HIPAA: HIPAA Transactions and Code Sets Medi-Cal Implementation Plan
Medi-Cal is continuing its efforts to comply with the federally mandated Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets Final Rule. Implementation is taking place in a series of phases, some of which will extend beyond the October 16, 2003 compliance date. Therefore, it is critical for providers to review monthly Medi-Cal Updates over the coming months for detailed HIPAA billing instructions and training information.Click on one of the following links to go directly to that section of this article:
- Electronic Data Interchange (EDI) and Paper Impact
- Health Care Claims (ASC X12N 837)
- Medicare/Medi-Cal Crossovers
- Administrative Code Sets
- Service/Procedure Code Sets
- Pharmacy Compound Drug Claim Submission
- Real-Time Pharmacy Claim Submission
- Remittance Advice (Health Care Claim Payment/Advice) for all Claim Types (ASC X12N 835)
- Testing
- Technical Specifications/Companion Guides
- Frequently Asked Questions
Electronic Data Interchange (EDI) and Paper Impact
Medi-Cal anticipates significant changes for electronic and paper billing submission requirements in order to comply with HIPAA standards. These changes include the code set values identified below, in addition to other billing requirements. Provider training sessions focused on HIPAA and these billing practice changes are scheduled for summer 2003. These changes will continue to be communicated in Medi-Cal Updates and on this Web site. Please check this site and provider bulletins regularly for the latest HIPAA information and upcoming training locations.
Medi-Cal’s phased implementation plan requires that providers continue to follow existing billing instructions until otherwise notified in future Medi-Cal Updates. Medi-Cal has scheduled the first implementation phase effective for dates of service on and after September 22, 2003. The following information provides more details about this phase of HIPAA implementation.
topHealth Care Claims (ASC X12N 837)
Medi-Cal will accept the ASC X12N 837 standard transaction (including Addenda) formats for Professional (004010X098A1) and Institutional (004010X096A1) claims beginning September 22, 2003. The corresponding ASC X12N 837 Companion Guides are being revised to provide clarity and address user inquiries. These guides are available on the Medi-Cal Web site by clicking “HIPAA Update” and then “Draft HIPAA ASC X12N and NCPDP Compound Specifications.” Medi-Cal will extend a phase-out period beyond October 2003 for submission of non-standard and proprietary electronic claim formats. During this phase-out, some field values of the non-standard and proprietary electronic claim formats will be modified. Revised non-standard and proprietary Computer Media Claims (CMC) technical specifications identifying these changes will be made available in a future Medi-Cal Update and on this Web site.
topMedicare/Medi-Cal Crossovers
Processing of Medicare/Medi-Cal crossover claims (electronically transmitted from Medicare intermediaries and carriers) will continue as it does currently, with the exception of the transaction standard upgrade. Medi-Cal is engaged in testing activities with Medicare intermediaries and carriers to receive and process ASC X12N 837 Institutional and Professional crossover claims. Medicare/Medi-Cal crossover claims processing functionality is not changing, including Part A and B pricing. Medicare Part A adjustments/replacements and Part B services billing to the Part A intermediary are not currently processed electronically and must be provider-generated. The requirement to bill provider-generated crossover claims on paper remains unchanged, although some code set values and form locations (FL) will change (as listed in the correlation tables referenced below). All other Medicare/Medi-Cal crossover claims billing instructions will remain in effect.
topAdministrative Code Sets
HIPAA mandates the standardization of internal (administrative) code sets, such as condition codes, Place of Service codes, delay reason codes, patient status codes, etc. The conversion of interim (formerly referred to as local) codes to national (administrative) codes will be implemented using the same update process as the current annual HCPCS update, in which code application is effective based on the date of service. The code values are effective for dates of service on and after September 22, 2003 for all billing media and all Medi-Cal (fee-for-service), waiver and public health program areas. There will not be a transition (grace) period. Medi-Cal’s administrative code correlation tables are condition codes, delay reason codes, patient status codes, Place of Service codes and value codes. The tables apply to both paper and electronic claim submission for the following claim types:
- Inpatient
- Outpatient
- Long Term Care
- Medical
- Vision
The tables have been developed and separated by claim type and billing media (paper, current proprietary and non-standard formats and HIPAA standards). The correlation tables also contain key billing requirement changes, form location changes, specification changes and tips for use. Providers will need to read through these documents carefully to determine the appropriate claim type and correlation tables for their billing practices. These values are provided to begin to prepare for business operation modifications, including software, practice management systems and vendor or clearinghouse use. These values are not to be used for billing purposes for dates of service prior to September 22, 2003. Additional policy, billing instructions and provider manual replacement pages will be included in future Medi-Cal Updates.
