Florida Medicaid Provider HIPAA Fact Sheet

This fact sheet from the Agency for Health Care Administration Florida Medicaid Program, and its fiscal agent, ACS State Healthcare, explains how the Agency intends to meet the federal HIPAA requirements on electronic transactions and code sets. This fact sheet does not explain HIPAA guidelines or advise providers on how to meet the guidelines. For information on those topics, see the "Additional Information Sources" listed at the end of the fact sheet. Additional information may also be available from many industry associations, newsletters, and consultants who have published information about HIPAA.

Who Should Read This Fact Sheet

This Fact Sheet contains important information for all Providers who bill Florida Medicaid for services rendered to Florida Medicaid Recipients.

Before We Get Started

• Transactions and Codes: This fact sheet pertains only to transactions such as claim payment, claims status, or eligibility verification transactions and code sets such as procedure codes, diagnosis codes or any other code you might find on a Medicaid claim form; other HIPAA topics such as security and privacy are not included.
• Exceptions: With minor exceptions discussed below, the Agency is not changing its policies on paper claims submission, prior authorization, and eligibility verification.
• Subject to change: Though the information in this document is subject to change, the Agency understands that providers need as much certainty as possible in planning for HIPAA implementation. Providers should check periodically for updates through AHCA's website: HIPAA Web Site
• Use of Clearinghouse: Electronic transactions will be routed through a clearinghouse operated by ACS EDI Gateway, Inc. This clearinghouse is called the State Healthcare Clearinghouse (SHCH). Providers will be given new dial-up access numbers and will be asked to complete an enrollment form specifically for the clearinghouse. Vendor software users will be tested and certified as a group. Custom software users will be tested individually. Further information will be provided closer to the date when the SHCH starts accepting electronic transactions from Florida providers.
• Pharmacy Providers: With the exception of Remittance Vouchers, the X12N transactions mentioned in this document do not apply to Pharmacies. Pharmacy providers will receive separate communication regarding HIPAA and the new NCPDP v5.1 platform in the near future.
• Training: Except where otherwise indicated, ACS Field Representatives will provide training. Contact your field representative or local area Medicaid office for more information about the training.
• Implementation date: Cutover dates and procedures will be provided by late summer 2003.

HIPAA Compliant Transactions

A brief summary of the X12N compliant transactions required by HIPAA legislation is provided below.

• 270/271 Health Care Eligibility Benefit Inquiry and Response: This transaction is used to inquire about the eligibility, coverage or benefits associated with a Medicaid recipient.
• 276/277 Health Care Claims Status and Response: This transaction is used to request and report on the status of a claim.
• 277U Unsolicited Claims Transaction: This transaction is used to report suspended claims to the provider.
• 278 Health Care Services Review: This transaction is used for providers to request Prior Authorization and for the agency to report the results.
• 820 Health Plan Premium Payment: Florida Medicaid will use this transaction to report premium (capitation) payments to a Managed Care Plan or provider who receives a capitation payment.
• 834 Benefit Enrollment and Maintenance: This transaction will be used to establish communication between Florida Medicaid and Managed Care entities.
• 835 Claims Payment and Remittance Voucher: This transaction is used to report paid or denied claims to the pay-to provider; suspended claims will be reported with the 277U transaction.
• 837P Professional Health Care Claim: This transaction will be used to submit health care claim billing information from providers of health care services to Medicaid. For purposes of this standard, providers include, but are not limited to Physicians, ARNPs, DME providers, Waiver Services providers, Rural Health Clinics (RHC), ambulance providers, Federally Qualified Health Clinic (FQHC), and other providers who currently bill on the 081, CMS-1500, 131, or 131A claim form.
• 837I Institutional Health Care Claim: This transaction will be used to submit health care claim billing information from providers of institutional services to Medicaid. For purposes of this standard, providers include, but are not limited to Hospitals, Nursing Facilities, ICF/DDs, Dialysis Centers, Hospice and other providers who currently bill on the UB92 or 021 claim form.
• 837D Dental Health Care Claim: This transaction will be used to submit claims for dental services to Medicaid. For purposes of this standard, dental services include services billed on the 111 claim form. (Standard ADA Codes)

Claims Submission

Providers may continue to submit claims electronically or on paper.

