MassHealth Health Care Claim: Institutional (837I) Residential Care Homes Companion Guide Refers to the Implementation Guides Based on ASC X12N version: 005010X223A2 October 2012 Version 3.0 Disclosure Statement The following Massachusetts Companion Guide is intended to serve as a companion document to the corresponding ASC X12N/005010X223 Health Care Claim: Institutional (837), its related Addenda (005010X223A2) and its related Errata (005010X223E1). 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 005010X223 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 RETRANSMISSION PROCEDURE 7 COMMUNICATION PROTOCOL SPECIFICATIONS 7 PASSWORDS 7 5. CONTACT INFORMATION 8 EDI CUSTOMER SERVICE 8 EDI TECHNICAL ASSISTANCE 8 PROVIDER SERVICE NUMBER 8 APPLICABLE WEBSITES/EMAIL 8 6. CONTROL SEGMENTS/ENVELOPES 10 ISA-IEA 10 GS-GE 12 ST-SE 13 7. PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 14 8. ACKNOWLEDGEMENTS AND/OR REPORTS 17 REPORT INVENTORY 24 9. TRADING PARTNER AGREEMENTS 25 TRADING PARTNERS 25 10. TRANSACTION SPECIFIC INFORMATION 25 STANDARD CLAIMS 25 COB CLAIMS 29 APPENDICES 1 A. IMPLEMENTATION CHECKLIST 1 B. BUSINESS SCENARIOS 2 C. TRANSMISSION EXAMPLES 3 D. FREQUENTLY ASKED QUESTIONS 4 E. CHANGE SUMMARY 5 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 837 Health Care Claim: Institutional transactions is 005010X223A2. This Companion Guide assumes compliance with all loops, segments and data elements contained in the 005010X223A2. This Companion Guide does NOT include any of the required loops, segments or data elements defined in the 005010X223A2 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. 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. We strongly encourage you to submit any electronic files directly to our Web portal in order to avoid a delay in processing your claims. By using our Web portal you can get a faster response on the status of your claims (e.g., if they will be paid or denied; if denied, with what error codes), that will allow you to determine the problem and be able to resubmit the claims electronically in a more timely manner. If you are unable to upload an electronic file to our web site due to a technical outage, we allow submitters to submit hard media to MassHealth for claims submission. If you have data on hard media, you must send it on a CD or diskette with the filename prominently displayed on the label, along with the following information. If this information is not clearly listed on the external label, you risk delays in processing your claims or potentially having the hard media returned to you. The external label on the hard media must appear as follows: Header: MassHealth Submission File Name: As determined by the submitter following the appropriate file-naming convention for test or production claims Transaction Type: Institutional MassHealth Submitter / Pay-to-Provider number The MassHealth number of the provider or billing intermediary submitting the hard media Submitter Name: The name of the provider or billing intermediary submitting the hard media Submission Date: MM/DD/YY Contact Name: The name of the person to contact if MassHealth has a problem with the hard media Contact Information: Telephone number and/or email address Please note that providers submitting single claims directly to MassHealth, via the POSC, using direct data entry (DDE), are not required to test. You must however, have a valid trading partner agreement on file with MassHealth to submit claims. Before submitting production claims to MassHealth, each trading partner must be tested. Trading partners planning to submit 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. If you are a first-time submitter and want to test electronically with MassHealth, we require the following: ? The test file must have a minimum of 10 and a maximum of 50 test claims. ? The member and provider data must be valid for a mutually agreed upon effective date. The test files should contain as many types of claims as necessary to cover each of your business scenarios. The following types of claims must be submitted in one or more test files: ? original claims; ? void claims (if you plan to submit void transactions); ? replacement claims (if you plan to submit void transactions and replacement claims); and ? coordination of benefits (COB) claims (COB claims testing is required for providers who plan to submit COB claims). Providers submitting test files containing COB claims (where the member has other insurance) should include a minimum of 10 and a maximum of 50 COB claims with the following criteria: ? claims with