MassHealth Health Care Payment/Advice (835) Standard Companion Guide Refers to the Implementation Guides Based on ASC X12N version: 005010X221A1 October 2012 Version 5.0 Disclosure Statement The following Massachusetts Companion Guide is intended to serve as a companion document to the corresponding ASC X12N/005010X221 Health Care Payment/Advice (835), its related Addenda (005010X221A1) and its related Errata (005010X221E1). The document further specifies the requirements to be used when preparing, submitting, receiving and processing electronic health care administrative data. The document supplements, but does not contradict, disagree, oppose, or otherwise modify the 005010X221 in a manner that will make its implementation by users to be out of compliance. Note: Type 1 TR3 Errata are substantive modifications, necessary to correct impediments to implementation, and identified with a letter ‘A’ in the errata document identifier. Type 1 TR3 Errata were formerly known as Implementation Guide Addenda. Type 2 TR3 Errata are typographical modifications, and identified with a letter ‘E’ in the errata document identifier. About MassHealth MassHealth helps the financially needy obtain high-quality health care that is affordable, promotes independence, and provides customer satisfaction. The MassHealth program provides comprehensive health insurance - or help in paying for private health insurance - to more than one million Massachusetts children, families, seniors, and people with disabilities. MassHealth is the second largest health insurer in the state and is nationally recognized for providing high-quality care in an innovative and cost-effective manner. http://www.mass.gov/masshealth. Medicaid Management Information System and Provider Online Service Center The Medicaid Management Information System (MMIS) and the Provider Online Service Center (POSC) offer a web-based environment that automates functions such as member eligibility verification, claim submission and status, claims processing, prior authorization, referrals, preadmission screening, online remittance advices, and reports. Contact for Further Information on this Companion Guide MassHealth Customer Service PO Box 9118 Hingham, MA 02043 Email: edi@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 2012 MassHealth All rights reserved. This document may be copied. Preface This Companion Guide to the 005010 ASC X12N Implementation Guide and associated errata and addenda adopted under HIPAA clarifies and specifies the data content when exchanging electronically with MassHealth. Transmissions based on this companion guide, used in tandem with the 005010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. Editor’s note: This page intentionally left blank. Table of Contents 1. INTRODUCTION 1 SCOPE 1 OVERVIEW 1 REFERENCES 1 ADDITIONAL INFORMATION 2 2. GETTING STARTED 2 WORKING WITH MASSHEALTH 2 TRADING PARTNER REGISTRATION 2 CERTIFICATION AND TESTING OVERVIEW 2 3. TESTING WITH THE PAYER 3 4. CONNECTIVITY WITH THE PAYER/COMMUNICATIONS 5 SAMPLE PROCESS FLOWS 5 TRANSMISSION ADMINISTRATIVE PROCEDURES 6 COMMUNICATION PROTOCOL SPECIFICATIONS 7 PASSWORDS 7 5. CONTACT INFORMATION 7 EDI CUSTOMER SERVICE 7 EDI TECHNICAL ASSISTANCE 8 PROVIDER SERVICE NUMBER 8 APPLICABLE WEBSITES/EMAIL 8 6. CONTROL SEGMENTS/ENVELOPES 10 ISA-IEA 10 GS-GE 11 ST-SE 12 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 13 8. ACKNOWLEDGEMENTS AND/OR REPORTS 16 9. TRADING PARTNER AGREEMENTS 16 TRADING PARTNERS 16 10. TRANSACTION SPECIFIC INFORMATION 16 APPENDICES 1 A. IMPLEMENTATION CHECKLIST 1 B. BUSINESS SCENARIOS 2 C. TRANSMISSION EXAMPLES 3 D. FREQUENTLY ASKED QUESTIONS 6 E. CHANGE SUMMARY 7 Editor’s note: This page intentionally left blank. 1. Introduction The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires MassHealth, and all other health insurance payers in the United States to comply with the electronic data interchange (EDI) standards for health care as established by the Secretary of Health and Human Services (HHS). The ANSI X12N implementation guides have been established as the standards of compliance for electronic health care transactions. Scope This section specifies the appropriate and recommended use of the Companion Guide. The standard adopted by HHS for electronic health care transactions is ANSI ASC X12N Version 005010 and is effective January 1, 2012. The unique version/release/industry identifier code for the 835 Health Care Payment/Advice transactions is 005010X221A1. This Companion Guide assumes compliance with all loops, segments and data elements contained in the 005010X221A1. This Companion Guide does NOT include any of the required loops, segments or data elements defined in the 005010X221A1 with the exception of those loops, segments or data elements that require further clarification. Overview This section specifies how to use the various sections of the document in combination with each other. MassHealth created this companion guide for MassHealth trading partners to supplement the X12N Implementation Guide. This guide contains MassHealth-specific instructions related to the following: ? Data formats, content, codes, business rules, and characteristics of the electronic transaction; ? Technical requirements and transmission options; and ? Information on testing procedures that each trading partner must complete before transmitting electronic transactions The information in this document supersedes all previous communications from MassHealth about this electronic transaction. The following standards are in addition to those outlined in the MassHealth provider manuals. These standards in no way supersede MassHealth regulations. Use this guide in conjunction with the information found in your MassHealth provider manual. References The implementation guide specifies in detail the required formats for transactions exchanged electronically with an insurance company, health care payer, or government agency. The implementation guide contains requirements for the use of specific segments and specific data elements within those segments and applies to all health care providers and their trading partners. It is critical that your IT staff, or software vendor, review this document in its entirety and follow the stated requirements to exchange HIPAA-compliant files with MassHealth. The Implementation Guides for X12N and all other HIPAA standard transactions are available electronically at http://www.wpc-edi.com/. Additional Information The intended audience for this document is the technical and operational staff responsible for generating, receiving, and reviewing electronic health care transactions. In addition, this information should be shared with the provider’s billing office to ensure that all accounts are reconciled in a timely manner. 