data Services). Continue reading

HETS to add Lifetime Psychiatric Remaining Days

Over the last several months, we have assisted customers in switching to the HETS (HIPAA Eligibility Transaction System) from DDE as customers prepare for the April 2014 elimination of eligibility data.

I have discussed in previous articles about differences between these two systems, how they obtain their information, and how this impacts the ability of certain providers to verify Medicare patient eligibility information.

One item that has been mentioned often by our customers is the Lifetime Psychiatric Remaining Days (LPRD).  This value is available through DDE, but is not returned by CMS through the HETS ANSI 271 response.  We have many customers who use DDE exclusively for the purpose of looking up patients and getting this single value.  We have reported this to the HETS help desk and it appears that they are responding to the problem. Continue reading

Direct Data Entry (DDE) Security Upgrade Requirement

As most of you know, CMS allows providers direct access to the Common Working File (CWF) through DDE.  This technology has existed for many years and has evolved from remote terminals, modems and phone lines to terminal emulator software running on personal computers connected to the CWF through secure networks.

As this technology evolved, some providers and vendors implemented more modern solutions for their DDE connections, others stuck with existing systems.  Regardless of the technology, the functionality of DDE remained the same.  Once you get connected, everyone sees the same screens and has the same capabilities.  How you got connected made no difference, until now. Continue reading

Operating Rules Update – More Good News for Providers

As I promised in my last article, I am revisiting the subject of ERAs and the operating rule changes taking effect on 1/1/14.  In previous articles we discussed the benefit of universal availability of the ANSI 835 electronic remittance and how it can improve your revenue cycle management.

There are two more aspects of this rule that will benefit providers.  First, the rules include the establishment of timing criteria between the arrival of the payments and the availability of the 835.  This is referred to as the “three day rule”.  Basically, the rule states that the 835 and the EFT will arrive within 3 business days of each other.  It does not say which one will come first, but that when you get one of the transactions, the other will either have been sent already, up to three days in the past, or will arrive up to three days later.  This will help facilities match the check to the 835 and react quickly when either transaction is late. Continue reading

Leveraging Operating Rules to Improve the Remittance Posting Process

As I discussed briefly in a previous article, the Affordable Care Act (ACA) includes regulations to implement operating rules for transactions previously defined as industry standards.

These include the HIPAA transaction used by CMS and other major payers to provide detailed payment and adjustment information associated with checks or Electronic Funds Transfers (EFT). This electronic remittance standard is referred to as the ANSI 835.

The ACA defines “operating rules” as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”  In other words, the standards, like the ANSI 835, regulate the structure and content of the data being exchanged between two healthcare industry stakeholders, typically a payer and provider.  These operating rules deal with enforcing the use of these standards among all covered entities so that benefits can be achieved by building administrative systems depending on the universal existence of these transactions, delivered in a standardized manner. Continue reading

HETS to Fix Hospice Prior Benefit Period Identification Issue


Over the last several months, the announcement that CMS was phasing out eligibility information currently available through Direct Data Entry (DDE) next April has driven providers to eligibility reporting solutions using the CMS HIPAA Eligibility Transaction System (HETS).

“HETS to replace Common Working File (CWF) for eligibility inquiries”

“How to Get Connected – HETS 270/271”

The providers and vendors who were early adopters of this technology noticed differences in the data reported through these two systems.  Recently, I co-wrote an article for Health Data Management that described these systems, how they work, and the differences between them.  It is available on our blog or through this link:

“A Primer on the HIPAA Eligibility Transaction System” Continue reading