commercial insurance (denied/paid); ? claims with Medicare (denied/paid); ? claims with multiple insurance (if applicable); and ? claims with a total non-covered amount if applicable to the submitter only as described in provider manual appendices. All test files submitted on hard media, regardless of the type of services provided, must be submitted using the following naming convention for all media types: ? TYYYYYYYYYY.ZZZ, where: ? T indicates Test data. ? YYYYYYYYYY is the 10-character MassHealth submitter ID/pay-to-provider number. ? ZZZ is the sequence number assigned to the file by the trading partner, starting with a value of “001.” ? This sequence number should be increased by one for each subsequent test file that is submitted. The sequence number will restart at 001 after it reaches 999. Providers are advised to submit the 835 remittance advice and/or the paper explanation of benefits (EOB) from the other insurer to be used in the testing process for verification of data in the COB loops. Providers must indicate which claims on the 835 remittance advice and/or paper EOB correspond to the claims on the test file. MassHealth will process these transactions in a test environment to verify that the file structure and content meet HIPAA standards and MassHealth-specific data requirements. Once this validation is complete, the trading partner may submit production transactions to MassHealth for adjudication. Test claims are adjudicated in the test system, but will not be adjudicated for payment. 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). Production File-naming Convention Files transmitted to MassHealth using the POSC may use any convenient file-naming convention. The system will rename files upon receipt and issue a tracking number for reference. Files transmitted to MassHealth via hard media must adhere to the following naming convention: HYYYYYYYYYY.ZZZ, where: H Indicates a HIPAA-compliant production file. YYYYYYYYYY Indicates the trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). ZZZ Indicates the sequence number assigned to the file starting with a value of ‘001’. The sequence number should be increased by one for each subsequent file that is submitted. The sequence number will restart at ‘001’ after it reaches ‘999’. Retransmission Procedure MassHealth does not require any identification of a previous transmission of a file. All files sent should be marked as original transmissions. 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 effectively 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 Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.5 ISA 07 Interchange ID Qualifier ZZ C.5 ISA 08 Interchange Receiver ID DMA7384 C.5 ISA 09 Interchange Date Format is YYMMDD C.5 ISA 10 Interchange Time Format is HHMM C.5 ISA 11 Repetition Separator The repetition separator is a delimiter and not a data element. It is used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different from the data element separator, component element separator, and the segment terminator. C.5 ISA 12 Interchange Control Version Number 00501 C.5 ISA 13 Interchange Control Number Must be identical to the associated interchange control trailer IEA02. C.6 ISA 14 Acknowledgement Requested 0 = No interchange acknowledgment requested (TA1) 1 = Interchange acknowledgment requested (TA1) C.6 ISA 15 Interchange Usage Indicator P = production data T = test data C.6 ISA 16 Component Element Separator The component element separator is a delimiter and not a data element. It is used to separate component data elements within a composite data structure. This value must be different from the data element separator and the segment terminator. 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 HC C.7 GS 02 Application Sender’s Code Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). C.7 GS 03 Application Receiver’s Code DMA7384 C.7 GS 04 Date Format is CCYYMMDD C.8 GS 05 Time Format is HHMM C.8 GS 06 Group Control Number Must be 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 005010X223A2 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 Must be 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 837 67 ST 02 Transaction Set Control Number Must be identical to the associated functional group trailer SE02. 