Dec | JAN 2011-12

inFocusNewsletter for users of the Availity® Health Information Network

A “Real” Gift for Your CompanyFewer Headaches, More Payments

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NEW!Availity inFocus (formerly Availity eFocus) has a brand new look and content. Tell us what you think— email us at efocus@availity.com

News Events Training

Reimbursement blues have you looking for tools to help you collect every possible dollar? You’re not alone.

contents

A “Real” Gift for Your Company Fewer headaches, more payments

Reimbursement blues have you looking for

tools to help you collect every possible dollar?

You’re not alone.

5010 Update Center Your source for HIPAA 5010 news, tips and training

Feeling a little Y2Kish? Don’t despair. Here’s

what you need to know about the deadline

and your Availity transactions.

Spotlight On CareProfile® for winter travelers

Sick travelers with no health records?

With CareProfile, it’s no problem.

Case Files

What's New?

Events

Training

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CareCost Estimator and Remit Reader are service marks (SM) of Availity, LLC.

CareCollect, CareProfile, CarePrescribe, and CareRead, are registered trademarks (®) of Availity, LLC.

CareCalc is a registered trademark of Blue Cross and Blue Shield of Florida, Inc.

ContactFor newsletter suggestions: efocus@availity.comFor customer support: support@availity.com P.O. Box 550857 Jacksonville, FL 32255-0857 1.800.AVAILITY (282.4548)

5010 Quick Tips A one-page reference for important 5010 changes

Availity inFocus, December/January 2011-12

www.availity.com 1

A “Real” Gift for Your CompanyFewer headaches, more payments

The pressures on health care

providers these days are

seemingly endless, from adoption

of new technology, to practice

consolidation, to changes in the

health care delivery process. But

you can capitalize on these changes

through effective revenue cycle

management, and give yourself and

your practice the gift of “one less

thing to worry about”—getting paid.

If you’re like most providers,

reimbursement pressures are

forcing your practice to focus on

the most efficient revenue cycle

management (RCM) process to

ensure that every possible dollar

is collected. That’s why more

providers are looking for revenue

cycle management solutions. With

average administration expenses

exceeding $85,000 per physician,

according to a 2009 study1, many

physicians are looking to fully

automate their processes and drive

economies across their business.

The study found that more than 50

percent of those administrative costs

were directly tied to interactions with

health plans, including:

• Follow-upandpayment

reconciliation

• Receivingandpostingpayments

• Creatingandfilingclaims

• Reimbursement

• Serviceauthorizations

• Clinicalcoding

• Databasemanagement,and

• Payerrelations

Automated revenue cycle

management gives you a lot of that

time back, allowing you and your

practice staff to focus on other

activities, like patient care.

Take an anesthesia practice in

western North Carolina, the subject

of a recent case study conducted

by RealMed, an Availity company.

This30-physicianpracticefaceda

growing accounts receivable file

and a payment collection process

that was too slow, so they went in

search of a technology solution that

would reduce time to payment, claim

rejectionsandback-enddenials.What

theyfoundimpressedthem.Fora

copy of this case study, click here.

The practice had historically

followed up on unpaid claims at

the120-dayagingmark,

story continued on page 8

A North Carolina anesthesia practice saw a 75% reduction in days in accounts receivable, from 28 days to less than seven days.

1 J.A. Sakowski et al. “Peering into the Black Box: Billing and Insurance Activities in a Medical Group,” Health Affairs Web Exclusive, May 14, 2009, w544-w554.

Learn more about RealMed and revenue cycle management at realmed.com, or call 1.877.REALMED

2 Availity inFocus | Dec/Jan 2011-12

Time is ticking away before the HIPAA

5010 compliance deadline of Jan. 1,

2012. Availity will be fully compliant with

the deadline, and will accommodate

everyone else who is as well.

Although CMS recently granted a

grace period for enforcement of the

deadline, Availity’s best guidance is

that you should continue to prepare

for the transition now, to avoid

extended disruption later.

Following are answers to a few

questions we’re already hearing.

More FAQs and general 5010

information are available at

www.availity.com/5010/.

Will Availity be down for any period

of time near January 1, 2012?

See the timeline graphic below for

details on Availity's 5010 migration.

FAQ continued on page 3

5010 Update CenterYour source for HIPAA 5010 news, tips and training

We've got your back.

Availity will be open Monday,

Jan. 2, 2012, fully staffed

and prepared to give you the

outstanding service you expect.

Availity 5010 Migration Timeline

*Payments from payers will continue during this time, but payment noti�cations (835s) will be delayed.

