HIPAA: Transactions - 837 Institutional
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Must the submitter ID in the ISA segment match the
submitter ID in the NMI segment?
A:
Yes. Medi-Cal captures the submitter ID from the NMI segment so
the submitter ID must be the same in the ISA and NMI segments.
Q:
Can I send more than one interchange envelope (ISA-IEA)
per transaction?
A:
No. As stated in the implementation guide, only one interchange
envelope (ISA through IEA) is allowed per transaction; otherwise,
multiple Computer Media Claims (CMC) errors occur.
Q:
Can I send more than one functional group (ST-SE) within a
single interchange envelope (ISA-IEA)?
A:
The “TA1” is the Interchange Acknowledgement. It can be used to
acknowledge receipt of a file as well as to indicate errors in the
Interchange (or ISA/IEA file “wrapper”). For Medi-Cal, the TA1 is
only returned when errors exist at the Interchange level.
Q:
Currently, the 277 response returns 12 weeks' worth of
claims history. But didn't the Webcast presentation state it would
return up to three years' worth of claims history?
A:
No. Submitting multiple functional groups within a single
interchange envelope creates duplicate volser numbers and results in
Computer Media Claims (CMC) errors. Submitters should send only one
functional group per interchange envelope (for example, one ST
within the ISA).
Q:
When I access the Medi-Cal Web site to check the status of
my transmission, I receive the message, “Information about the
volser is not available.” What does this mean?
A:
When a provider submits a claim electronically, a “Volser Number”
is assigned by the system to track the claims transmission. Volser
information is generally available 24 hours after the time of
transmission and is available for 30 days from the current date.
This message may mean that the batch was not processed due to
submission errors. Providers who cannot locate the volser detail 24
hours after the transmission should call the CMC Help Desk at
1-800-541-5555, Option 16.
Q:
Are there additional phone numbers available if I am
unable to connect to a test line to upload my test batches?
A:
A 277 Response transaction will be generated for every 276
Inquiry transaction, regardless of whether the claim was found in
the Medi-Cal claims processing system.
Q:
Is it possible to receive a hard copy response to a 276
Inquiry transaction?
A:
Yes. Medi-Cal has added two phone lines for a total of four
available lines:
- (916) 638-8127 (main line that rolls into another line)
- (916) 858-8611
- (916) 858-8612
Q:
The HIPAA Implementation Guide indicates the qualifiers
for Loop 2310A NM109 are 24 (Employer’s Identification Number), 34
(Social Security Number) and XX (HCFA NPI). Can the qualifier code
SL (State License) be used in this element?
A:
If the State License Number is used, the provider must put
either the Employer’s Identification Number (EIN) or Social Security
Number (SSN) in the NM109 element of Loop 2310A and then put the
State License Number in Loop 2310A, REF02, using qualifier “0B” in
REF01.
Q:
Is there a difference between the CMC proprietary format
and the new X12N 837 4010A1 electronic format when billing for
prosthetics, orthotics, vaccines and immunizations with multiple
modifiers?
A:
Yes. The X12N 837 4010A1 electronic format accepts up to four
modifiers for prosthetics, orthotics, vaccines and immunizations.
The CMC proprietary format accepts only one modifier. If you bill
using the CMC proprietary format, continue to do so the same way you
have done in the past.
For more information about billing with modifiers, refer to the July Medi-Cal Update.
To review which modifiers are associated with which claim types, refer to the HIPAA Code Correlations page.
Q:
If I continue to submit claims electronically using the
CMC proprietary format, do I use the one-digit Place of Service code
or the HIPAA-compliant two-digit type of bill code?
A:
Use the one-digit Place of Service code on claims submitted
using the CMC proprietary format. The two-digit type of bill code is
used only on claims submitted in the X12N 837 4010A1
electronic format and on the paper UB-92 Claim Form.
Q:
Are providers required to sign a new CMC Agreement or
Trading Partner Agreement with Medi-Cal for the ASC X12N 837
transaction?
A:
A newly signed
Medi-Cal Telecommunications Provider and Biller
Application/Agreement is required from CMC submitters
prior to testing and implementation of CMC billing. All
submitters must complete this new agreement form to be activated for
the X12N 837 V4010A1 transaction.
Q:
If non-applicable data in loops/fields is sent in, must
those sections be removed or will Medi-Cal simply ignore them?
A:
Medi-Cal will not store or use non-applicable data in a
loop/field. However, Medi-Cal will accept the transaction if the
provider sends it.
Q:
Loop 2300 NTE01 and NTE02 190 Claim Note: Do billing limit
exception codes (Box 11 on the old paper form) go here? What
reference code is necessary?
A:
In Loop 2300, CLM 20, the delay reason code is replacing the
billing limit exception code. The provider must use the national
values as defined in the Implementation Guide. See the June
Medi-Cal Update for correlations for the current billing limit
exception codes to the national delay reason codes.
Q:
Loop 2310A NM109 Attending Physician Primary Identifier:
Even though facilities don't have the Attending Physician Tax
Numbers yet, is this field validated by Medi-Cal?
A:
This field is required on all inpatient claims (including Long
Term Care claims). Therefore, Medi-Cal expects to see this field
populated with the appropriate information.
Q:
Loop 2310A PRV03 Provider Taxonomy Code: Since facilities
don't have this code yet, can a dummy value be used? Is this field
validated by Medi-Cal?
A:
The Provider Taxonomy Code is not a required field and
situational usage is appropriate. Medi-Cal has not defined
situational use of this data and does not expect this segment to be
included in the transaction. If data were sent in this field,
Medi-Cal would expect to see the appropriate value and not a dummy
value.
