Beaverlog Tips:  Volume 35 - February 28, 2007

More Changes in the CMS-1500 Claim Form

Provider ID Numbers

No sooner did we add support for the new CMS-1500 claim form then a new set of specifications were released. And we can expect further changes on July 1 of this year and subsequent years. We responded by making the additional changes to the form in Pro version 2.5.021 and EZ version 2.5.015. In the process, we made support for the new form easier in both products. For each provider, you can now set the NPIs and secondary IDs for both box 24 and 33 separately. Box 24j has the IDs for the rendering provider and box 33 has the IDs for the billing provider. If these are the same, the box 24 IDs will not be printed.

Additionally, you can override the secondary ID in both places for specific carriers. In the carrier options on the provider list (or the provider options on the carrier list), you can indicate whether you want to override either or both secondary IDs. You cannot override an NPI because these are assigned uniquely to each provider and provider organization; there is no different NPI for a different carrier.

Service supplemental information

Services in box 24 now have two lines of information with the top line used for supplemental information and the provider's secondary ID. The new specifications moved and expanded the supplemental information so that it begins in the first position of box 24a rather than starting in box 24d. This expands the size of the field from 30 characters to 57. Information on filling this box is described on page 40 of the new specification document (CMS1500.pdf will be installed into The THERAPIST's program folder in the latest versions). Due to the flexibility in supplying supplemental information, The THERAPIST gives you one long (57 characters) entry field where you enter a code followed immediately by the required information with no space, hyphen or other character separating the code and data. Several codes are described in the document but it is implied that some information is entered without a code and you can include multiple code/data sets separated by three spaces. You should consult the specification document and your payer before you use this new field.

In addition to the unstructured supplemental information field described above, there are two structured fields that are for qualifier codes. The first is in box 24g and is used to indicate the type of units entered in the Days or Units value. The second is in column 24h and is a similar code for EPSDT. Both of these new qualifier codes have right-click (or the F2 key) lookups.

The CMS-1500 specification is an odd duck. It "sort-of" has the force of law behind it. It is not like the ANSI X12 electronic claim standards that are rigorously enforced. With the new CMS-1500 form, the "sort-of" part is because the new forms are being mandated for Medicare and Medicaid use. If there is any regulatory mandate for other payers, we have been unable to find it and have been told that it doesn't exist. That said, all payers who accept printed claims are expected to completely switch to the new form by May 2007. How they use it and what they will require you to enter appears to be unregulated. This once again puts providers at the mercy of payers and their shenanigans to make it hard for you to get claims accepted and paid.

Old Form Going Away

We don't have a definite date or version to report to you but some time in the near future, The THERAPIST will no longer support the older HCFA-1500 form. Along with that support going away, all of the support fields will disappear as well. That will make the programs somewhat simpler and more streamlined, something we will all like.


THIN and Availity

We wrote about our difficulties working with the THIN electronic claims clearinghouse in Beaverlog Tips Volume 16. Since that time, our problems with that organization were resolved and we actually had a terrific working relationship with them. Unfortunately, with the merger with Availity, it seems that everything we achieved is going away. The new combined organization operates out of two locations, the original THIN offices in Texas and the Availity offices in Florida. With our dealings with this organization, it really looks like the right hand not knowing what the left hand is doing. Florida makes the rules but their support phone system routes calls to Texas and to support people who say they don't know anything about what the Florida folks are requiring. It is very frustrating.

We were told that we would have to go through another complete round of testing before our customers could submit claims. Then we told that our claims are fully compliant and we were completely approved. We were recently informed that all of our customers who were submitting claims through THIN will no longer be approved to submit claims even though they had been submitting successfully and were being paid. On top of that, for the last several weeks not one of our many phone messages or emails to Availity have been returned.

This once again sounds like payers (such as those that own Availity) are doing their best to not pay claims and are willing to do whatever it takes to make it hard or impossible for providers to submit claims. We haven't given up on them but they are not making it easy on us or on you.


Windows Vista

Windows Vista has some remarkable new and delightful features.  Unfortunately, some of them are going to make it trickier to install and run The THERAPIST. For security, Vista includes what they are calling User Account Control (UAC). UAC is major an extension of the user security features of Windows XP. UAC is also a major pain in the you-know-what, not just for us but for you as well. Here are just a few of the problematic "features" of UAC in Vista:

  • Many of the folders and files that were available to users on previous versions of Windows are now limited only to users with Administrator access. Even then, some of these will ask every time whether you really, really want to access them.
  • Some of the access-limited folders on Vista will appear to be available but Windows is actually storing the files in different folders for every user. This is referred to as virtualized folders. The main problem with virtualized folders is with the Program Files folder. This is the standard location where The THERAPIST is installed and where the data is stored. Access to this folder is not a problem for the installation programs because they normally operate with administrator access. The problem becomes evident when a non-administrator runs The THERAPIST and the find that they cannot access either the original data files or even their own virtualized files.
  • Virtualization in Vista is not limited to files and folders. The System Registry, a place where The THERAPIST stores some important information, is also subject to this per-user swaping. Our program can no longer rely on looking for startup information in the registry.

So what are we to do? There are both near-term and long-term solutions to these challanges. The long-term solutions include upgrading to new installation programs that are Vista-aware and have features that allow us to overcome some of Vista's difficulties. We will also have to make some changes to our programs to reduce or eliminate reliance on protected folders and registry entries. However, in the near-term, the only solution we have tested and found to work is to run Vista with an administrator account. Another "solution" is to disable UAC in Vista but we don't recommend this as it will leave you vulnerable to a variety of security attacks.

Of course, another near-term solution is not to upgrade to Vista.