29T H U R S D AY | D E C 30F R I D AY | D E C 31S AT U R D AY | D E C 1S U N D AY | J A N

Normaloperations*

Plan to send alltransactions by close ofbusiness 12/29 to avoidprocessing delays*

Transactionssuspendedafter 6 p.m.EST

• Normal operations resume.• 4010 transactions will be increasingly up-converted to 5010.• Providers should confirm correct use of NPI and PO Box �elds, regardless of version sent.

Transaction processingresumes.

Web Portal & B2B(key-entered or

received from a PMS)

EDI(large batch/

direct connection)TRANSACTIONS SUSPENDED

INTERMITTENT/SELECTEDOUTAGES

www.availity.com 3

Will we still receive payment from health

plans if Availity suspends processing?

On Dec. 29 and 30, as we migrate to

5010, payments will be processed from

your payers as usual, but the related

835 transaction acknowledgement may

be delayed until Jan. 1, after our 5010

change-over is complete.

Availity recommends that you talk with

your practice management software

vendor to make sure certain billing

processes aren’t dependent on these

835s, which could affect your month-

end or year-end closing process.

Will there be a cut-off date when transactions have to be in the new format

to be processed?

Availity will continue to up-convert

or down-convert your transaction to

accommodate the preference and

readiness of the receiver (health plan),

as we’ve been doing since January

of this past year. Availity does not

have any current plan to discontinue

up-conversion of 4010A1 files on a

specific date.

Even though Availity has no planned

date for discontinuing 4010 processing,

we strongly recommend that you

convert to 5010 as soon as possible.

What happens when Availity “up-converts” or “down-converts” a

file from 4010 to 5010 or vice versa?

When Availity “up-converts” a file,

it maps data from a submitted

4010A1-formatted transaction to the

corresponding required data fields on

the 5010 record format, to the minimum

standard necessary to comply with

5010 transaction requirements.

Conversely, if a provider sends a

5010 formatted file to a payer not

yet equipped to handle 5010 files,

Availity will “down-convert” the 5010

file by mapping data from it to the

corresponding necessary data fields

in the older 4010A1 format.

Either or both scenarios may be used

to complete a round-trip information

exchange between a submitter and

payer. In every event, it is Availity’s

goal to present the information to the

end-customer in whichever version

they prefer to process.

What is a dual-mode payer?

A payer continuing to accept both 4010

and 5010 is considered “dual-mode.”

The number of dual-mode payers will

decline steadily in 5010, as enforcement

of the 5010 mandate takes effect.

In the case where a payer is dual-

mode, Availity makes no up- or down-

conversion of the file.

Why might my up-converted file

get rejected?

If the receiving payer is 5010-only (not

dual-mode), all incoming transactions

to them must be 5010 compliant.

Availity’s conversion tool will

automatically pass your incoming 4010

file “up” to 5010, for 5010 validation.

If Availity can apply auto-corrections

to make your file 5010-compliant, then

we forward the file to the payer for

processing as usual.

FAQ continued on page 9

Still feeling a little antsy? Just click Free Training in the Availity portal for

live and on-demand 5010 training.

4 Availity inFocus | Dec/Jan 2011-12

You see it every year: As people

abandon their healthful living

routines and winter cold sets in,

a stuffy flight is enough to land

a visitor in your office—sick.

Help treat your sick traveler with

Availity®CareProfile®, and access

critical patient history for visitors

without local medical records.

WithCareProfile,yougeta

longitudinal care record that provides

up to 24 months of your patient’s

carehistory—supplementingself-

reported history that could be

incomplete or inaccurate. Because

CareProfileisbasedonapatient’s

claims, you can view health care

services rendered by all their health

care service providers, including:

• Professional,hospitaland

emergency room services

• Radiologicalandlaboratory

services and lab results

• Prescriptionmedicationhistory

• Immunizationhistory

• Patient-specificcaremessages

and alerts

Get started now

YouwillneedyourPAAto

grant access, as appropriate, to

CareProfile.1 If you’ve already

been assigned access, simply

select CareProfile from the Availity

services menu on the home page,

then select your patient’s health

plan.Freewebinarsareavailable—

just click Free Training at the top of

any page.

1Primary Access Administrators (PAAs) can assign or revoke user access to CareProfile by clicking Account Administration | Maintain User in the Availity menu. For more information, click Help at the top of the Availity portal and search for the “Maintaining Users” topic.

Spotlight On: CareProfileSick travelers with no health records? No problem.

Learn more about the CareProfile and how it can help you.