2. Getting Started Working with MassHealth This section describes how to interact with MassHealth’s EDI Department. MassHealth trading partners should exchange electronic health care transactions with MassHealth via the Provider Online Service Center (POSC) or system-to-system using the Healthcare Transaction Service (HTS) process. After establishing a transmission method, each trading partner must successfully complete testing. Additional information is provided in the next section of this companion guide. After successful completion of testing, production transactions may be exchanged. Trading Partner Registration This section describes how to register as a trading partner with MassHealth. All MassHealth trading partners are required to sign a trading partner agreement (TPA). If you have elected to use a third party to perform electronic transactions on your behalf, you will also be required to complete a trading partner profile (TPP). If you have already completed these forms, you will not be required to complete them again. Please contact MassHealth Customer Service at 1-800-841-2900 or via email at edi@mahealth.net if you have any questions about these forms. Certification and Testing Overview All trading partners will be certified through the completion of trading partner testing. All trading partners that exchange electronic transactions with MassHealth must complete trading partner testing. This includes billing intermediaries and software vendors and applies to submitters using a national provider identifier (NPI), as well as providers that are defined as atypical by MassHealth. Test transactions that are exchanged with MassHealth should include a representative sample of the various types of transactions that you would normally conduct with MassHealth. The size of the file should be between 25-50 transactions. MassHealth will post a status of billing intermediaries and software vendors, and their progress with testing. If a billing intermediary or software vendor submits electronic transactions for you, please check with them on the status of their testing, or view the posting on our Web site. Providers who use a billing intermediary or software vendor will not need to test for those electronic transactions that their entity submits on behalf of that provider. 3. Testing with the Payer Before exchanging production transactions with MassHealth, each trading partner must complete testing. All trading partners who plan to exchange transactions must contact MassHealth Customer Service at 1-800-841-2900 in advance to discuss the testing process, criteria, and schedule. Trading partner testing includes HIPAA compliance testing as well as validating the use of conditional, optional, and mutually defined components of the transaction. The following conditions must be addressed in one or more test files: • Providers with no claims on an 835 will not have any CLP segments. • Providers with professional claims and institutional claims that are adjudicated at the claim service line level will note 2110 loops on the 835, due to adjudication at the detail level. MMIS reports a single claim with multiple service lines as one CLP (loop 2100) and multiple SVC (loop 2110). • Providers with inpatient claims will note on the 835 that there is no 2110 CAS segment due to adjudication at the header level. MassHealth will send all fully adjudicated claims from a weekly cycle in one ST/SE segment, even if the number of CLP segments exceeds 10,000. This limit of 10,000 CLP segments is a recommendation for the 835 transaction, but not a requirement. Trading partners, especially those handling a large claim volume, are encouraged to proactively test their compliance software internally to ensure it allows over 10,000 CLP segments in one 835 transaction. Each 835 transaction is sent in a separate ISA/IEA envelope. For clearinghouses with multiple providers, multiple ST/SEs will be generated under the same ISA/IEA. For example, if a clearinghouse has been selected to receive three of their clients’ 835s, the structure will be as follows: • ISA Clearinghouse 123 • GS Clearinghouse 123 • ST Provider A • SE • ST Provider B • SE • ST Provider C • SE • GE • IEA The 835 files will be available for trading partners to download from the POSC for at least 180 days. Trading partners requiring access to their 835s beyond the 180-day period should contact MassHealth Customer Service. (See section 5 - contact information) The 835 transaction is available to those trading partners with a signed TPA on file. 835 transactions are generated at the completion of each weekly claims adjudication cycle for each provider with at least one paid or denied claim appearing in the weekly cycle or other financial activities. Information about pended or suspended claims can be obtained from the MassHealth proprietary remittance advice, which can be found on the POSC or via requesting the 276 Claims Status Inquiry and Response transactions. Since an 835 transaction must balance to a single check/electronic funds transfer (EFT), MassHealth is obligated to include all fully adjudicated claims from a weekly cycle, regardless of how the claim was submitted (POSC, paper, or as an 837 transaction). As usual, the State Comptroller sends the payment check or EFT separately. 835s are generated based on the TPA that the provider has submitted to MassHealth. If the provider has chosen to receive 835s for all associated PID/SLs to a designated PID/SL within the group, MassHealth will send all 835s to that PID/SL by indicating a different PID/SL in the ST segment. If the provider has chosen to receive individual 835s for all PID/SLs in the TPA, all providers will receive 835s for their PID/SL. Payment and Remittance Schedule 835s are available for retrieval each week. Retroactive Pay Cycles When a retro cycle produces a separate payment from the regular weekly claims run, a separate 835 transaction is also produced. 835 Transactions in Response to Retail Pharmacy Claims Retail pharmacy providers will receive their payment and 835 from MassHealth. Although MMIS does not accept pharmacy claims, the adjudicated pharmacy claim information is received from the Pharmacy Online Processing System (POPS) vendor, to be subsequently included in the MMIS financial process. It is from this information that the MMIS 835 for pharmacy claims is generated. Information about the contents in the retail pharmacy 835 transaction can be requested via e-mail to MassHealth.Providerrelations@acs-inc.com or by calling 617-423-9830. 