Q:
Loop 2320 DMG01 POS 305 Date Time Period Format: The
Medi-Cal draft indicates "D6," but the format shown in the draft
(CCYYMMDD) matches "D8" format. Is the indicator or the format
correct?
A:
The correct format is "D8." This was a typographical error on
the original draft Companion Guide and has been corrected.
Q:
Loop 2400 SV201 POS 375 Service Line Revenue Code: The
Medi-Cal draft uses Long Term Care accommodation codes. Should the
value from Box 15 on the old paper form in this field be used rather
than the currently used national revenue codes?
A:
Medi-Cal has not converted its interim LTC accommodation
codes to the national revenue codes and does not expect to complete
this conversion by October 16, 2003. The interim LTC accommodation
code currently placed in Box 15 of the paper form should be included
in SV201 for the ASC X12N 837 4010AI Institutional format.
Q:
There are several sections/fields that are in the ASC X12N
837 4010A1 Institutional HIPAA Implementation Guide (technical
specifications) that are not in the ANSI ASC X12N 837 Institutional
Long Term Care draft Companion Guide (technical specifications) that
are downloadable from this Web site. Are these fields required?
A:
As noted in the HIPAA Implementation Guide, the following
referenced fields are situational and not required. Therefore, since
Medi-Cal does not require this information for Long Term Care claim
processing, they were not included in the Medi-Cal draft Companion
Guide for Long Term Care. Note: Page number references are
from the HIPAA Implementation Guide.
- Loop 2300 DTP Discharge Hour (page 165)
- Loop 2300 AMT Patient Estimated Amount Due (page 180)
- Loop 2330B N3 Other Payer Address (page 412)
- Loop 2330B N4 340A Other Payer City/State/Zip (page 413)
- Loop 2010BC N3 Payer Address (page 129)
- Loop 2010BC N4 Payer City/State/Zip (page 130)
- Loop 2400 DTP 455A Service Line Date (Page 456)
- Loop 2400 DTP 455B Assessment Date (page 458)
Q:
Does Medi-Cal require loop 2310E (Service Facility Name)
to be completed by an institutional provider when including a charge
from an outside laboratory?
A:
Outside laboratory claims are billed to Medi-Cal as an
outpatient claim (claim type 04) and require the use of loop 2310E
(Service Facility Name). The institutional provider should include
the outside laboratory’s name in the NM1 (Individual or
Organizational Name) segment and the laboratory’s Medi-Cal provider
number in the REF (Reference Identification) segment. The
laboratory’s address is not required (N3 and N4 segments). The
outpatient specifications available in Outpatient Services on
the
HIPAA ASC X12N Technical Specifications Web page accurately
reflect this requirement.
Q:
In the Draft ANSI ASC X12N 837 – Institutional Common
Header Data Specifications, the first REF segment (Transaction Set
Header), position 015 (Transmission Type), segment ID REF02
(Reference Identification) lists the transmission-type codes. There
is a code for Test (004010X096DA1) and a code for Production
(004010X096FA1). In the October 2002 HIPAA Implementation Guide
Addenda, the code for Test matches, but the code for Production is
004010X096A1 (without the “F”). Does Medi-Cal have a unique
transmission-type code for Production mode?
A:
When the Medi-Cal Companion Guides were originally developed,
the “F” was used to designate format only, as opposed to data
content. The “F” reference is no longer applicable and this
designation is no longer needed. The Companion Guides will be
updated to reflect this clarification.
Q:
Currently, a Medi-Cal submitter number and the Julian date
are used as the submitter identifier when submitting claims
electronically. Should these values be used on an X12N 837 version
4010A1 Institutional claim to populate loop 1000A (Submitter Loop),
position 020 (Submitter Name), element NM109 (Identification Code)?
A:
No. Only the provider's submitter number should go in loop
1000A (Submitter Name), element NM109 (Identification Code). The
Julian date is not part of the field value.
Q:
Loop 1000B (Receiver Name), position 020, element NM103
(Last Name or Organization Name) of an X12N 837 version 4010A1
Institutional claim requires the Receiver Name. What value does
Medi-Cal want in this field and what value does Medi-Cal require in
element NM109 (Receiver Primary Identifier)?
A:
Medi-Cal wants to see “Medi-Cal” as the Receiver Name in loop
1000B, element NM103 and requires "610442" in loop 1000B, element
NM109.
Q:
In loop 2010AA (Billing Provider Name), position 35,
segment ID REF of an X12N 837 version 4010A1 Institutional claim, it
appears from the Medi-Cal Companion Guide that two choices are
possible for Billing Provider Secondary Identification: the
Employer's Identification Number (EIN)/Social Security Number (SSN)
or the Medi-Cal Provider Number. Is this choice based on what a
provider uses as their Primary Billing Provider Identifier in loop
2010AA, position 015, data element NM109? Should the EIN be used as
the Primary Billing Provider Identifier in NM109? Even though the
REF segment is situational, should field REF02 be populated with a
Medi-Cal Provider Number?
A:
Yes. The billing provider should enter their EIN or SSN in loop
2010AA, data element NM109 (Identification Code). The provider’s
Medi-Cal ID should go in loop 2010AA, data element REF02.
Q:
Currently, Medi-Cal recipients do not have Group Numbers.
The HIPAA Implementation Guide states that if the Group Number is
blank in loop 2000B (Subscriber Loop), position 005, element SBR03
of an X12N 837 version 4010A1 Institutional claim, there must be a
Group Name entered in element SBR04. What values should be placed in
these fields for Medi-Cal recipients?
A:
The HIPAA Implementation Guide states that element SBR04 (Group
Name) is required if there is a group number. There is not a group
number for Medi-Cal recipients. Therefore, there is not a group
name.
Note:
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