• Electronic Submissions: Effective with the implementation of HIPAA standards, ACS will no longer accept electronic claims in their current NSF formats (i.e., NSF3.1 and UB92 V5). Providers will have several ways to submit claims electronically.
1. X12N 837 format. Providers can send claims to the SHCH in X12N 837 format using a dial-up connection from their practice management system software. Claims currently submitted using the CMS-1500, Child Health Check-Up 221, Institutional 021, Non-Institutional 081, Transportation 131, 131-A, and 141, Dental 111, and the Hospital UB92 will be eligible for electronic submission using one of the three 837 formats. Pharmacy 061 claims will use NCPDC v 5.1 format. ACS will provide information separately about dial-up numbers.

   Technical Support: Support for the X12N 837 transaction will be provided by ACS EDI Gateway, Inc. They can be reached Monday through Friday from 8AM to 5PM Eastern Time at 1-800-829-0218.

2. WINASAP2003 - Proprietary billing software is available from ACS. WINASAP2003 can be downloaded from the ACS web site. Follow the links | Providers Only | EDI Software and Manuals.

   Technical Support: Support for the WINASAP software will be provided by ACS EDI Gateway, Inc. They can be reached Monday through Friday from 8AM to 5PM Eastern Time at 1-800-829-0218.

3. Vendor Software - Vendors are currently creating or upgrading existing client software to submit HIPAA transactions. Florida Medicaid does not recommend or certify vendors or their products. Information on this subject can be obtained by contacting business solution software providers, an Internet search (your business+business+software), or by contacting your professional or trade association for a list of software providers. ACS EDI Gateway, Inc. can supply providers with an approved vendor list upon request. These vendors' software products have been tested and approved to submit claims electronically to ACS. Vendor software should allow direct billing from the provider's business management system. Reconciliation of payments, claim status, and recipient eligibility verification may also be features of the software.

   Training: the software vendor should provide training.
   Technical Support: Support should be provided by the vendor.

4. Custom Software - Providers can contract with software developers to write programs tailored to their businesses.

   Training: the software developer should provide training.
   Technical Support: Support should be provided by the software developer.

5. Other Clearinghouse - Non-HIPAA compliant data can be sent to a clearinghouse for conversion to a HIPAA-compliant format prior to submission to Florida Medicaid. Florida Medicaid does not recommend or certify other clearinghouses or their products. Information on this subject can be obtained by contacting a business consultant, an Internet search (edi+clearinghouse), or by contacting your professional or trade association for a list of clearinghouses. Clearinghouses can submit claims to many different payers and may provide other services such as claim status or eligibility verification. HIPAA includes billing services, re-pricing companies, community health management information systems or community health information systems, and "value-added" networks and switches in the definition of a clearinghouse. Clearinghouses usually charge for their services.

   Training: the clearinghouse should provide Training.
   Technical Support: the clearinghouse should provide Support.

• Paper Submissions: Providers may continue to submit claims on paper to ACS using existing claim forms (i.e., CMS-1500, UB92, etc.) except as noted below. Some of the Florida Medicaid specific forms may be slightly changed, or billing instructions for entering data on claims may change. Providers will receive updates to their Florida Medicaid Reimbursement Handbooks beginning in the summer of 2003. Included below are some of the changes to paper billing:
1. Child Health Check Up (221) - The 221 claim form will be obsolete as of HIPAA implementation. It will be replaced with the CMS-1500.
2. Non-Institutional Other (081) - The 081 claim form will be revised to include fields for listing up to two modifier codes per line. The Place of Service Code for Schools will change from "18" to "03".
3. Institutional (021) - The Action Code will no longer be required.
4. Transportation (131) - The Time of Service field will be replaced by modifiers at the line level.
5. Dental (111) - Field 35 (Tooth/Letter No.) will be expanded to hold 2 digits.
6. CMS-1500 - The Place of Service Code for Schools will change from "18" to "03" and the instructions for entering diagnosis codes will change.
7. UB92 - Locally assigned Occurrence Codes 50, 51, and 54 will change to nationally recognized codes. The Employment Status Code will no longer be required.