835 Transactions in Response to Dental Claims Dental providers submitting both dental and medical claims will receive their payment and 835 from MassHealth. Adjudicated dental claim information is received from DentaQuest, a third party vendor, to be subsequently included in the MassHealth financial process. It is from this information that the MassHealth 835 for dental claims is generated. If a provider submits both dental and medical claims, they will access their 835 transaction from MassHealth. If a provider submits only dental claims, the 835 is distributed by DentaQuest. These providers should work with DentaQuest to establish connectivity to receive their 835 transaction. Support contact information for DentaQuest is as follows. DentaQuest/MassHealth Dental Program 12121 N. Corporate Parkway Mequon, WI 53092 Phone: 1-800-207-5019 E-mail: eclaims@masshealth-dental.net Website: www.masshealth-dental.net Production File-naming Convention 835 files produced by MassHealth have the following naming convention: XXXXXXXXXX.835.WEB.hhmmssnnn.jjj, where: XXXXXXXXXX Indicates the trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). HHMMSSSS Indicates the hours, minutes, seconds, and subseconds when the file was created. nnn Indicates the sequence number jjj Indicates the Julian date when the file was created. 4. Connectivity with the Payer/Communications The below illustrations outline the process flows for each of the message exchange scenarios provided by the Healthcare Transaction Services (HTS) submission method. Sample Process Flows Message exchange scenarios: • synchronous (real-time) messaging; and • asynchronous (polled-response) messaging. Figure 1: Real-Time Submission HTS/EDI Transaction Flow: Eligibility (270 & 271) Figure 2: Batch 270 Flow Transmission Administrative Procedures System Availability The system is typically available 24X7 with the exception of scheduled maintenance windows. Transmission File Size The current maximum file size for any file submitted to MassHealth is 16 MB. If you have any questions, or would like to coordinate the processing of larger files, please contact MassHealth Customer Service at 1-800-841-2900. Please note that the POSC does not unzip or decompress files. All files must be transmitted in an unzipped or uncompressed format. Transmission Errors When processing an interactive EDI transaction that has Interchange Header errors a TA1 will be generated. If the Interchange Header is valid, but the transaction fails compliance, 999 will be generated. If the Interchange Header has errors so severe and a TA1 or 999 cannot be generated the following error will be generated (e.g. ISA06 - Trading Partner ID is not on file). Communication Protocol Specifications Provider Online Service Center (POSC) The Provider Online Service Center is a web-based tool accessible via the internet, which gives providers the tools to manage their business with MassHealth electronically. The POSC can be used to enroll as a MassHealth provider, manage a provider’s profile information, enter claims via direct data entry (DDE), submit and retrieve transactions, or upload and download batch transaction files, access reports and receive messages/communications. Healthcare Transaction Services (HTS) MassHealth provides a Healthcare Transaction Service (HTS) submission method which allows trading partners to submit the 270/271 (Eligibility Inquiry and Response) and the 276/277 (Claims Status Inquiry and Response) transactions from their system directly to the MMIS via a fully automated process. This system-to-system EDI web service is supported by a specific MassHealth schema and Web Services Description Language (WSDL) that are outlined in the MassHealth HTS Guide. Once trading partners develop the web service to the guide’s specification they can test the web client application on the MassHealth test servers prior to being approved for production. Interested trading partners must contact MassHealth at 1-800-841-2900 to obtain a copy of the HTS guide. Passwords Providers using the Provider Online Service Center (POSC) to submit their EDI transactions must adhere to MassHealth’s use of passwords. Providers are responsible for managing their own data. Each provider is responsible for managing access to their organization’s data through the MMIS security function. Each provider must take all necessary precautions to ensure that they are safeguarding their information and sharing their data (i.e. granting access) only with users and entities who meet the required privacy standards. It is equally important that providers know who on their staff is linked to other providers or entities, in order to notify those entities whenever they remove access for that person in your organization. For more information regarding passwords and use of passwords, contact the Customer Service Team (CST) at 1-800-841-2900. 5. Contact Information EDI Customer Service (For written correspondence) MassHealth Customer Service PO Box 9118 Hingham, MA 02043 (Use this MassHealth address only for electronic claims.) MassHealth Customer Service 75 Sgt. William B. Terry Dr. Hingham, MA 02043-1545 Email: edi@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 EDI Technical Assistance MassHealth Customer Service PO Box 9118 Hingham, MA 02043 Email: hipaasupport@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 Provider Service Number MassHealth Customer Service PO Box 9118 Hingham, MA 02043 Email: providersupport@mahealth.net Phone: 1-800-841-2900 Fax: 617-988-8971 Applicable Websites/Email Accredited Standards Committee (ASC X12) ? ASC X12 develops and maintains standards for inter-industry electronic interchange of business transactions. www.x12.org Accredited Standards Committee (ASC X12N) ? ASC X12N Develops and maintains X12 EDI and XML standards, standards interpretations and guidelines as they relate to all aspects of insurance and insurance-related business processes. www.x12.org American Hospital Association Central Office on ICD-9-CM (AHA) ? This site is a resource for the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes, used in medical transcription and billing, and for Level I HCPCS. www.ahacentraloffice.org American Medical Association (AMA) ? This site is a resource for the Current Procedural Terminology 4th Edition codes (CPT-4). The AMA copyrights the CPT codes. www.ama-assn.org Centers for Medicare & Medicaid Services (CMS) ? CMS is the unit within HHS that administers the Medicare and Medicaid programs. CMS provides the Electronic Health-Care Transactions and Code Sets Model Compliance Plan at www.cms.hhs.gov/HIPAAGenInfo/ ? This site is the resource for information related to the Health-Care Common Procedure Coding System (HCPCS). www.cms.hhs.gov/HCPCSReleaseCodeSets/ ? This site is the resource for Medicaid HIPAA information related to the Administrative Simplification provision. www.cms.gov/medicaid/hipaa/adminsim Committee on Operating Rules for Information Exchange (CORE) ? A multi-phase initiative of CAQH, CORE is a committee of more than 100 industry leaders who help create and promulgate a set of voluntary business rules focused on improving physician and hospital access to electronic patient insurance information at or before the time of care. www.caqh.org/CORE_overview.php Council for Affordable Quality Healthcare (CAQH) ? A nonprofit alliance of health plans and trade associations, working to simplify healthcare administration through industry collaboration on public-private initiatives. Through two initiatives -- the Committee on Operating Rules for Information Exchange (CORE) and Universal Provider Datasource (UPD), CAQH aims to reduce administrative burden for providers and health plans. www.caqh.org Designated Standard Maintenance Organizations (DSMO) ? This site is a resource for information about the standard-setting organizations and transaction change request system. www.hipaa-dsmo.org Health Level Seven (HL7) ? HL7 is one of several ANSI-accredited Standards Development Organizations (SDOs), and is responsible for clinical and administrative data standards. www.hl7.org Healthcare Information and Management Systems (HIMSS) ? An organization exclusively focused on providing global leadership for the optimal use of information technology (IT) and management systems for the betterment of health care. www.himss.org MassHealth (MH) ? The MassHealth Web site assists providers with HIPAA billing and policy questions, as well as enrollment support. www.mass.gov/masshealth Medicaid HIPAA Compliant Concept Model (MHCCM) ? This site presents the Medicaid HIPAA Compliance Concept Model, information, and a toolkit. www.mhccm.org National Committee on Vital and Health Statistics (NCVHS) ? The National Committee on Vital and Health Statistics was established by Congress to serve as an advisory body to the Department of Health and Human Services on health data, statistics and national health information policy. www.ncvhs.hhs.gov National Council of Prescription Drug Programs (NCPDP) ? The NCPDP is the standards and codes development organization for pharmacy. www.ncpdp.org National Uniform Billing Committee (NUBC) ? NUBC is affiliated with the American Hospital Association and develops standards for institutional claims. www.nubc.org National Uniform Claim Committee (NUCC) ? NUCC is affiliated with the American Medical Association. It develops and maintains a standardized data set for use by the non-institutional health-care organizations to transmit claims and encounter information. NUCC maintains the national provider taxonomy. www.nucc.org Office for Civil Rights (OCR) ? OCR is the office within the Department of Health and Human Services responsible for enforcing the Privacy Rule under HIPAA. www.hhs.gov/ocr/hipaa United States Department of Health and Human Services (HHS) ? The DHHS Web site is a resource for the Notice of Proposed Rule Making, rules, and other information about HIPAA. www.aspe.hhs.gov/admnsimp Washington Publishing Company (WPC) ? WPC is a resource for HIPAA-required transaction implementation guides and code sets. http://www.wpc-edi.com/ Workgroup for Electronic Data Interchange (WEDI) ? WEDI is a workgroup dedicated to improving health-care through electronic commerce, which includes the Strategic National Implementation Process (SNIP) for complying with the administrative-simplification provisions of HIPAA. www.wedi.org 6. Control Segments/Envelopes ISA-IEA This section describes MassHealth’s use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information, and delimiters. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.3 ISA Interchange Control Header C.4 ISA 01 Authorization Information Qualifier 00 C.4 ISA 02 Authorization Information 10 blanks C.4 ISA 03 Security Information Qualifier 00 C.4 ISA 04 Security Information 10 blanks C.4 ISA 05 Interchange ID Qualifier ZZ C.4 ISA 06 Interchange Sender ID DMA7834 C.5 ISA 07 Interchange ID Qualifier ZZ C.5 ISA 08 Interchange Receiver ID Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.5 ISA 09 Interchange Date Format is YYMMDD C.5 ISA 10 Interchange Time Format is HHMM C.5 ISA 11 Repetition Separator Value ^ C.5 ISA 12 Interchange Control Version Number 00501 C.5 ISA 13 Interchange Control Number Identical to the associated interchange control trailer IEA02. C.6 ISA 14 Acknowledgement Requested 0 = No interchange acknowledgment requested (TA1) C.6 ISA 15 Interchange Usage Indicator P = production data T = test data C.6 ISA 16 Component Element Separator Value ':' TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.10 IEA Interchange Control Trailer C.10 IEA 01 Number of Included Functional Groups The number of functional groups included in an interchange. C.10 IEA 02 Interchange Control Number The control number assigned by the interchange sender. GS-GE This section describes MassHealth’s use of the functional group control segments. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how MassHealth expects functional groups to be sent and how MassHealth will send functional groups. These discussions will describe how similar transaction sets will be packaged and MassHealth’s use of functional group control numbers. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.7 GS Functional Group Header C.7 GS 01 Functional Identifier Code HP C.7 GS 02 Application Sender’s Code DMA7834 C.7 GS 03 Application Receiver’s Code Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.7 GS 04 Date Format is CCYYMMDD C.8 GS 05 Time Format is HHMM C.8 GS 06 Group Control Number Identical to the associated functional group trailer GE02. C.8 GS 07 Responsible Agency Code X C.8 GS 08 Version/Release/Industry Identifier Code 005010X221A1 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments C.9 GE Functional Group Trailer C.9 GE 01 Number of Transaction Sets Included Total number of transaction sets included in the functional group. C.9 GE 02 Group Control Number Identical to the associated functional group header GS06. ST-SE This section describes MassHealth’s use of transaction set control numbers. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 67 ST Transaction Set Header 67 ST 01 Transaction Set Identifier Code 835 67 ST 02 Transaction Set Control Number Identical to the associated functional group trailer SE02. 67 ST 03 Implementation Convention Reference 005010X221A1 TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 488 SE Transaction Set Trailer 488 SE 01 Number of Included Segments Total number of segments included in a transaction set including ST and SE segments. 488 SE 02 Transaction Set Control Number Identical to the associated functional group header ST02. 