With the implementation of Accredited Standards Committee (ASC) X12 Version 5010, the Medicare Administrative Contractors (MACs) have received a large increase in calls from billers regarding the 496 edit, more commonly referred to as "the linkage problem." In some cases, the problem may be the result of a provider not being properly linked to a clearinghouse/vendor submitter in Medicare's system; however, the problem may also be the result of billing errors. The tips that follow will assist you in determining the reason for receipt of a 496 edit and help you understand the resolution of the edit.
Since the 4010 versus 5010 electronic claim formats are not the same, you cannot assume a successful provider and clearinghouse/vendor submitter linkage in 4010 means you should be successfully linked in 5010. Some linkages were initially made nearly a decade ago. We have found that several large clearinghouses that have been repeatedly bought, sold, and combined are now using new submitter numbers. Prior to the implementation of the Common Edits and Enhancement Module (CEM) software, Medicare contractors maintained their own electronic data interchange (EDI) edits. Now that the 5010 format has a definitive CEM edit to ensure that all linkages are valid, invalid submitter IDs are being stopped for bad linkage. In addition to the provider and clearinghouse/vendor linkage issue, the 496 edit can also occur because of the following National Provider Identifier (NPI) billing issues: * Using a Rendering Provider's NPI instead of the Billing Provider NPI (Rendering Provider is not associated with the clearinghouse/vendor submitter) * Billing Part B services for a provider associated with a Group under his/her Individual NPI when it should be billed under the Group NPI Resolution of the 496 edit requires evaluation of the Health Care Claims Acknowledgement message (277CA) and all edits incurred in addition to it. While generally a 496 edit may indicate a simple linkage issue, additional edits might focus on the submission of an inappropriate or incorrect NPI as a result of improper billing. The 277CA, if delivered back to the provider from the clearinghouse/vendor, will have the following message components in the Status Segment (STC) related to a 496 edit: * First part: Claim Status Category Code = "A8" - Acknowledgement / Rejected for relational field error * Second part: Claim Status Code = "496" - Submitter not approved for electronic claim submissions on behalf of this entity * Third part: Entity Identifier Code = "85" - Billing Provider This message, "A8:496:85," utilizes the Washington Publishing Company (WPC)-maintained National Code values and relays that the claim was rejected for a relationship error between the submitter and the Billing Providers NPI. You will receive this same set of codes for a linkage problem and an improper billing problem (use of rendering versus billing provider NPI, for example, as described above). Clearinghouse/Vendor evaluation of all edits received should be completed before asking for linkage problem resolution from your MAC. Contact your MAC EDI support line after researching the nature of your 496 edits for assistance with the provider and clearinghouse/vendor submitter linkage and the collection of the CMS-required Provider Authorization to bill for each customer. The MAC EDI support lines are available at http://www.CMS.gov/ElectronicBillingEDITrans/03_EDISupport.asp<http://www.cms.gov/ElectronicBillingEDITrans/03_EDISupport.asp>. ________________________________ It's Not too Late to Give and Get the Flu Vaccine. Take advantage of each office visit and protect your patients against the seasonal flu. Medicare will continue to pay for the seasonal flu vaccine and its administration for all Medicare beneficiaries through the entire flu season. The Centers for Disease Control and Prevention (CDC) also recommends that patients, healthcare workers and caregivers be vaccinated against the seasonal flu. Protect your patients. Protect your family. Protect yourself. Get the Flu Vaccine-Not the Flu. Remember - The flu vaccine plus its administration are covered Part B benefits. CMS has posted the 2011-2012 seasonal flu vaccine payment limits at http://www.CMS.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp. Note that the flu vaccine is NOT a Part D-covered drug. For more information on coverage and billing of the flu vaccine and its administration, as well as related educational provider resources, visit http://www.CMS.gov/MLNProducts/35_PreventiveServices.asp and http://www.cms.gov/immunizations. ________________________________ Note: If you have problems accessing any hyperlink in this message, please copy and paste the URL into your Internet browser. If you know someone who would like to subscribe to a Medicare Fee-For-Service (FFS) provider listserv, go to (http://www.cms.gov/prospmedicarefeesvcpmtgen/downloads/Provider_Listservs.pdf). If you would like to unsubscribe from a specific provider listserv, please go to (https://list.nih.gov/cgi-bin/wa.exe?INDEX) to unsubscribe or to leave the appropriate listserv. Please DO NOT respond to this email. This email is a service of CMS and routed through an electronic mail server to communicate Medicare policy and operational changes and/or updates. Responses to this email are not routed to CMS personnel. Inquiries may be sent by going to (http://www.cms.gov/ContactCMS). Thank you.