topService/Procedure Code Sets
HIPAA mandates the use of standard service/procedure code sets for transactions. These standard code sets consist of revenue codes, national drug codes, ICD-9-CM codes, CPT-4 codes and HCPCS codes. The conversion of interim (local) codes to national service/procedure codes will be implemented in phases and effective based on date of service. In this first phase, Medi-Cal is converting Orthotics and Prosthetics, Chiropractic, and Immunization and Vaccine code sets. These specific code values are effective for dates of service on and after September 22, 2003 for all billing media and all Medi-Cal (fee-for-service) and public health program areas. There will not be a transition (grace) period. These service code pricing values also apply to Medicare/Medi-Cal crossover claims (from intermediaries, carriers or providers). All other interim code values remain in effect and should be used for billing purposes until providers are instructed otherwise. These changes will be announced in future Medi-Cal Updates.
Medi-Cal’s code correlation table for Inpatient revenue codes is being provided to allow for business operation modifications, including software, practice management systems and vendor or clearinghouse use. These values are not to be used for billing purposes for dates of service prior to September 22, 2003. Provider manual replacement pages will be included in a future Medi-Cal Update.
Note:The correlation table for Inpatient ICD-9-CM Volume 3 surgical codes (formerly CPT-4 codes) is not finalized yet. It will be published at a later date. Correlation tables will not be developed for Chiropractic, Orthotics and Prosthetics, and Immunizations and Vaccines code sets and associated modifiers because one-to-one correlations of interim (local) to national codes are not applicable for these groups. Click here for information regarding changes to these code sets.top
Pharmacy Compound Drug Claim Submission
Medi-Cal will accept pharmacy compound drug claims in the NCPDP Version 5.1 (Telecommunication) standard beginning September 22, 2003. Draft Technical Specifications were posted to the Medi-Cal Web site in April 2003. To correspond with the data element changes mandated by the NCPDP electronic standard for compound drugs, a new paper Medi-Cal Pharmacy Compound Drug Claim Form (30-4) will be implemented, and modifications will be made to the Real-Time Internet Pharmacy (RTIP) claim submission system to allow for compound drug claim submission. Compound drug claims will not be accepted in the NCPDP 1.1 batch format (CMC). Compound drug claims submitted on the current paper claim form (30-1) will be allowed during a transition (grace) period only.
This is a significant change for providers who dispense compound drugs to Medi-Cal recipients. It includes claims for sterile solutions (IVs, etc.) as well as ointments, capsules and other non-sterile compound preparations.
Because of the specialized nature of this provider community, Medi-Cal is pursuing additional avenues to ensure provider outreach and training. Pharmacy compound drug providers and their vendors are urged to call Medi-Cal at 1-800-541-5555, prompt option “4,” and provide the information requested at the prompts. An education and outreach mailing list will be developed from this information and further contacts and plans communicated.
Additional information regarding compound drug electronic claim submission, the new claim form, associated billing instructions and provider training will be communicated in future Medi-Cal Updates and on this Web site. Please check this site and provider bulletins regularly for the latest information regarding these changes.
topReal-Time Pharmacy Claim Submission
Medi-Cal is currently accepting pharmacy claims in the NCPDP 5.1/1.1 and 3.2 versions. Providers are urged to contact their software vendors and begin to transition to the NCPDP 5.1/1.1 standard. The transition period expires September 30, 2003. Medi-Cal will not accept real-time pharmacy claim transmissions in the NCPDP 3.2 standard beginning October 1, 2003.