7. Payer Specific Business Rules and Limitations This section describes MassHealth’s business rules, for example: ? Billing for specific services such as DME, Ambulance, Home Health ? Communicating payer specific edits ? CORE Level of Certification Before submitting electronic claims to MassHealth, please review the appropriate HIPAA implementation guide and MassHealth companion guide. In addition, MassHealth recommends that you review the MassHealth billing guides. The CMS-1500 and UB-04 billing guides provide additional billing instructions for specific provider types. These guides are located on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, and then click on Provider Library. The following sections outline recommendations, instructions, and conditional data requirements for claims submitted to MassHealth. This information is designed to help trading partners construct transactions in a manner that will allow MassHealth to efficiently process claims. Claim Level Data - CLP Segment 835s can also be generated without any CLP and SVC. This will be the 835 for providers with no claim activity, but with provider level adjustments. An 835 transaction has one loop 1000A, one loop 1000B, multiple iterations of loop 2000*, multiple iterations of loop 2100*, and multiple iterations of loop 2110*. MassHealth denies claims with the header submitted charges not matching the total detail submitted charges. These claims will be reported on the 835 with only header information (a CLP segment with a CAS segment offsetting the billed amount) and no SVC data. If the sum of the claim payment amounts (CLP04s) on the 835 transaction is positive, then a check or EFT payment is produced. One check or one EFT payment must balance to one 835 transaction. As a result, each 835 can have only one ST and SE segment. MassHealth produces all of a provider’s paid and/or denied claims in a weekly cycle in one ST/SE segment, even if the number of CLP segments exceeds 10,000. If the sum of the claim payment amounts (CLP04s) on the 835 is zero or negative, no check or EFT payment is sent. The 835 is still produced, but the financial fields are zero filled, as they will not be applicable. Note: If there is only one fully adjudicated claim for a provider, then there will be only a single iteration of this segment. Claims Adjustment - Denied Claims with a CAS Segment (2110/CAS) Denied claims with prior payer paid amount equal to the billed amount will not report the other paid amount, but spread the denied amount across all reportable edits. If a denied claim has a nonzero other paid amount, and the other paid amount is not equal to the billed amount, the other paid amount will be reported as an adjustment, and then the remaining dollars will be divided across all reportable edits. If a denied claim has a nonzero other paid amount, the other paid amount is equal to the billed amount. The other paid amount will not be reported as an adjustment, and all the adjustment dollars will be divided across all reportable edits. Here are examples of how this will work: Claim 1: Billed amount = $100.00 Other paid amount = $80.00 Denied edit codes cross-walked to adjustment reason codes AA and BB Adjustments: Other paid amount = $80.00 AA = $10.00 BB = $10.00 Claim 2: Billed amount = $100.00 Other paid amount = $100.00 Denied edit codes cross-walked to adjustment reason codes AA and BB Adjustments: AA = $50.00 BB = $50.00 Claim 3: Billed amount = $100.00 Other paid amount = $120.00 Denied edit codes cross-walked to adjustment reason codes AA and BB Adjustments: Other paid amount = $120.00 AA = -$10.00 BB = -$10.00 Sample of MassHealth Edit Code Crosswalks Current MassHealth Edit Code Adjustment Reason Code Remark Code 241 A1 M58 814 16 MA61 1055 52 M68 020 52 M68 6001 B13 N/A CAS03, CAS06, etc.: MassHealth returns in CAS03, CAS06, etc. The difference between SVC03 and SVC02, divided by the number of adjustment reason codes associated with the claim. For example, assume claim segment SVC03 – SVC02 = $300.25 and the MMIS edits in Table 1 are generated. Since there are three unique adjustment reason code/remark code pairs, $300.25 is divided by 3. For the claim that generates edit codes 241, 814, 1055, and 020 in the above example, the CAS and the LQ segments on the 835 appear as follows. CAS*CO*16*100.25**52*100**A1*100~ ? LQ*HE*MA61~ ? LQ*HE*M68~ ? LQ*HE*M58~ Edit code 6001 has no LQ segment because it does not have a corresponding remark code. Edit code 020 has no CAS and LQ segments because it has the same adjustment reason code/remark code pair as edit code 1055, thus it is not reported twice. Claims Adjustment - Denied Claims without a CAS Segment (2110/CAS) For denied claims that do not have a CAS segment (CLP03 = CLP04 and SVC02 = SVC03) there are as many iterations of the LQ segment as needed to accommodate up to 99 unique remark codes. ? LQ01: LQ01 is always HE. ? LQ02: In LQ02, MassHealth returns each unique remark code associated with the claim. Default Dates When an invalid date is submitted on the claim, or when a claim has a fatal error before the system is able to store the dates that were submitted on the claim, a default date of “19000101” will be coded on the 835 transaction for any date field. Additional Information for Member Name The member name submitted with a claim can be up to 60 characters for the last name and 35 characters for the first name. 2100 patient name segment will report the last and first name as submitted with the claim. 2100 corrected patient/insured name is only reported when the submitted name is different from the one stored in the MMIS database. 8. Acknowledgements and/or Reports MassHealth does not require an acknowledgement and will ignore the receipt of any 999 transactions. 9. Trading Partner Agreements Providers who intend to conduct electronic transactions with MassHealth must sign the MassHealth Trading Partner Agreements. A copy of the agreement is available at www.mass.gov or contact the Customer Service Team (CST) at 1-800-841-2900. Trading Partners An Electronic Data Interchange (EDI) Trading Partner is defined as any entity (provider, billing service, software vendor, employer group, financial institution, etc.) that conducts electronic transactions with MassHealth. The Trading Partner and MassHealth acknowledge and agree that the privacy and security of data held by or exchanged between them is of utmost priority. Each party agrees to take all steps reasonably necessary to ensure that all electronic transactions between them conform to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and regulations promulgated there under. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. 10. Transaction Specific Information This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that MassHealth has something additional, over and above, the information in the IGs. That information can: ? Limit the repeat of loops, or segments ? Limit the length of a simple data element ? Specify a sub-set of the IGs internal code listings ? Clarify the use of loops, segments, composite and simple data elements ? Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with MassHealth In addition to the row for each segment, one or more additional rows are used to describe MassHealth’s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 70 ----- BPR 01 Transaction Handling Code I, H When the total payment amount (BPR02) is greater then zero, BPR01 contains I (remittance information only). When the total payment amount (BPR02) is zero, BPR01 contains an H (notification only). For state transfers, this will always be H. 72 ----- BPR 04 Payment Method Code ACH, NON This will be populated with ACH when BPR01 = I. This will be populated with NON when BPR01 = H. 72 ----- BPR 05 Payment Format Code CTX For providers receiving payments electronically, this is CTX (corporate trade exchange). 