Lesson 3 Testing the 837. 2 Lesson 3 Topics Set Up RPMS –Input Provider Taxonomy Codes –Set Up Location file –Set Up Insurer file Populating RPMS for

Lesson 3

Testing the 837

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Lesson 3 Topics

• Set Up RPMS

– Input Provider Taxonomy Codes

– Set Up Location file

– Set Up Insurer file

• Populating RPMS for Error-Free Claims

• Test Mode

• Production Mode

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Section 3: Testing the 837

• Set Up RPMS





• Test Mode

• Production Mode

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What Is Provider Taxonomy Code?

• Each provider must have specific code assigned to him/her in RPMS

• Code must be entered into RPMS– OR entire 837 transaction will be rejected

by insurer

• Codes are called Provider Taxonomy Codes

• Each code is unique alphanumeric identifier, ten characters in length– Example: 207PE0004X Adult Day Care

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Find the Right Code

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Taxonomy Code Updates

• Published twice a year

– July 1st (becomes effective October 1st)

– January 1st ( becomes effective April 1st)

• OIT provides updates to be installed into RPMS under AUT namespace

– This means that Taxonomy updates are maintained separately

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Taxonomy Code List Structure

• Provider Taxonomy code list indicates specialty categories for:– Individuals

– Groups of individuals

– Non-individuals

• Provider Taxonomy is divided into 2 different groups:– Individual or group

codes • Classifies type of

provider or group

– Non-Individual taxonomies

• Classifies healthcare facilities, agencies, nursing units, and suppliers and various vendors

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Taxonomy Code List Structure (cont’d)

• Each of 2 groups on code list is structured into 3 distinct "Levels":– Level I, Provider Type (major grouping of

service(s) or occupation(s))

– Level II, Classification (more specific service or occupation related to the Provider Type)

– Level III, Area of Specialization (more specialized area of the Classification in which a provider chooses to practice or make services available)

• See example of levels on next screen

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Example of Levels

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Tip

• Providers may have more than one Taxonomy code associated to them

• When determining what code or codes to associate with a provider, review the requirements of the trading partner with which the code(s) are being used

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Input the Code

• Codes must be added manually using:– VA Fileman

– User Management options in Kernel Menu

• For help or access, see site manager or system manager

• Codes located in PRV segment, piece4

• One-time procedure

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Input Individual or Group Codes – General

• Enter codes in VA Fileman/New Person file

• Set up codes for all billable providers, including secondary providers (e.g., RN’s, Pharmacists) that facilities may have on a claim

• Start by inputting most common providers

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Input Individual or Group Codes - General (cont’d)

• Enter Level II description

• For example– If provider is an Emergency Room

Physician, enter ‘Emergency’ into RPMS and system will display the following:

Physicians (M.D. and D.O.)

Physician/Osteopath

Emergency Medicine

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• System is case-sensitive when entering Provider Taxonomy

• Provider name is correctly entered with lowercase letters

• For more specific categories, such as SPORTS MEDICINE, enter ‘Sports’

– System will attempt to locate all Sports Medicine providers

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• For specific steps to add Provider Taxonomy, go to:

– Manually Adding Provider Taxonomy

http://www.ihs.gov/AdminMngrResources/HIPAA/documents/HIPAA_Adding_Taxonomy_Codes.pdf

– Quick Reference Guide to 837 and 835 Transactions and Code Sets

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Input Non-Individual Taxonomies - General

• Enter information in VA Fileman/ Location file

• Will need to enter:

– Location name

– Classification of facility

• Set up codes for all billing locations

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Input Non-Individual Taxonomies – General (cont’d)

• To determine facility classification, may choose to use RPMS Provider Taxonomy Crosswalk http://www.ihs.gov/AdminMngrResources/HIPAA/documents/TAXONOMY_crosswalk_document.xls

– For standard I/T/U Location Taxonomy codes, scroll down to Non-Individual (Facility) Taxonomy Code section

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Input Non-Individual Taxonomies – General (cont’d)

• For specific steps to add Provider Taxonomy, go to:

– Manually Adding Provider Taxonomy

http://www.ihs.gov/AdminMngrResources/HIPAA/documents/HIPAA_Adding_Taxonomy_Codes.pdf


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Important Points About Taxonomy Codes

• Crosswalk:– Crosswalk was built into RPMS 3rd Party

Billing to alleviate sites from having to populate numerous locations

– See Provider/Location Taxonomy AUT Patch v98.1, Patch 13

• Billing and Claims Editor– Provider and location taxonomy codes

may be used right after entered

– User will not see codes in claim editor

– Access Provider Inquiry (PRTM) option in Table Maintenance to view codes

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• Set Up RPMS





• Test Mode

• Production Mode

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Set Up Location File

• Location files must be set up on a one-time basis– Step must be completed for each

location that is to be billed; required for 837

– Step provides physical street address to your claims

• If facility is already testing 837 format with other Insurers, this step may already be complete

