This is the latest update and reminder in a series of articles regarding Medi-Cal’s 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 their Medi-Cal Updates over the coming months for detailed HIPAA billing instructions and training information.

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• Code Correlations
• Admit Type on Outpatient Claims
• Type of Bill
• Billing Limit Exception on Paper Claims (Vision, LTC, HCFA 1500, UB-92)
• Place of Service for Subacute Facilities
• Billing Vision Qualifier Codes on the ASC X12N 837 Professional Version 4010A1
• Obstetrical Billing on Inpatient Claims
• Service/Procedure Code Sets
• Remittance Advice (Health Care Claim Payment/Advice) for all Claim Types (ASC X12N 835) and All Media (Paper and Electronic)
• Enrollment Process
• Testing and Activation Procedures
• Technical Specifications/Companion Guides
• Frequently Asked Questions

Code Correlations Medi-Cal developed code set correlation tables so providers can prepare for business and billing operation changes, software and practice management system modifications and vendor or clearinghouse use. Correlation tables are separated by claim type and billing media (paper, current proprietary and non-standard formats, and HIPAA standard formats). The tables reflect the correlation between the current code and the national code. The condition, delay reason, inpatient patient status, inpatient revenue and Place of Service code correlation tables were printed in the Part 1 section of the June 2003 Medi-Cal Update. The ICD-9-CM Volume 3 surgical code correlation table was printed in the Part 1 section of the July 2003 Medi-Cal Update. All of these tables can also be found on this Web site on the HIPAA Code Correlations page.

Note: Updates to the Outpatient Place of Service correlation table are as follows:

• LEA providers who currently bill with a Place of Service code “7” for outpatient services should bill with the national Place of Service code “89.”
• Rehabilitation clinics that bill outpatient occupational therapy, speech therapy, acupuncture, audiology and physical therapy services with a local Place of Service code “7” should bill the national Place of Service code “74.”

Admit Type on Outpatient Claims

For dates of service on or after September 22, 2003, providers must bill the Admit Type (FL 19 on paper claim and CL101 on the 837 V4010A1 Institutional) of “1” (Emergency) when billing for outpatient emergency services.

Type of Bill
For dates of service on or after September 22, 2003, Inpatient and Outpatient providers billing on the UB-92 Claim Form must enter the appropriate code in the Type of Bill field (Box 4) on UB-92 paper claims. Outpatient providers should no longer include the Place of Service in FL 50. For providers who submit using the ASC X12N 837, Version 4010A1 Institutional format, the Type of Bill is required. The Type of Bill values can be obtained from the National Uniform Billing Committee (NUBC) UB-92 Billing Manual.

Billing Limit Exception on Paper Claims (Vision, LTC, HCFA 1500, UB-92)
The HIPAA-mandated national delay reason code that replaces Medi-Cal’s billing limit exception code is two characters. Effective for dates of service on or after September 22, 2003, Medi-Cal will only accept the national delay reason codes as outlined in the ASC X12N 837 Version 4010A1 implementation guide. This data must be submitted in the following fields on the paper claims:

• Medical Services and Allied Health (HCFA 1500): Box 24J.
• Inpatient and Outpatient Services (UB-92): FL 31. The billing limit exception code was previously submitted in condition code fields 24-30.
• Long Term Care (25-1): Boxes 11, 30, 49, 68, 87 and 106. The two-character delay reason code may not fit in these boxes since the original box on the claim form was created as a single-character field. In cases where a two-digit delay reason code is needed, the first digit must be entered to the left of the one-digit box.
• Vision Care (45-1): Box 9. The two-character delay reason code may not fit in this field since the original box on this claim form was created as a single-character field. In cases where a two-digit delay reason code is needed, the data overflow may occur to the left or right of the one-digit box.

Place of Service for Subacute Facilities
On Medical Services claims, Medi-Cal currently uses local code values “91” (Subacute Care) and “96” (Pediatric Subacute Care) to differentiate between recipients who reside in an adult or pediatric subacute facility. For dates of service on or after September 22, 2003, providers must bill national Place of Service code 99 in Box 24B in conjunction with modifier -HA to indicate pediatric and -HB to indicate adult. These modifiers must be submitted with every procedure code on the claim. When Medi-Cal policy requires additional modifiers be billed with a specific procedure, then the -HA or -HB modifier must be entered in the last used modifier field.

On outpatient claims, Medi-Cal currently uses local code values “F” (Adult Subacute Care) and “M” (Pediatric Subacute Care) to differentiate between recipients who reside in an adult or pediatric subacute facility. For dates of service on or after September 22, 2003, providers must bill national Facility Type “27” in FL 4 in conjunction with modifier -HA to indicate pediatric and -HB to indicate adult. These modifiers must be submitted with every procedure code on the claim. When Medi-Cal policy requires additional modifiers be billed with a specific procedure, then the -HA or -HB modifier must be entered in the last used modifier field.