67 ST 03 Implementation Convention Reference 005010X223A2 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 Must be 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. National Provider Identifier (NPI) MassHealth expects the provider’s national provider identifier (NPI) in the appropriate NM109 data element, and taxonomy code (if instructed to do so by MassHealth) in the appropriate PRV data element, unless you are not required to use an NPI. If you are not required to use an NPI, your 10-character provider ID (comprised of nine digits and an alpha character to denote the service location) should be submitted in the appropriate REF02 data element with an REF01 qualifier of “G2.” For adjudication, MassHealth expects the billing provider identification and the doing business as (DBA) addresses for the billing provider address and ignores the 2010AB loop. To facilitate accurate cross-walking of claims, please include your actual DBA address in the appropriate fields as well. Claims Attachments Currently, residential care homes do not require attachments. Encounter Claims MassHealth does not accept encounter claims. Void and Replacement Transactions Void Transactions Void transactions are used by submitters to correct and report any one of the following situations: ? duplicate claims erroneously paid; ? payment to the wrong provider; ? payment for the wrong member; ? payment for overstated or understated services; and ? payment for services for which payment has been received from third-party payers. Void transactions must be submitted at the claim-header level and must include the original MassHealth-generated internal control number (ICN) for the service with a claim frequency code equal to “8.” The Affordable Care Act requires providers to submit a reason for void transactions. MassHealth has enhanced the notes section of the HIPAA-compliant 837 transaction to allow the provider to enter a void reason code for the overpayment. Providers submitting batch transactions should enter the three-character qualifier ADD in Loop 2300 NTE01. Providers should also enter one of the reasons, including the numeric code, from the following list in the Notes field of the 837 transaction (Loop 2300 NTE02). Code Definition 9050 Collection from Medicare Part A 9051 Collection from Medicare Part B 9052 Collection from commercial health insurance (state carrier’s name) 9053 Collection from auto insurance or workers’ compensation insurance (state carrier’s name) 9057 Claim paid to the wrong provider 9058 Wrong MassHealth member ID on the claim 9059 Provider billed incorrect service date 9060 Erroneous duplicate payment for same service date 9061 Provider billed service twice 9062 Collection from credit balance or patient account 9064 Provider performed only a certain component of the entire service billed 9065 Other (specify) 9067 Collection from Medicare (not known if Part A or Part B) 9078 Provider billed incorrectly (specify) 9085 Cost report issues (specify) Replacement Transactions Replacement transactions are used by submitters to adjust paid claims. If the submitter is trying to correct a paid claim where the member ID, provider ID, and claim type are staying the same, they can send in a replacement claim with appropriate lines from the original claim (both paid and denied). They can omit lines that have denied correctly and should not be resubmitted. Add additional lines if necessary or correct data elements on existing detail lines as appropriate. Replacement transactions must include the original MassHealth-generated internal control number (ICN) for the service with a claim frequency code equal to "7." The Affordable Care Act requires providers to submit a reason for void and replace transactions. MassHealth has enhanced the notes section of the HIPAA-compliant 837 transaction to allow the provider to enter a void reason code for the overpayment. Providers submitting claims electronically, via either batch or DDE on the Provider Online Service Center, should enter the three-character qualifier ADD in Loop 2300 NTE01. Providers should also enter one of the reasons, including the numeric code, from the following list in the Notes field of the 837 transaction (Loop 2300 NTE02). Code Definition 9050 Collection from Medicare Part A 9051 Collection from Medicare Part B 9052 Collection from commercial health insurance (state carrier’s name) 9053 Collection from auto insurance or workers’ compensation insurance (state carrier’s name) 9057 Claim paid to the wrong provider 9059 Provider billed incorrect service date 9060 Erroneous duplicate payment for same service date 9061 Provider billed service twice 9062 Collection from credit balance or patient account 9064 Provider performed only a certain component of the entire service billed 9065 Other (specify) 9067 Collection from Medicare (not known if Part A or Part B) 9078 Provider billed incorrectly (specify) 9085 Cost report issues (specify) Please note that a submitter should not attempt to void the original claim before sending in a replacement. This will result in denial of the replacement claim for error 550 - Adjustment Failed. Instead, the submitter should send in only the replacement transaction. The system will automatically inactivate the original claim. Coordination of Benefits Currently, residential care homes do not use coordination of benefits. 