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HIPAA: Important Notice About 835 Remittance Advice

August 29, 2012

The purpose of this article is to inform providers and submitters of important changes to the 835 Health Care Claim Payment/Remittance Advice (RA) transaction changes as a result of the HIPAA 5010 enhancement. 

4010 to 5010 Conversion
Providers may have more than one submitter sending electronic claims to Medi-Cal. As a result, the providers will receive an 835 RA in the HIPAA 5010 format if any of the submitters submits a claim in the 5010 format, even if the other submitters submit claims in the 4010 format.

Example:

Submitter A submits claims for Provider A in the 5010 format and the 835 RAs are returned in the 5010 format. The following week, Submitter B submits claims for Provider A in the 4010 format (Submitter B has not yet transitioned to 5010). The 835 RAs returned for Provider A’s claims are still returned in the 5010 format.

Points of Interest

  • Claims submitted in the 5010 and NCPDP D.0/1.2 formats will return a 5010 835 RA.
  • Paper only providers/submitters must contact the Computer Media Claims (CMC) Help Desk to switch from a 4010 to a 5010 835 RA.
  • Submitters must contact the CMC Helpdesk at 1-800-541-5555, Option 4 for Technical Help Desk and then Option 2 for CMC Help desk to switch from 4010 to 5010 transactions. When submitters successfully submit any 5010 or NCPDP D.0/1.2 transactions electronically in production, their 835 RA status will automatically change from 4010 to 5010.
    • Providers using a clearinghouse or other submitter to submit their claims will have their 835 RA status automatically changed from 4010 to 5010 upon a successful electronic 5010 submission.
    • If providers sometimes use a receiver, they must ensure that all receivers that they are associated with can receive the 5010 835 RA before they convert to 5010 submissions.
    • Claims submitted in the 5010 format through Coordination of Benefits Contractor (COBC), Internet Professional Claim Submission (IPCS) and Real-Time Internet Pharmacy (RTIP) will not automatically update the 835 RA from 4010 to 5010.
        • Data returned will be 5010 data, but in 4010 format.
        • Crossover claims, IPCS and RTIP 5010 claims will continue to receive a 4010 835 RA until the submitter submits a non-IPCS or RTIP 5010 or NCPDP D.0/1.2 transaction. The submitter can also contact the CMC Help desk to have the 835 RA returned in the 5010 format.
        • Claim Inquiry Forms (CIFs), appeals, Erroneous Payment Correction (EPC) adjustments and paper claims will be returned in the 835 version that the provider is approved to receive.
        • Since CIFs, appeals and paper claims were not received electronically, the information returned will currently be limited to available data and will not contain all 835 5010 compliant data fields.  EPC adjustments (corrections and reversals) are also currently limited to the available data in the California Medicaid Management Information System (CA-MMIS) and will not contain all the 835 5010 data fields.
        • 4010 claims that are in suspense or in process when the provider status is changed will be returned in the 835 5010 format.
        • Claims that are submitted in the 4010 format, and receive an 835 RA in the 5010 format, will be limited to available data from the 4010 submission and will not contain all 835 5010 compliant data fields.

Additional Information
A recorded webinar covering the 835 Remittance Advice transaction details is available for viewing through the Medi-Cal Learning Portal (MLP).

You must create an account in order to access the MLP and review recorded webinars. Instructions for creating an account can be found at Medi-Cal Learning Portal Job Aide.

For more information providers can call the CMC Help desk at 1-800-541-5555, Option 4 for Technical Help Desk and then Option 2 for CMC Help desk.