HIPAA: Transactions - 837 Professional
Q:
I'd like to see an example of a complete Medi-Cal response that
includes the 271 and 864 transactions. Is this possible?
A:
You can view an example of a complete Medi-Cal response on pages
70 – 79 of the
Webcast presentation for the 270/271 transactions.
Q:
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:
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:
What type of modifiers should be entered in the modifier
fields?
A:
Up to four 2-character modifiers may be entered in the
modifier fields Box 24D of the HCFA 1500. All modifiers must be
entered immediately after the procedure code. Information that
overflows into other fields (especially additional modifier fields)
will cause the claim to suspend and a Resubmission Turnaround
Document (RTD) will be issued. Specific modifiers identified in the
billing instructions should be entered in the first modifier field.
When billing multiple modifiers for a service not specified in the Medi-Cal billing instructions as needing multiple modifiers, existing Medi-Cal policy must be followed and the specific modifier in the first modifier field must be entered. If the billing instructions require a service to be billed with a specified modifier, that modifier must be entered in the first field.
Q:
Are there additional phone numbers available if I am unable
to connect to a test line to upload my test batches?
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:
In the X12N 837 version 4010A1 Professional Companion Guide,
does the ISA04 (Security Information) element contain 10 blank
spaces?
A:
Yes. Since the ISA is a fixed-record length, each character
must be accounted for and the blank spaces filled.
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
loop 1000B (Receiver Name), element NM103 (Last Name or Organization
Name), what is the Receiver Name the system wants to see?
A:
Medi-Cal wants to see “Medi-Cal” as the Receiver Name in
loop 1000B.
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
loop 1000B (Receiver Name), element NM109 (Identification Code),
what is the Receiver Primary Identifier?
A:
Medi-Cal requires “610442” as the Receiver Primary
Identifier.
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
loop 2000A (Billing/Pay To Provider), element PRV01 (Provider Code),
should the entry be “BI” or “PI”?
A:
Medi-Cal will only accept the “BI” qualifier for loop 2000A.
The Companion Guide will be updated to reflect this clarification.
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
loop 2000A (Billing/Pay To Provider), element PRV03 (Reference
Identification), should the national taxonomy code be used or does
Medi-Cal have a different taxonomy code?
A:
The appropriate national taxonomy code for the provider as
identified on the national list of taxonomy codes should be used.
These are maintained by the National Uniform Claim Committee and are
available at
www.wpc-edi.com/taxonomy.
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
loop 2010AA (Billing Provider Name), does Medi-Cal want the
provider’s Entity Identifier Number (EIN) in element NM101 (Entity
Identifier Code)?
A:
No. The billing provider should enter their EIN or Social
Security Number in data element NM109 (Identification Code), not
NM101. The qualifier (EIN or SSN) corresponding to the type of
number being sent should be used in NM108 (Identification Code
Qualifier). NM101 will always contain “85” for the billing provider.
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
loop 2010AA (Billing Provider Name), does Medi-Cal want the
provider’s submitter number in element REF02 (Reference
Identification)?
A:
No. The provider’s Medi-Cal ID should go in loop element
REF02. The qualifier of “1D” should be used in REF01. The provider's
submitter number should go in loop 1000A (Submitter Name), element
NM109 (Identification Code).
Q:
In the X12N 837 version 4010A1 Professional Companion Guide,
are elements N3 (Subscriber Address) and N4 (Subscriber
City/State/ZIP Code) required in loop 2010BA (Subscriber Name)?
A:
Yes. As identified in the Companion Guide, the N3 and N4
segments are required in loop 2010BA when the patient is the
subscriber.
Q:
The Medi-Cal Companion Guide for the 837 professional claim
version 4010A1 reflects two field crosswalks from the HCFA 1500
claim form to the Payer (Destination) Segment within subscriber loop
2010BB that do not appear to match the NM1 (Payer Name) segment.
NM103 (Payer Name) is matched to the HCFA 1500 field “2,”
which is Patient's Name. NM109 (Payer Identifier) references
field “1a,” which is Insured’s I.D. Number. Please clarify
these references.
A:
The HCFA 1500 designation of “1a” and “2” for the
Payer (Destination) Segment within subscriber loop 2010BB should not
be there since there is no box on the HCFA 1500 claim form
for Payer Name or Payer Identifier. This will be corrected in a
future release of the 837 version 4010A1 Professional Companion
Guide.
Note:
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