Recent questions specifically regarding Version D.0
Q: Do ECSS and CE2000 support ICD-10 Diagnosis Codes?
ECSS and CE2000 both support ICD-10 as well as ICD-9 Diagnosis Codes.
Q: When are ICD-10 Codes required?
Begining October 1st, 2015, HIPAA mandates the exclusive use of ICD-10 in claims that require Diagnosis Codes.
Q: Are ICD-10 Codes required on ALL claims?
If a claim previously required an ICD-9 code it now requires an ICD-10 instead. Most prescription drug claims do not require Diagnosis Codes at all
Q: How do I enter an ICD-10 Diagnosis Code?
A: While entering a claim, proceed to the Clinical Information Screen and proceed as follows
1. Enter the value 2 in Field 492-WE (indicates that you will be entering an ICD-10 code in the next field)
2. Enter a valid ICD-10 code in field 424-DO (DO NOT INCLUDE THE PERIOD)
3. Click Update
4. The first button of the nine across the top of the screen with change from Edit to Used
5. The second button at the top of the screen will change to Edit
6. Repeat this procedure for each additional Diagnosis Code (up to a maximum of nine)
Q: Can I mix ICD-9 and ICD-10 codes in the same claim?
A: While our products will allow a mix of ICD-9 and ICD-10 codes, the Processor might reject the claim depending on their rules.
Q: Do ECSS and CE2000 support the new fields required for Medicare Part D LTC Short Cycle Billing?
To get the latest External Code Set values added to your ECSS or CE2000 system you will need to download them from our web site. Contact DayTech Customer Support for instructions on how to do this.
Q: Can ECSS and CE2000 be used to create and transmit 340B claims?
“Section 34ØB” or “34ØB” refers to a portion of the Public Health Service Act of 1992 and Public Law 1Ø2-585 which, in its most basic sense, obligates participating drug manufacturers to offer discounted prices to select federal grantees and hospitals known as Covered Entities. Congress established the 34ØB program “to enable these entities to stretch scarce Federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.” The federal agency charged with administering 34ØB is called the Health Resources and Services Administration.
To be considered as 360B, a claim must meet the underlying business definition, be sent by an acknowledged 340B Covered Entity and be submitted with Field 420-DK Submission Clarification Code set to a value of 20 and Field 234-DN Basis of Cost Determination set to a value of 08.
Refer to the NCPDP 340B Information Exchange Reference Guide for more information.
Q: What are the most common fields that need to be added to a Version D.0 plan after it has been converted from Version 5.1?
147-U7 Pharmacy Service Type
307-C7 Place of Service
384-4X Patient Residence
409-D9 Ingredient Cost Submitted
412-DC Dispensing Fee Submitted
419-DJ Rx Origin Code
430-DU Gross Amount Due
These fields are now almost universally required for Version D.0 claims.
Missing Pharmacy Service Type, Place of Service or Patient Residence usually results in reject messages related to the Provider or Patient not being in network or a Nonmatched type of reject code relating to the Provider or Patient.
With price balancing now a requirement in Version D.0, missing Ingredient Cost, Dispensing Fee or Gross Amount Due usually results in M/I messages for the corresponding fields or some other reject related to pricing. Gross Amount Due usually contains the sum of Ingredient Cost plus Dispensing Fee (IC of $100.00 + DF of $10 = GAD of $110.00) unless there are charges for additional items such as Delivery Charges. If Gross Amount Due does not equal the sum of Ingredient Cost + Dispensing Fee the resulting reject message "GAD Does Not Follow Pricing Rules" is usually returned.
Rx Origin Code is used to indicate how the original Rx was received at the Pharmacy (paper, phone, fax, electronic, transfer, etc) and is required by CMS to monitor E-prescribing activity.
Q: With the second CMS announcement regarding an additional 90 day enforcement delay for HIPAA II TCS rules, should I delay my conversion to D.0?
The most recent announcement only covers "proactive CMS enforcement". Covered Entities were still expected to be using the D.0 format effective 01/01/2012. Many Payers have warned Providers that they MUST be sending claims in D.0 format on or before 03/31/2012. The federal requirement is now 06/30/2012.
Q: What Version of ECSS or CE2000 do I need to be on to support HIPAA II and NCPDP Version D.0?
A: ECSS Version 9.3 or CE2000 Version 9.3
Q: I installed Version 9.3. Am I done?