Billing Vision Qualifier Codes on the ASC X12N 837 Professional Version 4010A1
Beginning September 22, 2003, Vision Care providers may begin billing their claims on the ASC X12N 837 Professional Version 4010A1 format. The vision qualifier codes must be billed in the first modifier field of the SV101 segment (SV101-3). The current draft of the Vision Care Companion Guide erroneously states that the vision qualifier code may be placed in any available modifier fields. This will be updated in a future draft.

Obstetrical Billing on Inpatient Claims
Providers currently bill local accommodation codes 085 (nursery acute without associated delivery) and 095 (nursery acute with associated delivery). For claims with a “From Statement Covers Period” date on or after September 22, 2003, providers must bill national revenue code 172 (nursery, newborn, Level II) instead of code 085 or 095. To distinguish a claim with a delivery from one without a delivery, providers must bill the appropriate obstetrical related ICD-9-CM Volume 3 procedure code when there is a delivery. For appropriate codes, see the ICD-9-CM Volume 3 surgical code correlation table.

Service/Procedure Code Sets
Medi-Cal’s service/procedure code correlation table (for inpatient revenue codes) and policy and billing code changes (for Chiropractic, Orthotics and Prosthetics, and Immunizations and Vaccines) were included in the June 2003 Medi-Cal Update and are also posted on this Web site. 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. These specific code values are effective for dates of service on or after September 22, 2003 for all billing media and all Medi-Cal (fee-for-service) and public health program areas. There is no transition (grace) period.

The conversion of the remaining interim (local) codes to national service/procedure codes will be implemented in phases and effective based on date of service. All other interim code values remain in effect and will be used for billing purposes until providers are instructed otherwise. These changes will be announced in a future Medi-Cal Update.

Remittance Advice (Health Care Claim Payment/Advice) for all Claim Types (ASC X12N 835) and All Media (Paper and Electronic)
As previously published, Medi-Cal will begin generating the ASC X12N 835 transaction 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 can download the remittance advice from the Internet Bulletin Board System (IBBS) beginning October 1, 2003.

The ASC X12N 835 transaction enrollment process began July 21, 2003. An ASC X12N 835 transaction receiver must be an authorized Computer Media Claims (CMC) submitter or have a valid Medi-Cal Point of Service (POS) Network/Internet Agreement on file. Authorized providers are required to complete and sign the new Electronic Health Care Claim Payment/Advice Receiver Agreement form (included in the June Medi-Cal Update) before they can receive ASC X12N 835 transactions from Medi-Cal or designate a receiver for 835 transactions. This form was 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. Completed agreement forms must be sent to the address provided on the form in order to be processed. Providers will be notified when their enrollment is completed or if there is a problem with their application.

Enrollment Process
The following steps detail Medi-Cal’s enrollment process:

For New Enrollment:
Download the Electronic Health Care Claim Payment/Advice Receiver Agreement form from this Web site or make a copy of the form from the provider manual. Be sure the form and revision numbers (DHS 6246, 5/03) are present and legible.

1. Complete all boxes on the form.
2. Sign and date the form on page 6.
3. Mail to the address provided on page 6.

Note: The Electronic Health Care Claim Payment/Advice Receiver Agreement form also may be used to update and cancel a previous agreement.

For Additions:
If the update regards an addition of a receiver:

1. Check the “Change” box on page 1 and the second box on page 6.
2. Complete all boxes on page 1.
3. Indicate “Add” in the receiver information section on page 2, next to the words “Receiver #1.”
4. Complete the required information for the added receiver.
5. Sign and date the form on page 6.
6. Mail to the address provided on page 6.

For Deletions:
If the update regards a deletion of a receiver:

1. Check the “Change” box on page 1 and the second box on page 6.
2. Complete all boxes on page 1.
3. Indicate “Delete” in the receiver information section on page 2, next to the words “Receiver #1.”
4. Complete the required information for the deleted receiver.
5. Sign and date the form on page 6.
6. Mail to the address provided on page 6.

For Both an Update and Deletion:
If the update regards both an addition and deletion of a receiver:

1. Check the “Change” box on page 1 and the second box on page 6.
2. Complete all boxes on page 1.
3. Indicate “Add” in the receiver information section on page 2, next to the words “Receiver #1.”
4. Complete the requested information for the receiver to be added.
5. Indicate “Delete” next to the words “Receiver #2.”
6. Complete the requested information for the receiver to be deleted.
7. Sign and date the form on page 6.
8. Mail to the address provided on page 6.

For Cancellations (No Longer a Receiver of 835 Transactions):

1. Check the “Cancel” box on page 1 and the third box on page 6.
2. Complete all boxes on page 1.
3. Sign and date the form on page 6.
4. Mail to the address provided on page 6.

Providers will receive a confirmation notice within two weeks after submitting the Electronic Health Care Claim Payment/Advice Receiver Agreement form. The notice will confirm the new enrollment, addition/deletion (update) or cancellation of the receiver.

Effective September 8, 2003, providers who supply a valid e-mail address on the form will receive the notice by e-mail. A hard copy confirmation letter will be mailed to providers if the e-mailed notice returns as “undeliverable” or if a valid e-mail address was not entered on the Electronic Health Care Claim Payment/Advice Receiver Agreement form.

