J12 MAC Transition
(* = off-site link)

Transition Alert - Segment I
Maryland/Delaware/District of Columbia Metropolitan Area (Part B)

As you probably know, Congress is considering legislation that could possibly change the current negative (-10.6%) update that applies to service dates July 1, 2008 and forward.  All contractors have been instructed to “hold” claims subject to the Medicare Physician Fee Schedule (MPFS) for July dates of service that are received during the first ten (10) business days of the month.  Congress returned to session yesterday and immediately took this issue up. Unfortunately, we do not know when or how this matter will be resolved. 

Since the timing of this development coincides with the transition of the TrailBlazer Part B workloads in Maryland, Delaware, and the District of Columbia Metropolitan Area, we felt it was appropriate to supplement the information that has been released to date. It is crucial that our customers understand that the MPFS related actions are in no way connected to the J12 A/B MAC Transition. They are independent events that happen to overlap. The following information is offered to provide additional insight and understanding as to how these separate events will impact the processing schedule and subsequently affect your operations.  

Relative to MPFS processing, the following points apply:

• CMS has issued an instruction for all Fee-for-Service contractors to “hold” claims containing charges for July dates of service if there are services subject to the MPFS.  Certain services such as laboratory and ambulance services are not subject to the MPFS and the “hold” instruction.  However, if there is a combination of MPFS and non-MPFS services on the claim, the entire claim is placed on “hold”.
• Claims submitted and held by TrailBlazer at the time of cutover will be transferred to us automatically – no additional action is needed by you.
• Claims that are placed in a “hold” status have been entered into the claim processing system either as a result of  EDI front – end processing or by manual entry of paper claims.  The claims are correctly date stamped and readied for batch processing.   The claims will be released from the “hold” location per CMS direction. 
• The current instruction directs contractors to begin releasing held claims on the 11th business day in July on a first in first out basis. This activity would start on July 16th.  For example, claims received on July 1st with July dates of service will be released on July 16th.  On July 17th, claims received on July 2nd with July dates of service will be released from the hold location. This process will be repeated for each production cycle until all held claims are released. 
• Contractors will maintain a rolling 10 day hold and use the release technique described above until further notice from CMS.
• For claims released from the “hold”, the negative 10.6% update will apply until Congress enacts legislation that changes the percentage and until which time CMS makes the new fee schedule available to contractors. 
• If Congress changes the fee schedule retroactively to July 1, 2008, we will automatically adjust the affected claims – you do not need to request this adjustment.
• Relative to MPFS “held claim” processing, given the normal processing flows, the first claims released from the “hold” will finalize and be paid on or around July 23rd.   

The transition or “cutover” from TrailBlazer to Highmark Medicare Services begins July 11th and continues through July 14th.  During this period, Highmark Medicare Services will not be open for customer support except for EDI related matters on July 14th. 

Key or primary claim processing events associated with the Transition are described below in date order.

July 11 – The last daily TrailBlazer production cycle is run. This cycle will include claims that would have reached the 14 or 29 day payment floors on or before July 15th.  This represents a partial sweep of the payment floor and will create a larger than usual payment for many providers.   Checks and EFT will be dated July 15th.   Please note that none of the “held” claims will be included in the payment sweep since all fail the 14 day threshold.  

July 14 – 16 – Highmark Medicare Services runs daily production batch cycles. On the 16th,  claims will begin to be released from the MPFS “hold” as described earlier.   Payments generated as a result of these three production cycles will be held at CMS (HIGLAS) in order to synch up with their financial processing schedule. No checks or EFT will be generated during this time.  Please note that the initial payments following the cutover may be smaller than usual due to the partial payment floor sweep conducted by TrailBlazer.

July 17 – The first HMS payments (checks and EFT) will be produced, subject to validation on the 18th.   The payments will include finalized claims from cycles run on July 14, 15, 16, and 17 that meet the payment floor thresholds for paper claims and EMC.  Checks and EFT produced from the July 17th  production cycle will carry a July 21, 2008 date.   This means you should see a deposit via EFT in your bank account on this date or expect to receive a check in the mail on or shortly after this date.  Normal daily production cycles (including payments) begin.

Please check our website daily for updates at: http://www.highmarkmedicareservices.com.