New

In addition to the current, local

health plans, authorized users

also may access CareProfile

records for members with Blue

Cross and Blue Shield (BCBS) plan

coverage in Florida, Illinois, New

Mexico, Oklahoma and Texas.

www.availity.com 5

5010 Quick TipsA one-page reference for important 5010 changes

Update your address book to keep payments flowing

• Whensubmitting5010-complianttransactions, the billing provider and service facility addresses must be complete, physical street addresses and can no longer be a PO Box or a lock box.

• Todirectremittances(payments)toa different address, use the pay-to-provider, name and address fields.

• Dependingonthehealthplan,youwill receive warning messages or rejection errors for incomplete street address fields.

Put 9 on the line

• With5010-complianttransactions,the billing provider and service facility addresses must be complete street addresses and can no longer be a PO Box or a lock box.

• Completeisdefinedasincludingthe full 9-digit ZIP code: traditional 5-digits plus the extra 4 digits for localized mail delivery.

• Dependingonthehealthplan,youwill receive warning messages or rejection errors for incomplete street address fields.

• TheCentersforMedicareandMedicaid Services (CMS) will be validating the ZIP+4 sent in for both

billing provider and service facility. Please ensure you are properly registered in the PECOS system for Medicare before changing this data in your PM system.

• CheckouttheZIP code directory look-up and plan to update your address fields and PM system accordingly.

* Prior to making changes in the practice management system, providers should validate their credentialing and/or enrollment with health plans to ensure payments will not be negatively affected.

Minutes matterFor professional claim

transactions, the reporting of anesthesia minutes was revised. In 4010, payers could require the anesthesia time be reported as the total number of minutes or as units. In 5010, you can only report the total number of minutes. Units are no longer an acceptable format for reporting anesthesia time. Any requirements by a payer to submit anesthesia start and stop times in the 5010 transaction will be noncompliant with the TR3.

Billing provider clarification• In5010,abilling

provider must be a provider of health care services and can no longer be a

billing service or clearinghouse. New clarifications to the definition of a billing provider include: • Billingprovidersmustnowbe

those entities that perform services that are reimbursed by health plans.

• Makesureyouareusingthecorrect NPI for your organization. This must be the same NPI identifier for all trading partners.

• TheTaxIDmustbesentfortheBilling Provider on the claim.

Patients are a virtueAs your payers become capable of sending and

receiving 5010-formatted transactions, please remember that, for health plans that assign a unique identifier per member, the individual must be listed as a subscriber. The patient is not listed on the transaction.

For health plans that assign a number to the entire family, follow these rules:• Thepolicyholderisalwayslistedas

the subscriber.• Ifthepolicyholderisthepatient,the

patient is not listed in the transaction.• Ifthedependentisthepatient,

they are listed as the patient in the transaction.

6 Availity inFocus | Dec/Jan 2011-12

““

case fiLes Revenue management consultant says electronic access kept client in business

As a revenue management

consultant for multiple small

physician practices in Florida,

Merrilee Severino, CPC, CMM, CPM,

has seen the incredible impact of

electronic administrative tools using

the Availity multi-health plan network.

“Many small practices would not be

in business today if this didn’t exist.”

Severino teaches one and two-

physician practices to use available

information technology to simplify

the administrative aspects of running

a practice. “It’s frustrating for a

small practice when they don’t have

an easy way to get the information

they need from health plans,” says

Severino. “They emphasize quality

patient care, but when they can’t get

the information they need to manage

the business, they don’t get paid, and

that has a negative impact on their

ability to stay in business and help

people get better.”

She said that one of her past clients

avoided bankruptcy because of the

electronic access to health plans.

“This provider was the victim of some

fraudulent activity that left her in a

negative cash flow situation. She had

a number of bills that needed to be

submitted to health plans and she

could only afford one employee to help

manage the business end of things.”

In order to keep her practice running,

she needed to be paid right away.

Having electronic access to eligibility

and benefits, claims submission,

and claim status, the patient cost

estimator and online payment

collection tools were the keys to

keeping her in business. “We were

able to eliminate days of work and get

right to the information we needed

to get her paid. She was able to get

to cash flow positive in a matter of a

couple of weeks. It really saved her

business,” says Severino.

Has Availity helped your practice?

We want to hear from you! Send us

your story and you may be featured

in a future “Case Files” story. Email

us at efocus@availity.com.

I have been billing for 13 years and used several different clearinghouses, and

Availity is the best. I own a billing service and recently added a new doctor

who was using another clearinghouse. I told him if he wanted me to be his

biller, he would have to change from his current clearinghouse to Availity.