When Medicaid is Secondary Payer

• Medicare Crossover claims: AHCA will receive Medicare Crossover claims in X12N 837 formats directly from Medicare Carriers and Intermediaries. If a claim fails to automatically cross over from Medicare, providers can send their own X12N 837 transaction, WINASAP claim, or bill on paper per current billing instructions. If Crossover claims are not crossing over automatically, providers should contact ACS Provider Enrollment at (800) 377-8216 to verify information in their provider file.
• Third-party liability: Providers will be able to bill Medicaid claims with other third party payer information (either paid or denied) electronically using the X12N 837 formats.
• Coordination of Benefits: In most instances, Medicaid is the payer of last resort. Though Florida Medicaid will receive claims in X12N 837 formats, Medicaid will not send claims in X12N 837 formats to other payers. When Medicaid determines it is a secondary payer, providers will continue to be responsible for submitting the claim to the other payer prior to billing Medicaid
.

Remittance Vouchers

• Electronic Remittance Vouchers (RV): All electronic RVs will be in X12N formats.
1. The X12N 835 format contains information on paid and denied fee-for-service claims.
2. The X12N 820 format contains payment information on capitation claims.
3. The X12N Unsolicited 277 format contains information on suspended claims.
• Provider Choice: Providers will continue to choose whether to receive Remittance Vouchers (RVs) electronically or on paper
.
• New Fields: Both paper and electronic remittances will contain new or altered fields as explained below.
1. TPL Information: Currently, the Florida Medicaid Remittance Voucher (RV) provides third party payer information to providers when a claim is denied due to Third Party Liability (TPL). The name, address and phone number of the primary carrier are provided to assist the provider in contacting them. The X12N 835 transaction does not support this detail when reporting TPL information. Up to two TPL Carrier Codes will appear on the electronic or paper transaction.
2. Submitted Units of Service: Electronic and paper remittances reflect the original units of service submitted by a provider.
3. Reason Codes: The X12N 835 Health Care Claim Payment/Advice transaction does not support FMMIS EOB (denial codes or edits). Florida Medicaid EOB codes will be replaced with X12N compliant codes. One set of the X12N compliant codes are called Adjustment Reason Codes. Currently, Adjustment Reason Codes are used to indicate the reason for crediting or adjusting a claim that has previously been adjudicated by the FMMIS. Adjustment Reason Codes in the X12N transaction are used to report claim level adjustments that cause the amount paid to differ from the amount originally submitted. Another of the X12N compliant codes are called Remark Codes. Remark Codes are used to relay information that cannot be expressed with a claim Adjustment Reason Code. Please refer to "Code Sets" section in this Fact Sheet for more additional information.
4. Procedure Code Modifiers: Modifiers are used in conjunction with procedure codes to more clearly define the procedure performed. Florida Medicaid will store up to four procedure code modifiers and report them back on either the electronic or paper remittance. Please refer to "Code Sets" section in this Fact Sheet for more additional information.
5. Bundled RVs: The X12N 835 transaction is not designed to handle the bundling of remittances for numerous payments made to multiple providers into one RV. Only one X12N 835 transaction can be generated for each provider; therefore, intermediaries will receive multiple remittances.
6. Facility Type Codes: The Facility Type Code is the place of service field on professional claims.
7. Claim Frequency Code: The Claim Frequency Code indicates the frequency of the claim on the Institutional claim.
8. Cutback Units: Cutback Units display the difference between the submitted units and the number of units approved for payment.
9. Cutback Amount: This field reports the difference between the submitted charge amount and the amount approved for payment.

Codes Sets

HIPAA legislation mandates that locally assigned codes be replaced with nationally recognized codes. This applies to procedure, modifier, revenue center, occurrence, place of service, and EOB codes. AHCA will advise providers which national codes and modifiers should be used to replace existing local codes and modifiers. Please pay close attention to the HIPAA News bulletin, provider training session announcements, and the AHCA HIPAA website for more information.