74 ----- BPR 11 Originating Company Supplemental Code This field is used by MassHealth for tracking purposes to assist in issue resolution. It is populated with a voucher number from MMARS. 82 ----- REF 02 Receiver Identifier This data element is used only when the Payee is not the same as the receiver of the 835. MassHealth returns the 835 receiver’s MassHealth assigned provider ID/service location you provided on your trading partner profile form. 85 ----- DTM 01 Date/Time Qualifier 405 This field will always contain the value of 405 for production. 86 ----- DTM 02 Date This attribute is also known as the financial run date. The run date is calculated based on the system date in which the financial cycle was initiated. 87 1000A N1 02 Payer Identification / Name This value is always Commonwealth of Massachusetts/EOHHS/Offic e of Medicaid. 95 1000A PER 03 Payer Business Contact / Communication Number Qualifier TE TE 95 1000A PER 04 Payer Business Contact / Communication Number The phone number on the 835 will be for MassHealth Customer Service; however, if the questions are about a pharmacy claim, use the ACS phone number (617-423- 9830). If questions are about a dental claim, use the Doral phone number (1-800-207- 5019). 96 1000A PER 05 Payer Business Contact / Communication Number Qualifier EM EM 96 1000A PER 06 Payer Business Contact / Communication Number The e-mail on the 835 will be for MassHealth Customer Service: edi@mahealth.net However, if the questions are about a pharmacy claim, use the ACS e-mail: MassHealth.ProviderRelation s@acs-inc.com 97 1000A PER 01 Payer Technical Contact / Contact Function Code BL BL 98 1000A PER 02 Payer Technical Contact / Name EOHHS Customer Service 98 1000A PER 03 Payer Technical Contact / Communication Number Qualifier TE TE 98 1000A PER 04 Payer Technical Contact / Communication Number 18008412900 98 1000A PER 05 Payer Technical Contact / Communication Number Qualifier UR UR 99 1000A PER 06 Payer Technical Contact / Communication Number hipaasupport@mahealth.net 100 1000A PER 01 Payer Web Site / Contact Function Code IC IC 101 1000A PER 03 Payer Web Site / Communication Number UR UR 101 1000A PER 04 Payer Web Site / Communication Number www.mass.gov/masshealth 103 1000B N1 03 Identification Code Qualifier MassHealth returns national provider ID (XX in 1000B:N103) when the NPI is returned in N104. MassHealth returns federal taxpayer’s identification number (FI in 1000B:N103), when the provider tax ID is returned in N104. 103 1000B N1 04 Payee Identification Code MassHealth returns NPI. For an atypical provider, MassHealth returns provider tax ID. 104 1000B N3 01 Payee / Address Line In MMIS, this field is not used, therefore the billing address on file will not be returned. 105 1000B N4 01 Payee / City Name In MMIS, this field is not used, therefore the billing address on file will not be returned. 106 1000B N4 02 Payee / State In MMIS, this field is not used, therefore the billing address on file will not be returned. 106 1000B N4 03 Payee / Zip Code In MMIS, this field is not used, therefore the billing address on file will not be returned. 107 1000B REF 01 Payee Additional Identification / Reference Identification Qualifier TJ, PQ Code Definition TJ Federal taxpayer’s identification number (NPI) is reported when NPI is reported in 1000B:N104 and if available in MMIS. PQ Payee identification is reported for atypical providers (1000B:N104 = Federal Tax ID). 108 1000B REF 02 Payee Additional Identification / Additional Payee Identifier MassHealth returns = federal taxpayer’s identification number when 1000B:N104 = NPI. MassHealth returns MMIS provider ID/SL when the provider tax ID was used in 1000B:N104 (for atypical providers). 123 2100 CLP 01 Claim Payment Information / Patient Control Number For EDI 837 submitted claims, MassHealth would return the data in loop 2300 CLM01 of the 837. For paper and direct data entry (DDE) claims: MassHealth returns the patient control number or the patient account number. If this field is left blank on the incoming claim, then we return zeros. For pharmacy claims, the prescription number will be reported. 124 2100 CLP 02 Claim Status Code 1, 2, 3, 4, 22 Code Definition 1 Claim processed as primary 2 Claim processed as secondary 3 Claim processed as tertiary 4 Claims denied with edit 2001 indicating patient/subscriber billed is not known 22 Reversal of previous payment 138 2100 NM1 03 Patient Last Name For 837 claims, MassHealth returns the claim level rendering provider information as submitted on the claim. For paper and DDE claims, MassHealth returns the rendering provider’s name on the database. 138 2100 NM1 04 Patient First Name 138 2100 NM1 05 Patient Middle Name 154 2100 NM1 03 Corrected Patient Last Name For claims received on an 837, MassHealth returns the patient name information that you provided in Loop 2010BA NM103, NM104, NM105, and NM107. 154 2100 NM1 04 Corrected Patient First Name 154 2100 NM1 05 Corrected Patient Middle Name For claims received on an 837, MassHealth returns the patient name information that you provided in Loop 2010BA NM103, NM104, NM105, and NM107. For paper and direct data entry (DDE) claims MassHealth returns the patient name information that we have on file in our claims processing system. If the member number that you provide does not find a match in our system, MassHealth populates the member last name (NM103) and member first name (NM104) data elements with “name missing.” 147 2100 NM1 03 Service Provider / Rendering Provider Last or Organization Name For 837 claims, MassHealth returns the claim level rendering provider information as submitted on the claim. For paper and DDE claims, MassHealth returns the rendering provider’s name on the database. 147 2100 NM1 04 Service Provider / Rendering Provider First Name 148 2100 NM1 05 Service Provider / Rendering Provider Middle Name 148 2100 NM1 07 Rendering Provider Name Suffix 154 2100 NM1 03 Corrected Priority Payer Name / Name Last or Organization Name This segment is populated, to report the payer that caused the claim to deny with TPL edit. If multiple payers caused the claim to deny for TPL edit, MassHealth prioritizes the payer to be reported (Medicare takes priority.) Carrier name is populated in NM103. 154 2100 NM1 08 Corrected Priority Payer Name / Identification Code Qualifier PI Code Definition PI Payor Identification 154 2100 NM1 09 Corrected Priority Payer Name / Identification Code Carrier ID is populated here 169 2100 REF 01 Other Claim Related Information / Other Claim Related Identifier EA, SY, G1, F8. 