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Set Up Location File (cont’d)

• For specific steps to set up location file, go to one of the following:


– Trailblazers Medicare Part A: Testing and Production Procedures

– Trailblazers Medicare Part B: Testing and Production Procedures

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• Set Up RPMS





• Test Mode

• Production Mode

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Set Up Insurer Files

• Set up each insurer in Insurer file– Enter trading partner’s name

– Enter trading partner’s Associate Operator (AO) control number

• This is insurer’s electronic identification

• All sites use the same number for an insurer

– Enter Electronic Media Claims (EMC) submitter identification

• This is login number and password assigned by a particular insurer to a particular facility

• Found in the Companion Guide or provided by insurer

• Facility cannot test electronic claims submission process without EMC number

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Set Up Insurer Files (cont’d)

• For specific steps to set up Insurer file, go to one of the following:


– Trailblazers Medicare Part A, Testing and Production Procedures

– Trailblazers Medicare Part B, Testing and Production Procedures

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• Set Up RPMS





• Test Mode

• Production Mode

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Populating RPMS for Error-Free Claims

• Enter data correctly or claim will be rejected– If data element is mandatory, it

must have data in it

– Data elements must be entered exactly as prescribed

– No special characters or punctuation allowed

– Data elements for a patient must be entered the same way at every location

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Examples

• Ft. Defiance

– Entered as Ft Defiance or Fort Defiance

• P.O. Box

– Entered as PO Box

• 5-21-05

– Entered as 05212005

• 610-555-0123

– Entered as 6105550123

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Common Data Problems

• See Common Errors That Cause an 837 Claim to Be Rejected in “Quick Reference Guide to 837 and 835 Transactions and Code Sets”

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• Set Up RPMS





• Test Mode

• Production Mode

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Two Levels of Testing

• Level 1: HIPAA Compliance Testing

• Level 2: Insurer TestingImportant

Even if you pass Level 1 testing and file is accepted initially,

you could still fail Level 2 testing with insurer.

You MUST pass both levels of testing.

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Level 1 HIPAA Compliance Testing – 6 Types

• Integrity Testing

– Validates basic syntactical integrity of EDI file

• Implementation Guide Requirements Testing

– Involves requirements imposed by HIPAA Implementation Guide, including validation of data element values specified in Guide

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Level 1 HIPAA Compliance Testing – 6 Types (cont’d)

• Balancing Testing

– Verification that summary-level data is numerically consistent with corresponding detail level data, as defined in HIPAA Implementation Guide

• Inter-Segment Situation Testing

– Validates inter-segment situations specified in HIPAA Implementation Guide (e.g., for accident claims, an Accident Date must be present)

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• External Code Set Testing– Validates code set values for HIPAA

mandated codes defined and maintained outside HIPAA Implementation Guides

– Examples:• Local Procedure Codes for which states were given

waivers

• NDC Drug Codes

• Claim Adjustment Reason Codes

• Claim Status Codes

• Claims Status Category Codes

• Remittance Remarks Advice Codes

• Last four codes/updates published by Washington Publishing Company; OIT updates them

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• Product Type or Line of Service Testing

– Validates specific requirements defined in HIPAA Implementation Guide for specialized services such as durable medical equipment (DME)

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Level 2 Insurer Testing

• Trading partner-specific testing

• Involves testing coding and transaction requirements that are required by insurer but that are not specifically determined by HIPAA

• These requirements will be found in insurer’s Companion Guide

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Ready to Begin Level 2 Testing?

Required software installed. (See Lesson 2)

Trading Partner Agreement and EDI forms in place. (See Lesson 2)

RPMS set-up complete and correct.

(See this lesson) Have tested for HIPAA compliance.

(See this lesson)Have complied with insurer’s

requirements in Companion Guide. (See this lesson)

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What Does It Mean For You?

Financial Management Officer:“Ah, we thought we were done! . . . The ultimate benefit is a cleaner process that puts money back into the facility.”

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Testing Process #1

• Choose bills for initial test batch

• Bills should include variety of visit types that you already bill to insurer– E.g., Institutional, Professional, Dental

• If appropriate, include variety of locations

• See Companion Guide for how many bills to include in test batch– At least 3 of each type

• See Companion Guide for file naming conventions; max 16 characters

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Testing Process #2

• Check each bill carefully to make sure that it is correctly populated

– Mandatory fields are filled in

– Data entered adheres to 837 conventions

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Testing Process #3

• Set EMC Test Indicator to identify file as test file

– In 3P, go to Add/Edit Insurer (EDIN)

– Select INSURER: Indicate insurer you are testing

– EMC TEST INDICATOR: change value to “T”

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Testing Process #4

• On each claim, change mode of export– Go to Claim Editor.