Converting to Version 9.3 of our software gives you the ability to create new NCPDP Version D.0 plans and/or convert existing NCPDP Version 5.1 plans to Version D.0. Each Payer will be supporting Version D.0 on their own schedule and you will need to convert individual 5.1 plans to D.0 as the Payers announce that they are ready to accept them. You can either convert each existing plan from 5.1 to D.0 or keep your 5.1 plan and add a new D.0 plan. See the Version D.0 Companion Guide for details.
Q: Is the D.0 Companion Guide available directly in ECSS and CE2000?
Just click Help from the Create Insurance Plans screen or from the Claim Editor screen while creating a claim in D.0 format
Q: If I use the 5.1 to D.0 hypertext to convert an existing 5.1 plan to D.0 does ECSS or CE2000 automatically add any new D.0 fields that the Payer might require?
When converting a 5.1 plan to D.0 we can only convert the existing fields. We have no way to know about any new D.0 fields that the Payer might have decided to require. However, after the plan has been converted to D.0 the Data Dictionary will contain all supported D.0 fields. You can add any of them to the D.0 plan just as you normally would with a 5.1 plan. You may need to refer to the Payer's D.0 Setup Sheet or send a claim and add any new fields based on any reject(s) that might occur.
Q: Is there anything besides new claim fields I might need to add to a D.0 plan that I converted from 5.1?
Some Processors required us to re-certify our products for Version D.0. And some of them issued us a new Software Vendor Certification ID. After converting an existing 5.1 plan to D.0 for any of these Processors you will also need to update the Software Vendor/Certification field to reflect the new number.
The following Processors assigned us new Software Vendor Certification numbers for D.0:
Argus/Humana, Caremark, In Medicaid, Magellan, Omnisys, PA Medicaid, Relay Health
Processors do not allow us to publish these numbers on our web site. Please Email us at firstname.lastname@example.org for a complete list of our new ID's and their corresponding BIN numbers.
Q: What changed with the Version 5.1 field 307-C7 Patient Location Code?
307-C7 Place of Service
In Version 5.1 there was confusion as to whether this field referred to where the patient actually resided or where the patient received the product/service related to the claim submission.
In Version D.0 this field was given a new name and definition, limiting it to the place where the patient received the product/service and a new field was added to designate where the patient actually resided at the time they received the product/service.
Field 307-D7 now uses the CMS Place of Service Code Set which is not compatible with the previous NCPDP Patient Location Code Set. Here are the new values:
Code set maintained by CMS identifying the location of the patient when receiving pharmacy services: 01=Pharmacy, 03=School, 04=Homeless Shelter, 05=Indian Health Service Free Standing, 06=Indian Health Service Provider Based, 07=Tribal 638 Free Standing, 08=Tribal 638 Provider Based, 09=Prison, 11=Office, 12=Home, 13=Assisted Living Facility, 14=Group Home, 15=Mobile Unit, 16=Temporary Lodging, 17=Walk-in Retail Cininc, 20=Urgent Care Facility, 21=Inpatient Hospital, 22=Outpatient Hospital, 23=Emergency Room, 24=Ambulatory Surgical Center, 25=Birthing Center, 26=Military Treatment Center, 31=Skilled Nursing Facility, 32=Nursing Facility, 33=Custodial Care, 34=Hospice, 41=Land Ambulance, 42=Air or Water Ambulance, 49=Independent Clinic, 50=Federally Qualified Health Center, 51-Inpatient Psychiatric Facility, 52=Psychiatric Facility - Partial Hospitalization, 53=Community Health Center, 54=Intermediate Care Facility/Mentally Retarded, 55=Residential Substance Abuse Treatment Facility, 56=Psychiatric Residential Treatment Center, 57=Non-residential Substance Abuse Treatment Facility, 60=Mass Immunization Center, 61=Comprehensive Inpatient Rehab Facility, 62=Comprehensive Outpatient Rehab Facility, 65=End-Stage Renal Disease Treatment Facility, 71=Public Health Clinic, 72=Rural Health Clinic, 81-Independent Laboratory, 99=Other Place of Service
Note that in the original release of ECSS and CE2000 Version 9.3, the field Help information for Field 307-C7 still reflects the NCPDP code set. This information can now be updated from DayTech's web site to reflect the current CMS Code Set values. Please email us at email@example.com to receive information on how to download and apply this update.
384-4X Patient Residence
This new field in Version D.0 is used to designate where the patient lived at the time that the Product/Service was received. It uses an NCPDP Code Set:
Code set maintained by NCPDP identifying the patient's place of residence. 00=Not Specified, 01=Home, 02=Skilled Nursing Facility, 03=Nursing Facility, 04=Assisted Living Facility, 05=Custodial Care Facility, 06=Group Home, 07=Inpatient Psychiatric Facility, 08=Psychiatric acility - Partial Hospitalization, 09=Immediate Care Facility - Mentally Retarded, 10=Resedential Substance
The Help screen associated with this field is correct.
