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HIPAA: 4010 Transactions - 837 Institutional

  1. Must the submitter ID in the ISA segment match the submitter ID in the NMI segment?

    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.

  2. Can I send more than one interchange envelope (ISA-IEA) per transaction?

    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.

  3. Can I send more than one functional group (ST-SE) within a single interchange envelope (ISA-IEA)?

    The “TA1” is the Interchange Acknowledgement. It can be used to acknowledge receipt of a file as well as to indicate errors in the Interchange (or ISA/IEA file “wrapper”). For Medi-Cal, the TA1 is only returned when errors exist at the Interchange level.

  4. Currently, the 277 response returns 12 weeks' worth of claims history. But didn't the Webcast presentation state it would return up to three years' worth of claims history?

    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).

  5. 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?

    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.

  6. Are there additional phone numbers available if I am unable to connect to a test line to upload my test batches?

    A 277 Response transaction will be generated for every 276 Inquiry transaction, regardless of whether the claim was found in the Medi-Cal claims processing system.

  7. Is it possible to receive a hard copy response to a 276 Inquiry transaction?

    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
  8. 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?

    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.

  9. 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?

    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.

  10. 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?

    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.

  11. Are providers required to sign a new CMC Agreement or Trading Partner Agreement with Medi-Cal for the ASC X12N 837 transaction?

    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.

  12. If non-applicable data in loops/fields is sent in, must those sections be removed or will Medi-Cal simply ignore them?

    Medi-Cal will not store or use non-applicable data in a loop/field. However, Medi-Cal will accept the transaction if the provider sends it.

  13. Loop 2300 NTE01 and NTE02 190 Claim Note: Do billing limit exception codes (Box 11 on the old paper form) go here? What reference code is necessary?

    In Loop 2300, CLM 20, the delay reason code is replacing the billing limit exception code. The provider must use the national values as defined in the Implementation Guide. See the June Medi-Cal Update for correlations for the current billing limit exception codes to the national delay reason codes.

  14. Loop 2310A NM109 Attending Physician Primary Identifier: Even though facilities don't have the Attending Physician Tax Numbers yet, is this field validated by Medi-Cal?

    This field is required on all inpatient claims (including Long Term Care claims). Therefore, Medi-Cal expects to see this field populated with the appropriate information.

  15. Loop 2310A PRV03 Provider Taxonomy Code: Since facilities don't have this code yet, can a dummy value be used? Is this field validated by Medi-Cal?

    The Provider Taxonomy Code is not a required field and situational usage is appropriate. Medi-Cal has not defined situational use of this data and does not expect this segment to be included in the transaction. If data were sent in this field, Medi-Cal would expect to see the appropriate value and not a dummy value.

  16. Loop 2320 DMG01 POS 305 Date Time Period Format: The Medi-Cal draft indicates "D6," but the format shown in the draft (CCYYMMDD) matches "D8" format. Is the indicator or the format correct?

    The correct format is "D8." This was a typographical error on the original draft Companion Guide and has been corrected.

  17. Loop 2400 SV201 POS 375 Service Line Revenue Code: The Medi-Cal draft uses Long Term Care accommodation codes. Should the value from Box 15 on the old paper form in this field be used rather than the currently used national revenue codes?

    Medi-Cal has not converted its interim LTC accommodation codes to the national revenue codes and does not expect to complete this conversion by October 16, 2003. The interim LTC accommodation code currently placed in Box 15 of the paper form should be included in SV201 for the ASC X12N 837 4010AI Institutional format.

  18. There are several sections/fields that are in the ASC X12N 837 4010A1 Institutional HIPAA Implementation Guide (technical specifications) that are not in the ANSI ASC X12N 837 Institutional Long Term Care draft Companion Guide (technical specifications) that are downloadable from this Web site. Are these fields required?

    As noted in the HIPAA Implementation Guide, the following referenced fields are situational and not required. Therefore, since Medi-Cal does not require this information for Long Term Care claim processing, they were not included in the Medi-Cal draft Companion Guide for Long Term Care. Note: Page number references are from the HIPAA Implementation Guide.