• Local codes and modifiers: Effective with HIPAA implementation, Florida Medicaid can no longer accept local procedure codes and modifiers. Local procedure codes and modifiers are those that Florida Medicaid has assigned. In addition, Florida Medicaid will accept up to four modifiers on X12N 837 institutional and professional claims as shown in the X12N implementation guides. Only the first two modifiers will be used for pricing. Providers are advised to list the two modifiers related to claim pricing in the first two positions of the modifier segment.
• Revenue Center Codes: Some Revenue Codes currently used on outpatient claims have Florida Medicaid assigned descriptions that do not correspond to the national description. This will not be acceptable after HIPAA implementation. The Revenue Codes affected are 273 (Burn Pressure Garment), 274 (Cochlear Implant Handling), 278 (Norplant Subdermal Contraceptive Implant), 279 (Other Supplies/Devices), and 452 (Emergency Medical Screening Serv).
• Occurrence Codes: Locally assigned Occurrence Codes 50, 51, and 54 will be replaced with nationally recognized codes.
• Place of Service codes: Place of Service code "18" will be replaced with Place of Service code "03".
• EOB codes: The X12N 835 Health Care Claim Payment/Advice transaction does not support FMMIS EOB (denial codes or edits). Florida Medicaid EOB codes will be replaced with X12N compliant codes listed below:
1. Adjustment Reason Codes - Adjustment Reason Codes in the X12N transaction are used to report claim level adjustments that cause the amount paid to differ from the amount originally submitted
2. Remark Codes - Remark Codes are used to relay information that cannot be expressed with a claim Adjustment Reason Code
3. Claim Status
4. Claim Status Category
5. Entity Codes - This code is a nationally recognized value that identifies an organizational entity, a physical location, property, or an individual

Eligibility Verification

Providers will have the following ways to verify Medicaid eligibility and benefit limitations:

• Medicaid Eligibility Verification System (MEVS): MEVS switch vendors are private companies that provide current online Medicaid eligibility information. Medicaid providers may select the switch vendor of their choice and contract with that vendor to provide the agreed upon services. Eligibility transactions may be submitted using PC software supplied by the switch vendor, via a point of sale device similar to those used for credit card transactions, over the telephone using a voice response system, or other possibilities depending on what the switch vendor offers. For a complete list of current switch vendors available in the state of Florida and their telephone numbers, visit ACS' website (http:/floridamedicaid.acs-inc.com).
• X12N 270/271 transaction: Providers will be able to send an X12N 270 eligibility transaction to ACS, and ACS will send back the X12N 271 response.
• Automated Voice Response System (AVRS) and FaxBack: HIPAA does not require changes to AVRS or FaxBack.

Claims Inquiry

• Medicaid Eligibility Verification System (MEVS): MEVS switch vendors are private companies that provide current online Medicaid eligibility information. Medicaid providers may select the switch vendor of their choice and contract with that vendor to provide the agreed upon services. For a complete list of current switch vendors available in the state of Florida and their telephone numbers, visit ACS' website http://floridamedicaid.acs-inc.com.
• X12N 276/277 transaction: This will be a new way to check claims status. Providers will be able to send X12N 276 claims inquiry transactions to ACS, and ACS will send back the X12N 277 response in batch mode.
• Provider Inquiry: Providers will continue to be able to check claims status by calling Provider Inquiry at 1-800-289-7799, Monday through Friday, 7:00 a.m. through 6:00 p.m. Eastern Time.

Prior Authorization

Providers may continue to submit paper Prior Authorization (PA) forms for medical and dental services or they may transmit Prior Authorization requests via electronic media.

• Paper Process: Providers can continue to follow the current process for requesting Prior Authorization via paper.
• X12N 278 transaction: Providers may submit PA requests electronically to ACS using the X12N 278 format. If the X12N 278 format does not give the Agency all of the information it needs to make a decision, then the agency will contact the provider to request it. Once a decision has been reached, an electronic reply will be sent to the requesting provider.
• Home and Community Based Services: Providers of these services will continue to receive Prior Authorization through the management teams.
• Peer Review Organizations (PRO): Organizations such as KePRO and First Mental Health authorize inpatient and psychiatric hospital admissions respectively. Those organizations are responsible for receiving requests from providers and notifying providers of approved or denied requests.

Additional Information Sources

• Agency for Health Care Administration (AHCA) HIPAA website: HIPAA Web Site.
• ACS's Florida Medicaid Provider website: http://floridamedicaid.acs-inc.com
• Centers for Medicare and Medicaid Services: http://www.cms.gov/hipaa/hipaa2/default.asp
• Washington Publishing Co.: http://www.wpc-edi.com/hipaa/HIPAA_40.asp
• Workgroup for Electronic Data Interchange: http://www.wedi.org
• Designated standard maintenance organizations: http://www.hipaa-dsmo.org
• National Council for Prescription Drug Programs: http://www.ncpdp.org