340B Drug Information Currently, residential care homes do not identify 340B drugs. Service Codes Please consult Subchapter 6 or the appropriate appendix of your MassHealth provider manual for information on acceptable revenue and service codes. This information is also available on the Web. Provider Types to Invoice Types Map This section is not applicable to residential care homes. Additional Information MassHealth does not process certain loops that do not apply to the MassHealth business model. In certain circumstances, these loops may be required in a compliant 837 transaction. However, the data content of these loops will not affect the MassHealth claims adjudication process. 8. Acknowledgements and/or Reports Confirmation numbers are generated for all transaction files uploaded to the POSC, indicating successful file uploads. A TA1 interchange acknowledgment is generated for all batch files with ISA14 set to “1 - Interchange acknowledgment requested (TA1).” A 999 implementation acknowledgement is generated for all batch files that do not fail and includes interchange (ISA) errors. These acknowledgements will be available for download from the POSC. The TA1 Interchange Acknowledgement The TA1 allows the receiver of a file to notify the sender that a valid interchange control structure was received or that problems were encountered. The TA1 verifies only the interchange header (ISA/GS) and trailer (ISE/GE) segments of the file envelope. If the submitted file has an ISA14 value of “1” and contains ISA or GS errors then the generated TA1 report with the Interchange Header errors will be placed on the POSC or HTS for pickup. If the submitted file contains an ISA14 value of “1” and there are no ISA or GS errors detected, then the TA1 will indicate “no errors.” What to look for in the TA1 The TA1 segment indicates whether or not the submitted interchange control structure passed the HIPAA compliance check. If TA104 is “A” then the entire interchange control structure was accepted. The file will then proceed to be checked for compliance. If TA104 is “R” then the transmitted interchange control structure header and trailer were rejected because of errors. The submitter will need to correct the errors and resubmit the corrected file to MassHealth. Example: TA1*900000001*090721*1700*R*006~ The data elements in the TA1 segment are defined as follows: TA101 contains the Interchange Control Number (ISA13) from the file to which this TA1 is responding (“900000001” in the example above). TA102 contains the Interchange Date (“090721” in the example above). TA103 contains the Interchange Time (“1700” in the example above). TA104 code indicates the status of the interchange control structure (“R” in the example above). The definitions of the codes are as follows. “A” - The transmitted interchange control structure header and trailer have been received and have no errors. “R” - The transmitted interchange control structure header and trailer are rejected because of errors. TA105 code indicates the error found while processing the interchange control structure (“006” in the example above). The definitions of the codes are as follows. Code Description 000 No error 001 The Interchange Control Number in the Header and Trailer do not match. The value from the Header is used in the Acknowledgement. 002 This standard as noted in the Control Standards Identifier is not supported. 003 This version of the Controls is not supported. 004 The segment Terminator is invalid. 