It is unclear to us at this time exactly how Payers will use these fields in Version D.0 transactions. Providers need to pay particular attention to these fields in the individual Setup Sheets they receive from their Trading Partners.
Q: Why is it that when I go to Create & Transmit Insurance Claims, click View by BIN/PCN and select a D.0 plan no fields appear on the Claim Screen?
This is a known issue with the initial release of Version 9.3.0 and we have corrected the problem. Do not use the View by BIN/PCN option to select D.0 plans. Select them from the normal Plan ID view instead. If you have the ability to receive software updates via the Internet and would like to download a patch that fixes the problem please contact us at firstname.lastname@example.org and we can provide you with the necessary link.
Q: Can I still submit Compound Rx Claims using the most expensive ingredient only like I did with Version 5.1?
The only way to submit a compound under Version D.0 is to use the Compound Screen and detail each ingredient individually. See the Version D.0 Companion Guide that came with our software for details.
Q: What do I enter in field 407-D7 Product/Service ID when billing a Compound?
A: A single 0 (zero)
Q: What do I enter in field 436-E1 Product/Service ID Qualifier when billing for a Compound?
A: Two 0's (zeroes)
Q: What do I enter in field 995-E2 Route of Administration when billing a Compound?
A: A valid SNOMED code. Press the ? key while pointed to field 995 for a list of SNOMED codes used in NCPDP Standards.
Q: What do I enter in field 996-G1 Compound Type when billing a Compound?
A: Press the ? key while pointed to field 996 for a list of the Compound Type codes used in NCPDP Standards.
Q: What if I cannot find a field listed on the Payer Sheet in the red Data Dictionary box of ECSS or CE20000?
A: It may mean that the field in question is part of the claim "structure" such as a Count, Counter, Field Separator, Segment Separator or Group Separator, all of which we provide automatically. It may also indicate that the field is a part of a repeating field group used in Coordination of Benefits, Compounds, DUR/PPS, Clinical Measurements, Additional Pricing or Submission Clarification. These fields appear at the bottom of the red Data Dictionary box with the Field ID prefix of grp-. Selecting the proper grp field gives you ALL of the fields necessary to submit the information required for that particular function. For example, selecting grp-co gives you Compound Fields 488-RE, 489-TE, 448-ED, 449-EE, 490-UE, 363-2H, 450-EF and 451-EG.
Do ECSS and CE2000 support the larger 12 digit RX# allowed in NCPDP Version D.0?
YES! Both products were updated to allow for the larger number in ECSS and CE2000 Version 8. The ability to actually use the larger number is available in ECSS and CE2000 Version 9 and applies only to claims in the NCPDP Version D.0 format. Per HIPAA regulations, NCPDP Version 5.1 claims must still use 7 dight RX numbers.
Do ECSS and CE2000 support the billing of Supplies and Services?
YES! Starting with Version 9, both ECSS and CE2000 support the billing of both supplies and services.
Do ECSS and CE2000 support the new Predetermination of Benefits transaction?
YES! Starting with Version 9, both ECSS and CE2000 support this new transaction that allows you to determine the patients benefit and copay in advance without having to submit a live claim and then reverse it.
Do ECSS and CE2000 support the National Provider ID (NPI)?
YES! Starting with Version 7, both ECSS and CE2000 have the ability to identify the Provider by NPI number as well as all of the other accepted ID numbers used with NCPDP claims. Version 7.5 contains changes to the way both ECSS and CE2000 support the NPI and is the recommended version to use for both products. These changes will be carried forward into all future versions as well.
Do ECSS and CE2000 support Medicare Part D claim submission?
YES! Starting with Version 7, both ECSS and CE2000 support the creation and secure transmission of prescription drug claims to Medicare PDPs, Supplemental Payers, SPAPs, Medicare Advantage programs, etc... See News for more information.
Do ECSS and CE2000 support the Medicare Part D Eligibility transaction?
YES! Starting with Version 7, both ECSS and CE2000 support the creation and secure transmission of TrOOP Eligibility requests. See News for more information.
Do I need to sign up to do Medicare Part D Eligibility Transactions?
If you use Change Healthcare (Envoy) as your Switch, there should be no signup or additional paperwork required to access TrOOP Facilitation services.
