DMERC Region A Supplier Manual - Chapter 04

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DMERC Region A Supplier Manual - Chapter 04 Powered By Docstoc
					Chapter 4: Electronic Data Interchange

Electronic Billing


Medicare claims submitted electronically, via Electronic Data Interchange (EDI), have the benefits of being
filed faster, more efficiently, and more cost-effectively than paper claims. Suppliers who do not bill claims
electronically should consider the following advantages of EDI:
  •    14-day payment floor versus 28-day payment floor for paper claims
  •    Increased accuracy and minimized rejections - direct processing (processors do not re-key claims)
  •    Availability of Electronic Remittance Notice (ERN) for faster posting
  •    Online claim status verification/eligibility
  •    Electronic Certificates of Medical Necessity (CMNs)
  •    Ability to submit claims seven days a week, including holidays (excluding system maintenance)
  •    A department dedicated solely for EDI support for faster problem resolution
  •    Electronic Funds Transfer (EFT)

EDI is available to both participating and non-participating suppliers; also, assigned and non-assigned claims
are accepted.

Suppliers have several options available to them for electronic billing. If suppliers wish to bill directly to the
Region A Durable Medical Equipment Regional Carrier (DMERC A), they can order DMERC A's low cost
Health Insurance Portability and Accountability Act (HIPAA) compliant software, they may purchase a
vendor's software package, or they can have an in-house programmer create software for them. Alternatively,
suppliers can use a third party, such as a billing service or clearinghouse, to bill electronically to DMERC A.
Suppliers using a vendor or in-house software are required to pass format testing with EDI before billing.
[Note: Visit DMERC A's Web site ( for information on HIPAA.]

ViPs Provider Inquiry System
One benefit of electronic billing is online claim status. Online claim status inquiries allow an electronic biller
to check on a claim-by-claim basis the status of their assigned claims. To access the ViPs Provider Inquiry
System (VPIQ), suppliers must fill out an IVANS service agreement and an addendum for VPIQ. To obtain
the forms via the DMERC A Web site:
  •    Visit
  •    Click on "IVANS service agreement"
  •    Print the form, then mail the completed form to the address listed on the service agreement or fax both
       pages to 813-282-7029
  •    Click on "On-Line Claim Status Inquiry (CSI) Agreement"
  •    Print the form, then mail the completed form to the address listed on the addendum

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                                                                                 Chapter 4: Electronic Data Interchange

Electronic Eligibility
This feature allows Medicare Part B physicians and suppliers, and their authorized billing agents, automated
access to beneficiary eligibility data, as long as the provider bills electronically. The following are the rules
and regulations for using electronic eligibility, per the Medicare Carriers Manual (MCM) Section 6100:
•     The claims-to-inquiry ratio must be at least 70%.
•     If the claims-to-inquiry ratio does not exceed 70% from a given provider, that provider will
      receive an educational contact from DMERC A. If there is a problem, or the behavior continues,
      then the provider loses inquiry access.
•     The eligibility information that the provider receives is only for their use. It is not to be shared with any
      healthcare providers that are not certified and doing business electronically with the Medicare
      intermediary or carrier.
•     Please note that penalties for illegal disclosure of this information are as follows: being found guilty of a
      misdemeanor and being fined not more than $5,000.
•     Disclosure of Common Working File (CWF) eligibility data is restricted under the provisions of the
      Privacy Act of 1974, 5 U.S.C. 552A. Under limited circumstances, the Privacy Act permits DMERC A to
      disclose information without the consent of the individual; one of these is for "routine uses," that is,
      disclosure for purposes that are compatible with the purpose for which DMERC A collects information.
      In the case of this provider access, a routine use exists which permits release of data to providers or their
      authorized billing agents for the purpose of verifying a patient's eligibility for benefits under the Medicare
      program. The use of the data by a provider in preparing bills for hospital-based physicians would be an
      example of unauthorized use, because the physicians are not Medicare providers as defined in the act.
•     Access of eligibility data is used only for submitting a complete and accurate claim and is not to be
      disclosed to anyone that is not responsible for submitting a claim.
•     The eligibility data is only good for the time the provider is receiving it. This information could change at
      any time.