005 Invalid Interchange ID Qualifier for sender 006 Invalid Interchange Sender ID 007 Invalid Interchange ID Qualifier for receiver 008 Invalid Interchange Receiver ID 009 Unknown Interchange Receiver ID 010 Invalid Authorization Information Qualifier value 011 Invalid Authorization Information value 012 Invalid Security Information Qualifier value 013 Invalid Security Information value 014 Invalid Interchange Date value 015 Invalid Interchange Time value 016 Invalid Interchange Standards Identifier value 017 Invalid Interchange Version ID value 018 Invalid Interchange Control Number value 019 Invalid Acknowledgment Requested value 020 Invalid Test Indicator value 021 Invalid Number of Included Groups value 022 Invalid Control Structure 023 Improper (Premature) End-of-File (Transmission) 024 Invalid Interchange Content (e.g., Invalid GS Segment) 025 Duplicate Interchange Control Number 026 Invalid Data Element Separator 027 Invalid Component Element Separator 028 Invalid Delivery Date in Deferred Delivery Request 029 Invalid Delivery Time in Deferred Delivery Request 030 Invalid Delivery Time Code in Deferred Delivery Request 031 Invalid Grade of Service Code The TA1 segment will be sent within its own interchange (i.e., ISA-TA1-IEA) Example of a TA1 within its own interchange ISA*00* *00* *ZZ*DMA7384 *ZZ*receiver *110721*1701*^*00501*000000001*0*P*~ TA1*900000001*110720*1245*R*006~ IEA*0*000000001~ For additional information, consult the Interchange Control Structures, X12.5 Guide. Implementation guides may be obtained by logging on to http://www.wpc-edi.com/ and following the links to ‘EDI Publications’ and ‘5010 Technical Reports.’ The 999 Implementation Acknowledgement Each time a 5010 X12 file is submitted to MassHealth, a system-generated 999 acknowledgement is sent to the submitter within one business day. A 999 does not guarantee processing of the transaction. It only signifies that MassHealth received the Functional Group. The following sections explain how to read the 999 to find out whether a file is accepted or rejected. If a Functional Group is accepted, no action is required by the submitter. If the Functional Group is rejected, the submitter must correct the errors and submit the corrected file to MassHealth. What to look for in the 999 Locate every AK9 segment. These segments indicate whether or not the submitted Functional Group passed the HIPAA compliance check. If each AK9 segment appears as AK9*A, this means the entire Functional Group was accepted for processing. The transaction will process. If any AK9 segment begins with AK9*R (Rejected), or AK9*P (Partially Accepted - At least one transaction set was rejected), you should review the IK5 segments for any and all IK5*R values. This segment displays which transaction set or sets have been rejected. An Example of the 999 Acknowledgement ST*999*0001*005010X231~ AK1*HC*6454*005010X231~ AK2*837*0001~ IK5*A~ AK2*837*0002~ IK3*CLM*22**8~ CTX*CLM01:123456789~ IK4*2*782*1~ IK5*R*5~ AK9*P*2*2*1~ SE*8*0001~ AK1: This segment refers to the (GS) group set level of the original file sent to MassHealth. AK101 is equal to GS01 from the original file (e.g., the AK101 of an 837 Claims file would be “HC”; the AK101 of a 270 Eligibility Inquiry file would be “HS”). AK102 is equal to GS06 from the original file (Group Control Number). AK103 is equal to GS08 from the original file (EDI Implementation Version). AK2: This segment refers to the (ST) Transaction set level of the original file sent to MassHealth. AK201 is equal to ST01 from the original file (e.g., the AK201 of an 837 Claims file would be “837”; the AK201 for a 270 Eligibility Inquiry file would be “270”). AK202 is equal to ST02 from the original file (Transaction Set Control Number). AK203 is equal to ST03 from the original file (EDI Implementation Version). IK3: This segment reports errors in a data segment. Example: IK3*CLM*22**8~ IK301 contains the segment name that has the error. In the example above, the segment name is “CLM.” IK302 contains the numerical count position of this data segment from the start of the transaction set (a “line count”). The erroneous “CLM” segment in the example above is the 22nd segment line in the Transaction Set. Transaction Sets start with the “ST” segment. Therefore, the erroneous segment in the example is the 24th line from the beginning of the file because the first two segments in the file, ISA and GS, are not part of the transaction set. IK303 may contain the loop ID where the error occurred. IK304 contains the error code and it states the specific error. In the example above, the code ‘8’ states ‘Segment Has Data Element Errors.'” Code Description 1 Unrecognized segment ID 2 Unexpected segment 3 Required segment missing 4 Loop occurs over maximum times 5 Segment Exceeds Maximum Use 6 Segment not in defined transaction set 7 Segment not in proper sequence 8 Segment has data element errors I4 Implementation “Not Used” segment present I6 Implementation Dependent segment missing I7 Implementation loop occurs under minimum times I8 Implementation segment below minimum use I9 Implementation Dependent “Not Used” segment present CTX: This segment describes the Context/Business Unit. The CTX segment is used to identify the