If you use RelayHealth (NDC) as your Switch you can either call the TrOOP Facilitator Help Desk at 1-866-835-7595, or you can use the following URL to get to the TrOOP Facilitator Web Site and then click the Pharmacy Eligibility Agreement link to sign up online:
Regardless of which Switch you use, you will be charged a standard amount for each Eligibility Transaction you submit. This charge will be in addition to your normal Switch charge for the transaction.
Can my claims be transmitted over the Internet?
YES! Starting with Version 5, both ECSS and CE2000 support the secure transmission of claims over the Internet.
Are ECSS and CE2000 "HIPAA Certified"?
There is no such thing as "HIPAA Certified" hardware or software.
Health and Human Services wrote the HIPAA rules in a "technology neutral" manner. However, Version 5 and higher of our products are "HIPAA TCS Compliant" meaning that they support the mandated Transactions and Code Sets for retail pharmacy. Our products also support items specified in the HIPAA Privacy and Security rules such as User ID's, passwords, privileges and database encryption. DayTech is a member of the NCPDP and monitors several industry news groups in order to remain abreast of the latest HIPAA developments. As finalization of the regulations move forward, we are committed to working with our clients and the industry to achieve the highest level of compliance possible for both our products and business practices. See News for additional information on our national Switch Certifications.
HIPAA compliance is a "process" that involves policies, procedures and training in addition to hardware and software. No single vendor or technology can make your organization "HIPAA Compliant." It will take a joint effort between you, your vendors, your payers and your other business partners to achieve that goal.
What are Switching Companies and why are they used?
Most payers do not allow providers to dial directly into their adjudication system. Instead they require you to connect a "Switch" computer which, in turn, routes the claim to the payer and the response back to you. Switches provide an 800 number or secure internet portal for you to use when sending claims. They, in turn, charge you a few cents per claim for providing the switching services. This system improves overall security and provides you with a single phone number to use regardless of the number of different payers to whom you submit claims. Our help desk can assist you in signing up with whichever Switching Company you decide to use.
Can I use more than one Switch?
Yes - each Plan can be assigned to a different Switching company.
Can I submit claims for more than one provider?
Yes - each plan you create has a field for Provider ID - simply create multiple plans. You can also use a single plan for multiple providers if you specify zeros in the Provider ID field of the plan. The system will then prompt you for the data on each claim you create. Since an image of the claim is saved after payment, you will not need to enter this value again on refills or reversals.
Can ASC X12, NSF or UB92 claims be sent using this system?
No - these formats are used for batched claims and are not designed for real-time transmission or on-line adjudication.
Can DME claims be transmitted using this system?
It depends; when the HIPAA regulations were first formulated, CMS was not aware that NCPDP formats could support the submission of supply and service claims. Accordingly in the final rule they assigned these claim types to the ASC X12 standard. NCPDP appealed this decision and in HIPAA II, NCPDP Version D.0 may now be used for these claim types.
Some payers accept DME claims directly. Most of the other claims for DME items can be sent to a Clearinghouse using our software. The Clearinghouse will perform front-end edits, then convert the claim to the format required by the DME payer and forward it to them.
What about transmitting drugs with supplies?
When the HIPAA regulations were first formulated, CMS was not aware that NCPDP formats could support the submission of supply and service claims. Accordingly in the final rule they assigned these claim types to the ASC X12 standard. NCPDP appealed this decision and in HIPAA II, NCPDP Version D.0 may now be used for these claim types.
In some cases the payer can accept both the supply and drug in real-time mode. Otherwise you can usually submit the drug with our system and the supply on a CMS 1500. Submitting the drug real-time lets you know immediately whether or not the claim will pay and since the drug is usually the major expense on the claim, submitting it in real-time mode results in quicker payment and improves cash flow. The supply will pay later from the CMS 1500 submission.
Can I submit Medicare claims real-time?
The answer depends on which Medicare program you need. Medicare Part D prescription drug claims must be created and transmitted using NCPDP formats. That means that those claims can be submitted using ECSS and CE2000. Medicare Part A and B claims are still considered to be Medical as opposed to Pharmacy and cannot be processed using NCPDP formats. Therefore they cannot currently be submitted using ECSS or CE2000.
Can I install ECSS on a Server?
Yes - but only one user at a time can access it. For multiple concurrent users you need CE2000. ECSS is a single-user product. Each copy requires a separate license and activation code.
Does CE2000 support concurrent licensing?
Yes. CE2000 can be installed on up to 250 workstations. The number of concurrent users allowed is controlled by the system and is based on the number of seats you purchased.