– EDTD>EDCL.

– Desired ACTION: enter “E” (Edit).

– Desired FIELDS: Enter “7”.

– Mode of Export: Enter “??”.

– Select appropriate form: 837 UB or 837 1500

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Testing Process #5

• Submit different batches for each 837 format

• Once claims (3 or more) of one 837 format are approved, export batch in usual process via RPMS Pub Directory

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Testing Process #6

• Once you submit batch via FTP or your usual process:– E-mail insurer that file has been submitted

– Request verification from insurer that file was received

– Consult local or Area IT if you have problems

• Wait for response or error report from insurer– If no word within 24 hours, call insurer

contact to find out status of file

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Testing Process #7

• If you receive error report, make fixes locally – Either by Business Office or Patient

Registration, depending on error

• If you can’t figure out how to fix error, consult with local or Area IT contact

• Once fixes made, resubmit claims to insurer

• Repeat process until claims pass with no errors

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Testing Process #8

• After initial claims go through with no errors, prepare a larger batch (@ 25 claims) of each 837 format

• Test these claims following steps in Testing Process #2 - #7

• NOTE: See Lesson 4 for how to read error reports and make corrections

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Testing Realities

• Testing process may be lengthy– Testing time varies by:

• Time you put into it

• Insurer

• Process used

• Number of claims that have to be tested

• If clearinghouse involved, another level of preparation and testing is required– May also be more labor intensive

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Testing Realities (cont’d)

• If claims have errors, they will not be paid until they are corrected

• If testing involves several locations and/or insurers, there are more possibilities for errors

– Monitor each batch submitted and provide timely corrections

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Testing Tips

• Evaluate staffing before you begin testing– Demands on staff time will increase

– Anticipate this and assign adequate resources

• For example:– Cleaning up patient database may require a

massive effort

– You now have a double workload in Billing Office:

• Maintaining regular claims process so payments continue

• Creating and submitting test files

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More Testing Tips

• Be as prepared as you can but don’t delay testing – The sooner you

jump in, the sooner you will be through it

• Keep everyone informed of progress being made in testing process through e-mail group– Insurer contacts

– OIT contacts

– Area contacts

– Service Unit contacts

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Assistant Site Manager:“There’s no reason why anyone shouldn’t start.”

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More Testing Tips

• Keep in frequent communication with insurer contacts

• Insurer may be willing to provide training on what plan covers and what needs to be included on 837

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More Testing Tips

• Document the process

– Teaching tool for you and others

– Will also show patterns that need to be addressed

• If you need help:

– Turn first to own IT person

– If can’t figure it out locally, follow local procedures to get assistance

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More Testing Tips

• Submit batches frequently to keep them small

– You will have to correct errors and small batches are more manageable

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• Set Up RPMS





• Test Mode

• Production Mode

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Production Mode

• Once all test claims are accepted as error free, insurer will place facility in production status– NOTE: You may have to request to go into

production

• At this point, you will need to:– Change “T” to “P” in Insurer file for each

insurer at time granted approval for production (see next slide for steps)

– Change mode of export on a permanent basis (see following slide for steps)

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Edit Insurer File



– In 3P, go to Add/Edit Insurer (EDIN)

– Select INSURER: Indicate insurer you are testing

– EMC TEST INDICATOR: change value to “P”

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Change Export Mode

• For Visit Type, change each mode of export to default 837 HIPAA format– In Table Maintenance/Insurer file

– TMTP>INTM

– Scroll down to Select VISIT TYPE: Enter appropriate selection

– Mode of Export: Enter “??”.

– Select appropriate form

• Must be done for each insurer

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Trailblazers Testing and Production

• Trailblazers Medicare Part A: 837 Testing and Production Procedures

http://www.ihs.gov/AdminMngrResources/HIPAA/documents/HIPAA_837_TB_PartA.pdf

• Trailblazers Medicare Part B: 837 Testing and Production Procedures

http://www.ihs.gov/AdminMngrResources/

HIPAA/documents/HIPAA_837_TB_PartB.pdf

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Site Manager:“Once you set up one major payer, it moves very quickly.”

Compliance/Privacy Officer:“Anything electronic is just more efficient. That’s just good management.”

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Lessons Learned

• Set Up RPMS– Input Provider Taxonomy Codes

– Set up Location file

– Set up Insurer file

• Make sure that data elements are entered correctly

• Implement two levels of testing using steps described

• Make RPMS changes prior to beginning production

Documents

Lesson 3 Testing the 837. 2 Lesson 3 Topics Set Up RPMS –Input Provider Taxonomy Codes –Set Up Location file –Set Up Insurer file Populating RPMS for