data that triggered the situational requirement in the IK3. Example: IK3*CLM*22**8~ CTX*CLM01:123456789~ IK4: This segment reports errors in a data element. Example: IK4*2*782*1~ IK401 contains the data element position in the segment that is in error. “2” in the example above represents the second data element in the segment. IK402 contains the data element reference number as found in the appropriate implementation guide. “782” in the example above represents the CLM02 data element from the 837P. IK403 contains the error code and states the specific error. “1” in the example above represents “Required Data Element Missing.” Code Description 1 Required data element missing 2 Conditional required data element missing 3 Too many data elements 4 Data element too short 5 Data element too long 6 Invalid character in data element 7 Invalid code value 8 Invalid date 9 Invalid time 10 Exclusion condition violated 12 Too many repetitions 13 Too many components I10 Implementation “Not Used” data element present I11 Implementation too few repetitions I12 Implementation pattern match failure I13 Implementation Dependent “Not Used” element present I6 Code value not used in implementation I9 Implementation dependent data element missing IK404 may contain a copy of the bad data element. IK5: This segment reports errors in a transaction set. Example: IK5*R*5~ IK501 indicates whether the transaction set is: A = Accepted R = Rejected Other codes such as M, W, or X are for security decryption purposes but are rarely used. “R” in the example above means the transaction set was rejected due to errors. IK502 indicates the implementation transaction set syntax error. “5” in the example above indicates “One or More Segments in Error.” Below is a sample of IK502 error codes. Please refer to the 999 Implementation Guide for a complete list of these error codes. Code Description 1 Transaction Set not supported 2 Transaction Set trailer missing 3 Transaction Set Control Number in Header/Trailer do not match 5 One or more segments in error AK9: This segment reports the functional group compliance status. Example: AK9*P*2*2*1~ AK901: indicates whether the entire functional group is: A = Accepted P = Partially Accepted, at least one transaction set was rejected. The rejected transaction set within the functional group needs to be corrected and resubmitted. R =Rejected, the functional group was rejected and was NOT forwarded for further processing. The file will need to be corrected and resubmitted. Other codes such as M, W, or X are for security decryption purposes but are rarely used. “P” in the example above means the functional group was partially accepted and at least one transaction set was rejected. AK902: contains the total number of transaction sets. In the example above, two transaction sets were submitted. AK903: contains the number of received transaction sets. In the example above, two transaction sets were received. AK904: contains the number of accepted transaction sets in a Functional Group. In the example above, one transaction set was accepted. AK905: contains the Functional Group Syntax Error Code. Below is a sample of AK905 error codes 1. Please refer to the 999 Implementation Guide for a complete list of error codes. Code Description 1 Functional group not supported 2 Functional group version not supported 3 Functional group trailer missing 4 Group Control Number in the functional group Header and Trailer do not agree 5 Number of included transaction sets does not match actual count 6 Group Control Number violates syntax 17 Incorrect message length (Encryption only) 18 Message authentication code failed 19 Functional Group Control Number not unique within interchange 1 Security-related error codes are not included. For additional information, consult the Implementation Acknowledgment for Health Care Insurance (999) Guide. Implementation guides may be obtained by logging onto www.wpc- edi.com and following the links to “HIPAA” and “HIPAA Guides.” Report Inventory There are no acknowledgement reports at this time. 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. Standard Claims TR3 Page # Loop ID Reference Name Codes Length Notes/Comments 69 BHT 04 Date Enter the date claims were billed. 69 BHT 06 Transaction Type Code CH In the beginning of hierarchical transaction (BHT) loop, BHT06 should always be equal to CH, and all submitted 837 transactions should be claims for payment. 72 1000A NM1 09 Submitter Identification Code Trading partner ID assigned by MassHealth OR the 10- digit MassHealth MMIS provider number including service location 77 1000B NM1 09 Receiver Identification Code Enter DMA7384. 