    • Loop 2300 DTP Discharge Hour (page 165)
    • Loop 2300 AMT Patient Estimated Amount Due (page 180)
    • Loop 2330B N3 Other Payer Address (page 412)
    • Loop 2330B N4 340A Other Payer City/State/Zip (page 413)
    • Loop 2010BC N3 Payer Address (page 129)
    • Loop 2010BC N4 Payer City/State/Zip (page 130)
    • Loop 2400 DTP 455A Service Line Date (Page 456)
    • Loop 2400 DTP 455B Assessment Date (page 458)
  19. Does Medi-Cal require loop 2310E (Service Facility Name) to be completed by an institutional provider when including a charge from an outside laboratory?

    Outside laboratory claims are billed to Medi-Cal as an outpatient claim (claim type 04) and require the use of loop 2310E (Service Facility Name). The institutional provider should include the outside laboratory’s name in the NM1 (Individual or Organizational Name) segment and the laboratory’s Medi-Cal provider number in the REF (Reference Identification) segment. The laboratory’s address is not required (N3 and N4 segments). The outpatient specifications available in Outpatient Services on the HIPAA ASC X12N Technical Specifications Web page accurately reflect this requirement.

  20. In the Draft ANSI ASC X12N 837 – Institutional Common Header Data Specifications, the first REF segment (Transaction Set Header), position 015 (Transmission Type), segment ID REF02 (Reference Identification) lists the transmission-type codes. There is a code for Test (004010X096DA1) and a code for Production (004010X096FA1). In the October 2002 HIPAA Implementation Guide Addenda, the code for Test matches, but the code for Production is 004010X096A1 (without the “F”). Does Medi-Cal have a unique transmission-type code for Production mode?

    When the Medi-Cal Companion Guides were originally developed, the “F” was used to designate format only, as opposed to data content. The “F” reference is no longer applicable and this designation is no longer needed. The Companion Guides will be updated to reflect this clarification.

  21. Currently, a Medi-Cal submitter number and the Julian date are used as the submitter identifier when submitting claims electronically. Should these values be used on an X12N 837 version 4010A1 Institutional claim to populate loop 1000A (Submitter Loop), position 020 (Submitter Name), element NM109 (Identification Code)?

    No. Only the provider's submitter number should go in loop 1000A (Submitter Name), element NM109 (Identification Code). The Julian date is not part of the field value.

  22. Loop 1000B (Receiver Name), position 020, element NM103 (Last Name or Organization Name) of an X12N 837 version 4010A1 Institutional claim requires the Receiver Name. What value does Medi-Cal want in this field and what value does Medi-Cal require in element NM109 (Receiver Primary Identifier)?

    Medi-Cal wants to see “Medi-Cal” as the Receiver Name in loop 1000B, element NM103 and requires "610442" in loop 1000B, element NM109.

  23. In loop 2010AA (Billing Provider Name), position 35, segment ID REF of an X12N 837 version 4010A1 Institutional claim, it appears from the Medi-Cal Companion Guide that two choices are possible for Billing Provider Secondary Identification: the Employer's Identification Number (EIN)/Social Security Number (SSN) or the Medi-Cal Provider Number. Is this choice based on what a provider uses as their Primary Billing Provider Identifier in loop 2010AA, position 015, data element NM109? Should the EIN be used as the Primary Billing Provider Identifier in NM109? Even though the REF segment is situational, should field REF02 be populated with a Medi-Cal Provider Number?

    Yes. The billing provider should enter their EIN or SSN in loop 2010AA, data element NM109 (Identification Code). The provider’s Medi-Cal ID should go in loop 2010AA, data element REF02.

  24. Currently, Medi-Cal recipients do not have Group Numbers. The HIPAA Implementation Guide states that if the Group Number is blank in loop 2000B (Subscriber Loop), position 005, element SBR03 of an X12N 837 version 4010A1 Institutional claim, there must be a Group Name entered in element SBR04. What values should be placed in these fields for Medi-Cal recipients?

    The HIPAA Implementation Guide states that element SBR04 (Group Name) is required if there is a group number. There is not a group number for Medi-Cal recipients. Therefore, there is not a group name.