With easy-to-read reports and great technical support, Availity is my

clearinghouse of choice.

Twyla Huffman, OwnerSan Angelo Medical Claims Service | San Angelo, TX

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www.availity.com 7

Enhancement and update news from Availity

Availity message center retired Availity has retired the Message

Center and removed its tab from

the Availity menu. The retirement

of this feature provides Availity the

opportunity to offer an enhanced site

design for a quick and easy Availity

portal experience.

To view retired or updated help

topics, please review the "What’s

New and Changed" Availity help topic.

Updates: Quick hitsHere’s a summary of what else is new

from Availity:

• Registrationservicesandsecure

messaging is now available for

Anthem providers in California,

Colorado and Nevada

• BlueCrossandBlueShieldplan

providers in Florida, Illinois, New

Mexico, Oklahoma and Texas can

now submit Availity® CareProfile®

inquiries to those plans, outside a

member's Blue plan home state

• 5010transactionsforAnthem:

Eligibility and benefits and claim

status inquiry

• Registrationservicesand

secure messaging now available

for Blue Cross and Blue Shield

of Georgia providers

• 5010transactionsforBlueCross

and Blue Shield of Georgia:

Eligibility and benefits and claim

status inquiry

• Availity® CareRead® is now

available to Anthem Blue Cross

and Blue Shield providers in

Indiana

• Healthplansaddmore5010

Web transactions:

•Aetna

• AnthemBlueCrossin

California

• AnthemBlueCrossand

Anthem Blue Shield plans in

Colorado, Indiana, Kentucky,

Missouri, Nevada, Ohio,

Virginia, and Wisconsin

• BlueCrossandBlueShieldof

Georgia

•MedicalMutualofOhio

•UniversalHealthCare

• BlueCrossandBlueShieldof

Kansas City

•FloridaHealthPlans

•Humana

•KaiserFoundationOhio

•PreferredCarePartners

•USFamilyHealthPlan

OCTOBER

For complete updates:

NOvEMBER

what's new

Get up-to-the-minute info on 5010 transactions

Find out which payers support

what transactions in 5010 format

by visiting availity.com/5010.

Search by health plan or by partner.

8 Availity inFocus | Dec/Jan 2011-12

A "Real" Gift for Your Companycontinued from page 1

but after implementing RealMed

as their RCM solution, realized

such significant efficiencies that

the practice redeployed its staff

to follow up on unpaid claims

three times: at 30, 60 and 90

days. Automated revenue cycle

management, coupled with best

practices in claim follow-up, allowed

the practice to significantly reduce

its timely filing denial rate, and

greatly reduce time to payment. The

practice saw a 75-percent reduction

in days in accounts receivable, from

28 days to less than seven days.

It was one of many benefits the

anesthesia practice realized—

benefits that translated to saved

time, faster payment collection, and

a better way of doing business—

which benefit everyone. If you

aren’t automating your revenue

cycle, your administrative staff, and

even some clinical staff, may be

spending more time on process

and less time than they’d like on

patients. So give everyone a “Real”

gift with RealMed.

Your FastestPath to Payment

© 2012 RealMed Corporation. All rights reserved.

www.realmed.com

Health care providers turn to RealMed, a complete revenue cycle management solution, when they want real results:

•Fastercashflow and fewer days in accounts receivable.•Automatedeligibilitychecking during claim submission.•Improvedoperationalefficiency including fewer claim errors and fewer denials.•Betterunderstandingofworkflowpatterns, to help you maximize revenue.

www.availity.com 9

5010 Update Centercontinued from page 3

If Availity can’t know with 100%

certainty how to populate the 5010

required fields, (e.g., a missing NPI

is something that can’t be populated

by Availity), the transaction gets

rejected by Availity because the

receiving payer requires 5010

compliant transactions only.

If your file can be made compliant by

our conversion tool, it gets sent ahead

to the payer. But, since each payer

has the ability to customize its edits

for processing, your valid 5010 file

sent in by Availity may still encounter

a rejection by the payer, based on the

payer’s own criteria. Payers may relax

or tighten their custom edits as more

and more of their network providers

begin submitting in the new format.

Depending on the type of error, your

error messages are provided on

either the IBR or the EBR, to help

you correct your submission.

Availity offers fast, easy training

on 5010 transactions

Interested to learn more about

submitting Availity portal

transactions in the new 5010 format?