topRemittance Advice (Health Care Claim Payment/Advice) for all Claim Types (ASC X12N 835)
Medi-Cal will generate the ASC X12N 835 004010X091A1 standard transaction (including Addenda) format for claims remittance advice beginning October 1, 2003 for claims adjudicated on or after September 22, 2003. Providers who elect to receive an electronic remittance advice in the ASC X12N 835 standard format will be able to download the remittance advice from the Internet Bulletin Board System (IBBS) beginning October 1, 2003. In addition to the adjustment reason codes required in the standard transaction format, Medi-Cal also will provide situational health care remarks codes. The health care remarks codes provide an additional level of detail not contained in the adjustment reason codes. Medi-Cal has begun correlating health care remarks codes with the Remittance Advice Details (RAD) codes currently used on the paper remittance advice. It is not anticipated that all RAD code correlations to remarks codes will be finalized by October 1, 2003.
The ASC X12N 835 transaction enrollment process begins July 21, 2003. An ASC X12N 835 transaction receiver or receivers will be required to be an authorized Computer Media Claims (CMC) submitter or have a valid Medi-Cal Point of Service (POS) Network/Internet Agreement on file. Authorizing providers will be required to complete and sign the new Electronic Health Care Claim Payment/Advice Receiver Agreement form before they can receive ASC X12N 835 transactions from Medi-Cal or designate a receiver or receivers for 835 transactions. This form has been added to the end of the Remittance Advice Details (RAD): Electronic section of the Medi-Cal Provider Manual and on the forms page of the Provider Relations Organization Web site. Providers will be notified when their enrollment has been completed or if there is a problem with their application.
On the receiver agreement, the authorizing provider may designate up to two receivers (CMC submitter or Internet-enabled) for ASC X12N 835 transactions (the authorizing provider may designate itself as a receiver). If a provider with multiple sites chooses the same receiver, one downloadable zip file will be sent with all of the sites’ warrant information (ASC X12N 835 transactions) included. An ASC X12N 835 transaction will equate to one check. This is consistent with Medi-Cal’s current disbursement policy. Medi-Cal does not price Inpatient or Medicare/Medi-Cal crossover claims at the detail line. Therefore, Medi-Cal will not be sending the service (SVC) segment for these claims.
Medi-Cal’s adjustment reason code correlation table will be published and posted to the Medi-Cal Web site at a later date. These values will be provided to allow for business operation modifications, including software, practice management systems and vendor or clearinghouse use.
topTesting
Medi-Cal currently is not prepared to accept or acknowledge test transactions for HIPAA-compliant standards from its trading partners. Future Medi-Cal Updates will outline specific testing requirements and time schedules. Electronic billing activation and media testing for the ASC X12N 837 Professional (004010X098A1) and Institutional (004010X096A1) standard transactions will be required for all CMC submitters. This will require completion of a new Medi-Cal Telecommunications Provider and Biller Application/Agreement form, which constitutes a Trading Partner Agreement. Electronic billing activation and media testing for all CMC providers is scheduled to begin this summer. Providers preparing to submit NCPDP 5.1 compound drug claims will not be required to complete a test transaction if they already are approved for the NCPDP 5.1 standard. Medi-Cal will not require testing of the ASC X12N 835 transaction with authorized receivers.
Medi-Cal will perform beta testing for transaction submission, system processing and end-to-end remittance advice generation with a select group of providers, submitters, vendors and clearinghouses. Beta testing for the ASC X12N 835 and ASC X12N 837 transactions is scheduled for late summer. More testing information will be provided in future Medi-Cal Updates and on this Web site.
topTechnical Specifications/Companion Guides
Newly revised Medi-Cal draft ASC X12N Companion Guides and NCPDP 5.1 compound drug Technical Specifications are available on the ASC X12N and NCPDP Specifications page of the Medi-Cal Web site. Medi-Cal does not expect substantive changes to these draft documents and encourages providers, submitters, vendors and clearinghouses to review them and prepare for internal testing based on these guides. These drafts will be finalized following the testing phase scheduled for late summer. The Companion Guides and Technical Specifications will be published in their final forms by October 2003.
topFrequently Asked Questions
Medi-Cal has developed a HIPAA Frequently Asked Questions section of the Medi-Cal Web site. Providers are encouraged to check the Web site regularly for updates. For more information about HIPAA and Medi-Cal’s implementation plan, call the Provider Support Center (PSC) at 1-800-541-5555 and select prompt option “4.”
topNote:
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