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TO: All Providers
FROM: CareFirst of Maryland, Inc.
DATE: September 6, 2001
SUBJECT: Electronic Remittance Advice Changes for HIPAA

  • Providers receiving electronic remittances will need to make arrangements to accept the format ANSI835 version 4010 (from the current versions 3030M, 3051.3A, or 3051.4A), or contract with a clearinghouse to translate the data on their behalf.
  • Providers, provider billing services, trading partners, vendors or clearinghouses that elect to use a clearinghouse for translation services are responsible for those costs.
  • PC-Print software for version 4010 will be available (by January 2, 2002), and can be obtained through the EDI department. Further instructions for requesting the software will be issued when the final copy is available.
  • The version 4010 835 implementation guide can be downloaded without charge from Washington Publishing Company's website www.wpc-edi.com/HIPAA;
  • Providers, agents and clearinghouses who prefer advance testing to assure system compatibility of version 4010 of the 835 must schedule testing with their intermediaries prior to October 2002. (Testing dates will be announced as soon as they are known) Appointment slots will be assigned on a first come basis. Intermediaries will not be able to guarantee completion of testing by the end of September 2002 for any entity that delays requesting a testing appointment until late in the transition period. Current 835 remittance recipients will automatically be sent production 835 version 4010 transactions in October 2002.
  • It may not be feasible to accommodate all entities that may want to be tested during the last quarter of the transition process because of the large number of providers, agents, clearinghouses, and trading partners who could request testing on the multiple HIPAA standard transactions;
  • There is no Medicare charge for this system testing;
  • Differences exist between the current 835 versions and the 4010 version of the 835. These differences may impact the use of version 4010.
  • Although Medicare will furnish providers with basic information on HIPAA transaction requirements to enable them to make educated and timely decisions to plan for their transition to HIPAA standards, Medicare will not furnish in-depth training on the use and interpretation of the standard implementation guides. Providers with a need for such in-depth training for their staff are expected to obtain training of that nature from commercial vendors, their clearinghouse, or through standards development organizations.

Notes:
The Secretary of Health and Human Services has established version 4010 of the X12N 835 (provider remittance advice), 837 (claim, encounter and coordination of benefits (COB)), 270/271 (eligibility query/response), 276/277 (claim status query/response) and 278 (prior authorization) implementation guides as national standards for use by all health plans in the United States, including Medicare intermediaries. This fulfills certain requirements of the Administrative Simplification provisions of HIPAA. Further information on the HIPAA standards requirements in general may be obtained at http://aspe.hhs.gov/admnsimp. This Program Memorandum (PM) contains the requirements for implementation of the remittance advice standard by the standard system maintainers and intermediaries.

Version 4010 of the 835 includes some significant changes from earlier versions of the 835 supported by Medicare, including requirements to identify any secondary payer with whom benefits are coordinated, and to identify the primary payer if denying a claim because Medicare should be the secondary payer. See appendix D of the 835 version 4010 implementation guide for a summary of the changes. Version 4010 implementation guides may be downloaded without charge from www.wpc-edi.com/HIPAA, or you may phone 1-800-972-4334 to purchase hard copies.

(Source: Program Memorandum A-01-57; Change Request 1522)

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. ALL BULLETINS ISSUED AFTER OCTOBER 1, 1999