Availity offers several live and on-

demand training options to help you

become familiar with changes. For

more information click Free Training

in the Availity portal.

events

Jan. 4 greenway Regional user group Las vegas, nv

Jan. 17 greenway Regional user group chicago, iL

Jan. 18 iht2 health summit scottsdale, aZ

Jan. 18 wisconsin hfma 2012 mega conference wisconsin Dells, wi

Jan. 20american academy of orthopaedic surgeons and Karen Zupko & associates Present coding and Reimbursement workshops

Dallas, tX

Feb. 8 san antonio mgma annual education conference san antonio, tX

Feb. 20 himss 12 annual conference & exhibition Las vegas, nv

Feb. 21 georgia hfma summer institute greensboro, ga

Feb. 23 indiana hfma winter institute carmel, in

Stop by our booth and say "hello" at one of these upcoming events.

10 Availity inFocus | Dec/Jan 2011-12

tRaining

Optimizing Your Clinical Workflow with Technology

Explore ways to improve your day-to-day operations by using technology, and learn about qualifying for ARRA/HITECH meaningful use incentives—all without being a computer jockey. Industry expert Rosemarie Nelson will share how high-performing groups integrate patient portals, EMRs and registries, e-prescribing, automated reminders and devices into and around the patient encounter.

Understanding and Implementing ICD-10 in Physician Practices

ICD-10 expert Robert Tennant will teach you the basic parameters of ICD-10-CM. He’ll discuss how the associated coding changes will affect your organization—and how you and your team can stay ahead of the curve.

Do you want to gain a competitive

edge in your field, but need flexible

learning options? Availity’s Health

Care Business Expert Series delivers

continuing education via national experts

in health care information technology.

Unlike your portal training webinars—

which continue to be offered at no

cost to you—the Health Care Business

Expert Series is a fee-based service

that will equip you with knowledge

needed to broaden your skills, train for

expanding job responsibilities, fulfill

continuing education requirements,

or simply enhance value to your

employers. Sign up for your free

Availity Learning Center account,

then log in to purchase one or more

webinars for $129 per session.

Learn from top industry experts and

make your practice more efficient,

without ever leaving your office. You’ll

be CEU application-ready*, and will

receive a certificate of completion

after the session.

Please note that the fee for Availity

Learning Center courses applies only

to our continuing education courses.

Training on how to use the Availity

portal is always available to you at

no cost.

Register now!

*AAPC members receive 1 CEU for each webinar.This program has the prior approval of AAPC for 1 continuing education hour. Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

Get more from Anthem BCBS on Availity

Want a faster, more efficient way to access Anthem Blue Cross and Blue Shield value-added services, like secure messaging, specialty pharmacy and imaging precertification? You can avoid two logins and two sites by registering for these services on Availity. Just follow these simple steps:

1. Log in to Availity and click My Account, Anthem Services Registration. If prompted, select your organization.

2. In the display field, click Non-Registered Users. 3. Enter the user Anthem Blue Cross and Blue

Shield User ID (also known as the EAM ID) in the field provided and click Register.

Training on using these Anthem services is available through the Availity Learning Center. Just click Free Training at the top of any page in the Availity portal to find out more information on upcoming webinar schedules.

#1

Introducing the Availity Learning Center

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www.availity.com 11

Across2. More people are traveling outside of

theUSforthistypeofholiday4. The kind made of sugar, not wood 5. Forpancakesoracough8. ThisDaisyBBgunmakesafamous

appearancein“AChristmasStory”10. An empty sock11. A popular medical myth claims this

happens at a higher rate on Christmas12. Thought to be the source of a large

amount of body heat lost in the cold14. You are likely to make, and fail to keep,

one of these 15. This Celtic holiday signifies the

reversal of the longer nights and shorter days

17. January’s birthstone19. Known for nutty health benefits22. Roast on an open fire23. The type of tree you decorate24. A winter medicine cabinet is likely to

be stocked with these

Down1. ASeinfeld-bornholiday“fortherest

of us” 3. You’ll head to the gym in January for it6. Why turkey causes sleepiness7. Good for a kiss, poisonous if

swallowed9. Popularholidayplantinhomes,

churches and offices13. HaveaBowlonNewYear’sDay16. Don’tforgettoleavetheseforthebig

man in the red suit18. This winter festival was initially

celebrated by Germanic people20. Candles, holiday lights and Christmas

trees cause several hundred of these each year

21. You may do this type of eating during the holidays

22. Thousands of injuries occur each year as a result of these shopping companions

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Availity and RealMed wish you a happy, healthy holiday season. Watch for another issue of Availity inFocus in the New Year!

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