6P If applicable to the claim, MassHealth returns the following information. There may be zero to five iterations of this segment, depending on how many of the above criteria are met. 170 2100 REF 02 Other Claim Related Information / Other Claim Related Identifier 1. Medical Record Number: REF 01 EA REF 02 The inpatient or outpatient medical record number 2. Social Security Number: REF 01 SY REF 02 The member social security number 3. Prior Authorization Number: REF 01 G1 REF 02 The six-character prior authorization number 4. Former ICN: REF 01 F8 REF 02 The 10-character former TCN 2 5. TPL Policy Number : REF 01 6P REF 02 The TPL policy number The group number of the other insured for the payer will be reported in the corrected priority payer name/identification code. 182 2100 AMT 01 Service Supplemental Amount / Amount Qualifier Code AU Code Definition AU Coverage Amount 183 2100 AMT 02 Service Supplemental Amount / Monetary Amount Allowed amount from the claim line 182 2100 AMT 01 Service Supplemental Amount / Amount Qualifier Code F5 Code Definition F5 Patient Paid Amount 183 2100 AMT 02 Service Supplemental Amount / Monetary Amount On a provider submitted original claim, use the greater of provider submitted PPA or the PPA on our database. 174 2100 DTM 01 Statement From or To Dates / Date/Time Qualifier 232, 233 Code Definition 232 Claim statement period start 233 Claim statement period end 174 2100 DTM 02 Statement From or To Dates / Date Format is CCYYMMDD 175 2100 DTM 01 Coverage Expiration Date / Date/Time Qualifier 36 Code Definition 36 Expiration 175 2100 DTM 02 Coverage Expiration Date / Date Format is CCYYMMDD 187 2110 SVC 01-1 Service Payment Information / Composite Medical Procedure Identifier - Product/Service ID Qualifier NU, HC, ADA, N4 In order to provide the most detailed information to providers on why a claim denied, MassHealth supplies remark codes when applicable on all denied claims. To include remark codes, the 835 Implementation Guide mandates that we also provide service line information. The following is a list of defaults we use, if the incoming claim is missing this required data. Segm ent Value For certain 837-Institutional claims or claims received on a UB-04 form, a revenue code and no HCPCS is provided: SVC 01-1 NU SVC 01-2 Revenue Code 188 2110 SVC 01-2 Service Payment Information / Composite Medical Procedure Identifier - Product/Service ID For an 837 Institutional claim, or claims received on a UB- 04 form – if HCPCS submitted, both a service and a revenue code are provided: SVC 01-1 HC SVC 01-2 Service Code SVC 04 Revenue Code 190 2110 SVC 04 Service Payment Information / Product/Service ID For 837 Professional claims, a HCPCS code is provided: SVC 01-1 HC SVC 01-2 Service Code For 837 Dental claims: SVC 01-1 ADA SVC 01-2 Procedure Code For 837 Pharmacy claims: SVC 01-1 N4 SVC 01-2 National drug code in 5-4-2 format 195 2110 DTM 02 Service Date For paper claims submitted with an invalid date such as spaces or 20020231, we return 99990101. 198 2110 CAS 01 Claims Adjustment / Group Code CO, OA, PI, PR Code Definition CO Contractual Obligations OA Other adjustments PI Payor initiated Reductions PR Patient Responsibility 198 2110 CAS 02 Claims Adjustment / Reason Code Providers can refer to claim adjustment reason codes at http://www.wpc- edi.com/custom_html/claimad justment.htm 199 2110 CAS 03 Claims Adjustment / Monetary Amount Use this monetary amount for the adjustment amount. A negative amount increases the payment, and a positive amount decreases the payment contained in SVC03 and CLP04. 2110 CAS 04 Claims Adjustment / Quantity A positive number decreases paid units, and a negative value increases paid units. 206 2110 REF 01 Line Item Control Number / Reference Identification Qualifier 6R Code Definition 6R Provider control number 206 2110 REF 02 Line Item Control Number / Reference Identification For claims received on an 837, MassHealth returns the line item control number, which is used by the provider for tracking purposes. 207 2110 REF 01 Rendering Provider Information / Reference Identification Qualifier D3, HPI, G2 Code Definition D3 National Council for Prescription Drug Programs pharmacy number HPI Provider NPI G2 Provider commercial number (used when the atypical provider PID/SL is reported). 208 2110 REF 02 Rendering Provider Information / Reference Identification MassHealth returns the service level rendering provider information as submitted on the claim. 211 2110 AMT 01 Service Supplemental Amount / Amount Qualifier Code B6 Code Definition B6 Allowed – Actual 212 2110 AMT 02 Service Supplemental Amount / Monetary Amount Allowed amount from the service line. 215 2110 LQ 01 Health Remark Codes / Code List Qualifier Code HE Code Definition HE Claim payment remark codes There are as many iterations of the LQ segment as needed to accommodate each unique remark code associated with the claim. When an EOB/remark code relates the header of the claim, the related header LQ segments will appear in each service line loop of the claim. 216 2110 LQ 02 Health Remark Codes / Industry Code LQ02 will contain each unique remark code associated with the claim. Providers can refer to remark codes at: http://www.wpc- edi.com/content/view/507/22 8 219 ----- PLB 03-1 Provider Adjustment / Adjustment Identifier/ Adjustment Reason Code 72, CT, FB, IR, LE, WO, CS This segment is used only if there are non-claim related adjustments and/or adjustments made by MMARS. Code Definition 72 Authorized return CT For capitation payment FB For forwarding balance IR Internal Revenue Service Withholding LE Levy WO Overpayment recovery CS Adjustment- will be used to identify an adjustment applied to payment due to MMARS. 222 ----- PLB 03-2 Provider Adjustment / Adjustment Identifier / Reference Identification All 9s will be populated here when a MMARS adjustment has been performed (PLB03- 1 = CS). Appendices A. Implementation Checklist This appendix contains all necessary steps for going live with MassHealth. 1. Call the EDI Help Desk with any questions at the Toll Free Number. 2. Check the EOHHS website for the latest updates regarding our system implementation. 3. Confirm you have an EOHHS User Name and/or Provider ID. 4. Make the appropriate changes to your systems/business processes to support the updated companion guides: ? If you are a NEHEN provider or use third party software, work with your software vendor to have the appropriate software installed ? If testing system-to-system (Health Care Transaction Service) interface the Trading Partner or provider must work with your software vendor to have the appropriate software installed at their site(s) prior to performing testing with MassHealth 5. Identify the functions you will be testing: ? Health Care Eligibility/Benefit Inquiry and Information Response (270/271) ? Health Care Claim Status Request and Response (276/277) ? Health Care Premium Payment (820) ? Health Care Benefit Enrollment and Maintenance (834) ? Health Care Payment/Advice (835) ? Health Care Claim: Institutional (837I) ? Health Care Claim: Professional (837P) ? Crossover/COB Claims 6. Confirm you have reported all the NPIs you will be using for testing by validating them with MassHealth. Make sure your claim(s) successfully pay to your correct Provider ID, if you have associated multiple MassHealth provider IDs to one NPI and/or taxonomy code. ? If the entity testing is a billing intermediary or software vendor, they should use the provider’s identifiers on the test transaction. 