Electronic Transactions
Another benefit of electronic billing is the Electronic Remittance Notice (ERN). An ERN is available to the
supplier several days sooner than the paper remittances, which arrive in the mail. (Refer to Chapter 7 of this
manual for samples of remittance notices.) More importantly, when using vendor-billing software, the
remittance information can be interpreted by the supplier's computer system and automatically posted to the
patient's account. Several clerical posting steps can be abbreviated or eliminated.

To sign up for ERNs, suppliers will need to know the ERN version number their software supports and sign
and return an ERN addendum to DMERC A. The form is available via the DMERC A Web site
( If suppliers develop their own software, they can download
the latest ERN specification from the Washington Publishing Company (WPC) Web site (
to assist in the creation of ERN processing software.

DMERC A also offers the option of receiving payments electronically. Electronically deposited funds are
available in the supplier's account within three days after DMERC A transmits an Electronic Funds Transfer
(EFT) to the bank. This means the DMERC EFT funds will usually be available to the supplier one week

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Chapter 4: Electronic Data Interchange

sooner than the DMERC paper funds. To sign up for EFTs, suppliers will need to complete and return an
"Authorization Agreement for Electronic Funds Transfer" form to DMERC A. This form is available via the
DMERC A Web site ( Suppliers will need to review the online
instructions ( prior to completing the form.

ERN/EFT Process
  •    Payment Floor: DMERC A has a mandated payment floor. This means we must wait a specific
       number of days after we receive a claim before we create a payment. Currently, the payment floor for
       electronically submitted claims is 14 days. The payment floor for paper claims is 28 days.
  •    Packaging and Delivery: DMERC A will create two electronic packages, one containing the ERN
       and one containing the EFT. ERNs may be retrieved via the Region A Bulletin Board System (see next
       page for information on the bulletin board system). DMERC A will send the EFT to our originating
       bank, Bank One. Bank One will send the EFT to the supplier's receiving bank, where it will be
       immediately deposited into the supplier's account.
  •    ERN Format: DMERC A provides the CMS-specified format for electronic remittance notices. At
       present, it is the American National Standards Institute (ANSI) X12N version 4010A1 standard, as
       mandated by the Health Insurance Portability and Accountability Act (HIPAA). [Note: Information
       about HIPAA is available in the DMERC Medicare News and on the DMERC A Web site
  •    EFT Format: DMERC A will send the supplier's EFT payment to Bank One in the CCD+ format.
       Bank One will send the same format to the supplier's bank. Most banks belong to the National
       Automated Clearing House Association (NACHA) and accept this format. The supplier will want to
       confirm this with the supplier's bank. (The CCD+ format is a banking format. Suppliers will generally
       not have to be concerned with this format in their computer accounting systems.)
  •    Fund Availability: Generally, DMERC A will transmit the supplier's EFT to Bank One on the
       fourteenth day after date of receipt. Funds will be available in the supplier's account on the following
       business day.

Coordination of Benefits
CMS has standardized electronic data formats for Coordination of Benefits (COB). In the past, this activity
was called Medicare Crossover. The ANSI X12N 837 4010A1 format makes it possible for insurers to
receive claims from all durable medical equipment regional carriers (DMERCs) without having to
accommodate multiple formats. Use of this standard format is mandatory. (Refer to Chapter 3 of this
manual for more information on this subject.)

DMERC A posts the updated list of Other Carrier Name and Address (OCNA) number assignments to our
Web site on a periodic basis ( [Note: Additional information about
HIPAA and its impact to COB transactions is available in the DMERC Medicare News and on the Web site

NOTE: All automatic crossovers processed by DMERC A will be indicated on Medicare remittance notices.
If the indication is not present, suppliers will need to contact the appropriate secondary insurer for resolution.

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                                                                                Chapter 4: Electronic Data Interchange

Bulletin Board System
A Bulletin Board System (BBS) is available. The BBS:
  •   Allows the submitter to view or download important newsletters and provider notices regarding EDI
      and Medicare immediately.
  •   The submitter can leave messages or questions on the board for the EDI Department. The submitter
      will receive a personal reply to the question(s) by the EDI Department on the Bulletin Board.
  •   To maintain security, each supplier will receive a submitter number and password to log onto the BBS.
  •   Submitters receive electronic file rejection reports, 24 to 48 hours after transmitting a file, via the BBS.

Contact the EDI Helpdesk at 570-735-9429 to obtain additional information on Electronic Data Interchange
submission and/or its features.     Or, visit the EDI section on the DMERC A Web site at

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