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HIPAA: December 1, 2006 Electronic Claim Transition

HIPAA Transactions Updated November 8, 2006

Due to the required changes in support of the federally mandated National Provider Identifier (NPI), Medi-Cal must discontinue proprietary non-HIPAA compliant electronic claim transactions.

Beginning December 1, 2006, all Medi-Cal providers submitting electronic claims must submit using HIPAA-compliant transactions, except for Child Health and Disability Prevention (CHDP) cliams (claim type 11). CHDP claims will make the transition to a HIPAA-standard claim format at a future date.

Medi-Cal accepts the HIPAA-compliant ASC X12N 837 v.4010A1 transaction for Computer Media Claims (CMC). Electronic submissions may be made using dial-up, tape or Internet. CMC must still meet current Medi-Cal policy and billing requirements.

Application/Agreement Form
Medi-Cal providers may submit 837 electronic transactions directly or employ a billing service to prepare and submit their 837 transactions. To become an authorized 837 electronic transaction submitter, providers and billing services must first complete and mail an application/agreement to the CMC Unit. The Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) is available on the "Forms" Web page. More information can also be found in the CMC Enrollment Procedures section of the Part 1 manual.

IPCS for Professional Claim Submissions
Another option for professional claim submitters only is Internet Professional Claim Submission (IPCS). IPCS is a free-of-charge, direct data entry system accessible via the Transaction Services area. IPCS is used to submit single claims in the HIPAA-compliant ASC X12N 837 v.4010A1 Professional format.

To use IPCS, a provider must have a Medi-Cal Point of Service (POS) Network/Internet Agreement and a Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) on file with Medi-Cal. There is no testing required for IPCS once both forms are submitted to Medi-Cal. For more information on IPCS, please refer to the Internet Professional Claim Submission (IPCS) User Guide.

CMC Developers, Vendors and Billing Services Directory
 For information on selecting an approved third-party vendor for 837 electronic claim submissions to Medi-Cal in the HIPAA-standard format, see the CMC Developers, Vendors and Billing Services Directory. The directory includes contact information for software vendors, billing agents and clearinghouses approved to submit HIPAA-standard electronic transactions as well as information about transaction types, special segments and claim types that may be submitted.

Paper Claims for Non-Compliant Submissions
Providers submitting electronic claims on or after December 1, 2006, that are not in the new HIPAA-compliant ASC X12N 837 v.4010A1 format risk having their claims rejected and may have to bill their claims on paper or submit single professional claims using IPCS until they have an activated submitter ID that has successfully transitioned to the new HIPAA-compliant format.

Self-Service HIPAA Transaction Utility Tool
To support the transition, Medi-Cal has implemented a Web-based, self-service transaction validation environment – "The HIPAA Transaction Utility Tool." The utility tool offers everything providers need to exchange Electronic Data Interchange (EDI) files with Medi-Cal at no cost to the provider.

The utility tool allows providers to test transactions prior to actually sending them to Medi-Cal. The tool also contains documentation such as EDI specifications (companion guides) in a format that can be viewed online or easily downloaded. The utility tool validates transactions based on the companion guide requirements and offers troubleshooting and reporting features that enhance Medi-Cal’s current testing and media activation requirements.

Providers can access "The HIPAA Transaction Utility Tool” from the sysdev "Transaction Services" Web page. Providers are strongly encouraged to take advantage of this resource.

  • Providers should enter their current Medi-Cal submitter ID and password. (Submitter IDs must have “CMCSUB” as a prefix. The password is the same password used for CMC dial-up access.) Click “Submit.”
  • The “Transaction Services” menu will appear. Click "The HIPAA Transaction Utility Tool” link. A separate window will open for the application.
  • When "The HIPAA Transaction Utility Tool” application is open, click the “User Guide” link located on the left navigation bar for step-by-step instructions.
  • An e-mail address will be requested when providers enter their contact information.

Information for 837 Transactions
The HIPAA Update and HIPAA News pages include links to important information for 837 electronic transaction submitters and applicants, including technical specifications, implementation instructions, companion guides, frequently asked questions (FAQs) and biller updates.

If you have any questions, contact the Medi-Cal Telephone Service Center at 1-800-541-5555.





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