7. When submitting test files, make sure the members/claims you submit are representative of the type of service(s) you provide to MassHealth members. 8. Schedule a tentative week for the initial test. 9. Confirm the email/phone number of the testing contact and confirm that the person you are speaking with is the primary contact for testing purposes. B. Business Scenarios This appendix contains typical business scenarios. The actual data streams linked to these scenarios are included in Appendix C. 1. Examples of 5010 loop changes: A. 2100 AMT Allowed Amount The sample 837I EDI shows the new AMT*AU allowed amount posted only for information. Note: AMT*AU is not part balancing. B. 2100 CAS Claim Adjustment Group Code Sample 837P reversal ICN and a denied replacement ICN shows the new reversal qualifier OA reporting the CAS adjustment amount previously reported with qualifier CR. C. 2100 DTM Claim Date Coverage Expiration Date Sample denied ICN where denial is for member’s coverage ended. The 835 displays the member’s coverage end date in the DTM*036 line resulting in member denying for no open coverage on service date billed. 2. 2100 CLP samples: A. 2100 CLP Sample #1 Sample denied claim where the CLP02 / claim status = 1. Prior to 5010, the CLP02 status would equal 4 for all denied claim records. B. 2100 CLP Sample #2 Sample denied claim for edit 2001/member not on file, where CLP02/claim status = 4. This is the only denial edit reason that will result in a CLP02 status of ‘4’ being moved to the CLP02 claim status field post-5010 implementation. C. 2100 CLP Sample #3 Sample paid claim where CLP02/ claim status = 1. C. Transmission Examples This appendix contains actual data streams. The business scenarios linked to the data streams are included in Appendix B. 1. Examples of 5010 loop changes (note the underlined text within the example): A. 2100 AMT Allowed Amount The sample 837I EDI shows the new AMT*AU allowed amount posted only for information. Note: AMT*AU is not part balancing. LX*1~ CLP*26010*4*1000*0*0*MC*2211219000001~ CAS*CO*133*333.34~ CAS*OA*23*333.33~ CAS*CO*45*333.33~ NM1*QC*1* LASTNAME*FIRSTNAME****MR*999999999999~ NM1*74*1* CORRECTEDLASTNAME*CORRECTEDFIRSTNAME~ DTM*232*20110601~ DTM*233*20110604~ AMT*AU*8145.63~ B. 2100 CAS Claim Adjustment Group Code Sample 837P reversal ICN and a denied replacement ICN shows the new reversal qualifier OA reporting the CAS adjustment amount previously reported with qualifier CR. CLP*77257553652330001019*22*-130*-18.06*0*MC*2010102702533~ CAS*OA*B13*-111.94~ NM1*QC*1*LASTNAME*FIRSTNAME****MR*999999999999~ NM1*74*1*CORRECTEDLASTNAME*CORRECTEDFIRSTNAME~ REF*EA*000002195988~ REF*G1*S000000001~ DTM*232*20100405~ DTM*233*20100405~ CLP*77257553652330001019*4*130*0*0*MC*5911208001002 CAS*CO*B5*130~ NM1*QC*1*LASTNAME*FIRSTNAME****MR*100056666666~ NM1*74*1*CORRECTEDLASTNAME*CORRECTEDFIRSTNAME~ REF*EA*000002195988~ REF*G1*S000000001~ REF*F8*2010102702533 ~ DTM*232*20100405~ DTM*233*20100405~ C. 2100 DTM Claim Date Coverage Expiration Date Sample denied ICN where denial is for member’s coverage ended. The 835 displays the member’s coverage end date in the DTM*036 line resulting in member denying for no open coverage on service date billed. CLP*24622*4*155*0*0*MC*2011201700001~ NM1*QC*1*LASTNAME*FIRSTNAME****MR*999999999999~ NM1*74*1* CORRECTEDLASTNAME*CORRECTEDFIRSTNAME~ REF*EA*125~ DTM*232*20110712~ DTM*233*20110712~ DTM*036*19791231~ SVC*HC:99214*150*0**0**1~ DTM*472*20110712~ CAS*CO*31*150~ REF*6R*321~ REF*HPI*1821017195~ LQ*HE*N30~ 2. 2100 CLP samples: A. 2100 CLP Sample #1 Sample denied claim where the CLP02 / claim status = 1. Prior to 5010, the CLP02 status would equal 4 for all denied claim records. CLP*TEST WI 26768*1*155*0*0*MC*201128070999*11*1~ NM1*QC*1*LASTNAME *FIRSTNAME ****MR*999999999999~ REF*EA*125~ DTM*232*20110822~ DTM*233*20110822~ DTM*036*19791231~ SVC*HC:99214*150*0**0**1~ DTM*472*20110822~ CAS*CO*31*150~ REF*6R*321~ REF*HPI*1821017195~ LQ*HE*N30~ SVC*HC:82270*5*0**0**1~ DTM*472*20110822~ CAS*CO*31*5~ REF*6R*322~ REF*HPI*1821017195~ LQ*HE*N30~ SE*58*28001~ GE*1*28~ IEA*1*000000396~ B. 2100 CLP Sample #2 Sample denied claim for edit 2001 / member not on file, where CLP02 / claim status = 4. This is the only denial edit reason that will result in a CLP02 status of ‘4’ being moved to the CLP02 claim status field post-5010 implementation. CLP*TEST WI 26768*4*155*0*0*MC*201128070999*11*1~ CAS*CO*31*155~ NM1*QC*1*LASTNAME *FIRSTNAME ****MR*999999999999~ REF*EA*125~ DTM*232*20110811~ DTM*233*20110811~ CLP*TEST WI 26768*1*155*0*0*MC*2011280700001*11*1~ NM1*QC*1*CHURCHILL*GARY****MR*100002040465~ REF*EA*125~ DTM*232*20110822~ DTM*233*20110822~ DTM*036*19791231~ SVC*HC:99214*150*0**0**1~ DTM*472*20110822~ CAS*CO*31*150~ REF*6R*321~ REF*HPI*1821017195~ LQ*HE*N30~ SVC*HC:82270*5*0**0**1~ DTM*472*20110822~ CAS*CO*31*5~ REF*6R*322~ REF*HPI*1821017195~ LQ*HE*N30~ SE*58*28001~ GE*1*28~ IEA*1*000000396~ C. 2100 CLP Sample #3 Sample paid claim where CLP02 / claim status = 1. CLP*Defect 26686*1*155*77.1*0*MC*201128570999*11*1~ NM1*QC*1*D*Evelyn****MR*999999999999~ NM1*74*1*LASTNAME *FIRSTNAME~ REF*EA*125~ DTM*232*20110902~ DTM*233*20110902~ SVC*HC:99214*150*73.71**1~ DTM*472*20110902~ CAS*CO*45*76.29~ REF*6R*321~ REF*HPI*1821017195~ AMT*B6*73.71~ LQ*HE*N419~ SVC*HC:82270*5*3.39**1~ DTM*472*20110902~ CAS*CO*45*1.61~ REF*6R*322~ REF*HPI*1821017195~ AMT*B6*3.39~ LQ*HE*N419~ D. Frequently Asked Questions This appendix contains a compilation of questions and answers relative to MassHealth and its providers. Typical question would involve a discussion about code sets and their effective dates. Q: Do I have to receive an 835 remittance response if I submit my claims electronically? A: No. You can submit an 837 transaction, but elect not to receive the 835 response. You will still receive the PDF remittance advice. Q: Will any paper claims I submit also appear on the 835? A: Yes. All paid and denied claims adjudicated in the weekly cycle will appear, regardless of how the claims were submitted. Q: Will suspended and pended claims appear on the 835? A: No. Suspended and pended claims will appear only in the PDF remit. Q: Can I have my billing intermediary receive my 835? A: Yes. You can have your billing intermediary receive your 835, as long as you indicate that in your TPP information. E. Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Version Date Section/Pages Description 5.0 10/2012 Entire document Complete revision to comply with CAQH® (Council for Affordable Quality Healthcare) CORE™ (Committee on Operating Rules for Information Exchange) v5010 Master Companion Guide Template. Transaction specific data elements, and their values, were not changed. All previous versions are obsolete. MassHealth 005010 835 Companion Guide October 2012, Version 5.0 iv MassHealth 005010 835 Companion Guide October 2012, Version 5.0 i October 2012, Version 5.0 28 MassHealth 005010 835 Companion Guide October 2012, Version 5.0 Appendix 7