If the agreement form cannot be processed, the receiver form will be returned to the provider with a letter explaining the error(s) made on the form. Provider testing is not required prior to receiving ASC X12 835 transactions on the Medi-Cal Web site. Providers can call the Provider Support Center at 1-800-541-5555 and select prompt option “4” to check the status of their receiver agreement form or (916) 636-1000 for out-of-state providers and software vendors.

Note: When a provider enrolls to receive an 835 transaction, the provider can choose to discontinue receipt of the paper RAD.

Testing and Activation Procedures
Testing and activation for X12N 837 transactions began July 23, 2003. Computer Media Claims (CMC) and paper claims must meet the same edit and audit requirements based on Medi-Cal billing policy. Participation as a CMC submitter is open to all Medi-Cal providers. The acceptable media submission types are dial-up, tape or Internet. For specific information regarding requirements for each media submission type, refer to the Medi-Cal CMC Billing and Technical Manual. The proper formats are the X12N 837 Institutional and Professional Version 4010 A1.

A signed Medi-Cal Telecommunications Provider and Biller Application/Agreement is required from CMC submitters prior to testing and activation of the X12N 837 V4010A1 format. All submitters must sign a new agreement form to be activated for the X12N 837 V4010A1. Billing services submitting electronic claims must complete the biller portion of the form. Providers for whom the billing service submits claims must complete the provider portion of this form. It is not necessary for the active billing service/clearinghouse to submit an application/agreement for each of its existing providers. Application/agreement forms from physicians and physician groups must contain the group provider number and the signature of an authorized physician within the group. Individual providers who bill with the group number do not need to submit separate provider application/agreement forms.

Once enrollment is complete, submitters must send a test file to the CMC Unit. Test submissions should contain a cross section of claim type data that can be expected in a production environment and consist of a minimum of 10 claims for each claim type to be billed. A maximum of 100 claims is allowed for testing. Files exceeding that limit are subject to rejection. Submitters should use data from previously adjudicated claims, as claims contained on the test file will not be processed for payment. Any format problems discovered during the testing period must be corrected and a new test file submitted for review prior to the final approval. Questions should be directed to the CMC Help Desk at (916) 636-1100.

Submitters may test for multiple media using the same submitter number. Once approval is received for each medium, submitters may use the same submitter number for all media. Billing services already tested and approved are not required to retest for each provider as long as they use the same approved CMC submitter number, format, medium and claim types. A new application/agreement form is still required for all new providers.

X12N 837 health care claim transactions may be submitted through the CMC system for providers who bill Long Term Care, Inpatient Services, Outpatient Services, Medical Services, Vision Care and Allied Health claim types. The X12N 837 transaction record format is described in the appropriate companion guide on the HIPAA ASC X12N and NCPDP Technical Specifications page. Data elements included in a submission are either required for X12N 837 standard transactions or Medi-Cal claims processing.

The test telephone number is (916) 638-8127. Submitters using the CMC TelePoint telecommunications system should perform a protocol test before submitting test data. Additional information is available in the telecommunications submission section in the Medi-Cal CMC Billing and Technical Manual.

Submitters are notified of format infractions by one of the following methods:

• Submitters can log in through the Transaction Services page on the Medi-Cal test Web site to view their error reports and files submitted.
• Submitters without Internet access will receive a call from the CMC Help Desk each time an error is encountered. Submitters may call the CMC Help Desk at (916) 636-1100 for help correcting submission errors.

Note: The entire 837 CMC submission will be rejected if the Receiver ID is not “610442” and all claims on a transaction are not processed.

Approximately two weeks after the tests are processed, submitters receive a CMC test approval or denial letter with the test results via regular postal mail. The test results also include a review of field data formatting specifications. This review is not a requirement for CMC submission approval. It is meant to assist in preventing claim denial due to format specification errors.

Test tapes should be labeled according to the instructions in the CMC tape submission section of the Medi-Cal CMC Billing and Technical Manual.

Mail CMC test tapes to:

EDS Corporation
CMC Unit
P.O. Box 15508
Sacramento, CA 95852-1508

Send CMC test tapes delivered by courier to:

EDS Corporation
CMC Unit
3215 Prospect Park Drive
Rancho Cordova, CA 95670-6017

EDS must approve each CMC submitter for electronic claim submission of the new X12N 837 format. For new submitters and providers, EDS will notify the Department of Health Care Services (DHS) upon completion of the testing process. DHS will then place the submitter in “Active” (production) status and will send the provider and/or billing service a letter authorizing CMC submission. The letter will include the name(s) of the providers/billers authorized to submit claims.

Technical Specifications/Companion Guides
The Medi-Cal ASC X12N 837 Institutional and Professional companion guides are available on this Web site's HIPAA ASC X12N and NCPDP Technical Specifications page.

Frequently Asked Questions
Medi-Cal developed a HIPAA Frequently Asked Questions section of this Web site. Providers are encouraged to check it regularly for updates. For more information about HIPAA and Medi-Cal’s implementation plan, call PSC at 1-800-541-5555 and select prompt option “4.”