Providers who submit Long Term Care, Inpatient Services, Outpatient Services, Medical Services, Vision Care and Allied Health claim types can bill using the new 837 transactions. The 837 transactions specifications are described in the appropriate provider companion guide on the HIPAA ASC X12N Companion Guides and NCPDP Technical Specifications Web page.

Click on one of the following links to go directly to that section of this article:

• Enrollment
• Test Claim Submissions
• Test Results
• Technical Information/Companion Guides

Enrollment
Providers may submit 837 transactions directly or employ a billing service to prepare and submit their 837 transactions. To become an authorized 837 4010A1 submitter, providers and billing services must complete and sign a Medi-Cal Telecommunications Provider and Biller Application/Agreement. This application/agreement is found after the CMC Enrollment Procedures section in the Part 1 manual. This applies both to current CMC submitters and those who have never submitted claims electronically. Software vendors may also be issued a submitter number for test purposes ONLY.

Providers who submit their own 837 transactions should note the following:

• Application/agreement forms from physicians and physician groups must contain the group provider number and an authorized signature of an active group member.
• Individual providers who bill with a group number do not need to submit separate application/agreement forms.

Billing services and clearinghouses that submit 837 transactions on behalf of providers should note the following:

• The “Biller Information” and “Billing Service Signature Information” sections of the application/agreement must be completed.
• Providers for whom the billing service submits claims must complete and sign the provider sections.
• An active third-party billing service does not need to complete and sign an application/agreement for each of the providers for whom it submits claims. An application/agreement from any one submitter is adequate.

top

Test Claim Submissions
After the application/agreement is processed and a Medi-Cal submitter ID number is issued for a new applicant submitter, or the current CMC submitter’s profile has been updated to accept the new 837 4010A1 transaction format, the applicant submitter must send a test claim file to the CMC unit. Claim files are tested for formatting only. Claims will not be processed for payment and test results will not result in a dollar amount.

1. Test claim files must include a cross section of provider claim type data commonly included in an actual production environment.
2. To ensure thorough testing, each claim type test file must include at least 10, but no more than 100 claims.
3. Applicant submitters should use data from previously adjudicated claims to ensure that data is “mapped” correctly. Test claim files will not be processed for payment.
4. Applicant submitters must use “610442” as the Receiver ID for test claim file submissions. Without the correct Receiver ID, submissions will be rejected. (“610442” is the also the Receiver ID used by authorized 837 transaction submitters in production.)
5. Applicant submitters will be notified whether their test claim files passed or failed.
6. Formatting problems identified by Medi-Cal during the testing period must be corrected by the applicant submitter and a new test claim file must be submitted for approval prior to final Medi-Cal authorization.
7. Claim files can be submitted only after an applicant submitter’s test claim files are approved and authorization is granted.

Note: Submitters who wish to submit remarks to production must include them in their test claim file submission.

Applicant submitters may test for multiple media (dial-up, tape or Internet) using the same submitter number. A billing service that receives authorization from Medi-Cal to submit 837 transactions does not need to repeat the test procedures for additional providers for whom it submits 837 transactions, as long as the same approved submitter number, format, medium and claim types are used. However, the billing service’s information and signature must be included on application/agreement forms for all new providers.

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

Send CMC test tapes delivered by courier to:

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

To send a test via telephone, call (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.

Questions should be directed to the CMC Help Desk at 1-800-541-5555 (option 16). Submitters outside California should call (916) 636-1200.

top

Test Results

• All submitters will receive notification of their test results from the CMC Help Desk by telephone or letter.
• Approximately two weeks after the tests are processed, applicant submitters receive via regular postal mail the test results, with either a CMC approval or denial letter. The test results include a review of field data formatting specifications. The purpose of this review is to help prevent future claim denials due to format specification errors.
• EDS must approve each CMC submitter for electronic claim submission of the new 837 transaction. For new submitters and providers, EDS will notify the Department of Health Care Services (DHS) upon their successful completion of the testing process. DHS will then place the submitter in “Active” (production) status for the ASC X12N 837 4010A1 format and will send the provider and/or billing service a letter authorizing CMC submissions. The letter will include the name(s) of the providers/billers authorized to submit claims.
• Submitters can access the Medi-Cal test Web site and log in at the Transaction Services Web page page to view error reports. The online error reports are available on the first business day following submission, if the test claim file is received by 4:00 p.m. Tuesdays are the exception: tests received before 4:00 p.m. Monday will be available the following Wednesday.
• Submitters with questions about submission errors may call the CMC Help Desk at 1-800-541-5555 (option 16). Submitters outside California should call (916) 636-1200.

top

Technical Information/Companion Guides
For specific information regarding requirements for each media submission type, refer to the Medi-Cal CMC Billing and Technical Manual. The companion guides are the ASC X12N 837 Institutional Version 4010A1 and ASC X12N 837 Professional Version 4010A1.

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

For more information about Computer Media Claims and CMC enrollment, see CMC and CMC Enrollment Procedures in the Part 1 manual.

top