80 2000A PRV 01 Provider Code Enter BI for billing. Enter this only if the residential care home has been instructed to use taxonomy codes for claims. 80 2000A PRV 02 Reference Number Qualifier PXC Enter PXC (health care provider taxonomy code). Note: PXC is the only valid value. 80 2000A PRV 03 Provider Taxonomy Code Enter the taxonomy code if the residential care home has been instructed to enter a taxonomy code. 86 2010AA NM1 08 Identification Code Qualifier This data element should be left blank. 86 2010AA NM1 09 Identification Code Qualifier This data element should be left blank. 90 2010AA REF01 Reference Identification Qualifier EI Enter EI (employer identification number). 90 2010AA REF 02 Billing Provider Additional Identifier Enter the tax identification number (TIN) of the entity to be paid for the submitted services. 110 2000B SBR 09 Subscriber Information Claim Filing Indicator Code MC Enter MC. 114 2010BA NM1 09 Subscriber Name/Identification Code Enter the 12-character MassHealth member when NM102 is “1.” 123 2010BB NM1 08 Payer Identification PI Enter PI. 123 2010BB NM1 09 Identification Code Enter DMA7384. 129 2010BB REF01 Billing Provider Secondary ID Qualifier G2 Enter G2. 130 2010BB REF 02 Billing Provider Additional Identifier Trading partner ID assigned by MassHealth OR 10-digit MMIS provider ID/service location (PID/SL). 145 2300 CLM 02 Monetary Amount Total claim charge amount. This amount must balance to the sum of all service line charge amounts reported in Loop ID-2400 SV203. 145 2300 CLM 05-1 Facility Code Value UB-04 – Facility code value 145 2300 CLM 05-3 Claim Frequency Type Code 0 - 8 UB-04 – Claim frequency type code value: Code Definition 0 Nonpayment/zero 1 Admit through discharge claim 2 Interim – first claim 3 Interim – continuing claim 4 Interim – last claim 5 Late charges only 7 Replacement 8 Void 151 2300 DTP 01 Admission Hour and Day Enter the hour and date the resident was admitted. 164 2300 REF 01/02 Original Reference Number/Reference Identification If submitting a void or replace transaction, enter F8 in REF01 and the 13-character internal control number (ICN) from the original claim. 258 2300 HI XX-1 XX ranges from 01 to 12 Claim Information/Occurrence Span Information Code List Qualifier Code BI If you are reporting medical leave-of-absence (MLOA) or non-medical leave-of- absence (NMLOA) days, enter BI here. This field allows for up to three separate occurrences of MLOA or NMLOA days. 258 2300 HI XX-2 XX ranges from 01 to 12 Claim Information/Occurrence Span Information Industry Code 71, 74 For MLOA days, use occurrence span code 71. For NMLOA days, use occurrence span code 74. 259 2300 HI XX-3 XX ranges from 01 to 12 Claim Information/Occurrence Span Information Date Time Period Format Qualifier RD8 Enter RD8. 259 2300 HI XX-4 XX ranges from 01 to 12 Claim Information/Occurrence Span Information Date Time Period (Occurrence Span Code Associated Date) If you are indicating MLOA or NMLOA days, enter the start and end dates. 284 2300 HI XX-2 XX ranges from 01 to 12 Claim Information/Value Information 24, 80, 81, FC, BE, 86 Enter value code 24 Medicaid rate code for all MassHealth claims, and the total amount of the claim. If applicable, also enter value code 80 for covered days and the number of covered days. If applicable, also enter value code 81 for noncovered days and the number of noncovered days. If a member has a patient- paid amount, also enter value code FC and the patient-paid amount. If you are a nursing facility billing for a member occupying a rest home bed, enter BE in the HIXX-1 field, 86 in the corresponding HIXX-2 field, and enter the total charges of the claim in the HIXX-5 field. 180 2300 NTE 01 Note Reference Code Enter the note code. Please Note: For void and replacement transactions, please refer to Void and Replacement Transactions. 180 2300 NTE 02 Note Description Enter the description. Please Note: For void and replacement transactions, please refer to Void and Replacement Transactions. 321 2310A NM1 09 Attending Physician Name Enter the NPI of the attending physician. 328 2310E NM1 09 Service Facility Name Enter the NPI of the service facility name. COB Claims Currently, residential care homes do not use coordination of benefits. 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. 5010 MassHealth 837I Transaction with NDC information being billed: SUBMITTER: Outpatient Claim EDI #: 999999999A CONTACT: EDI Dept TELEPHONE: 860-555-1124 RECEIVER: MassHealth EDI#: DMA7384 BILLING PROVIDER: Billing Agent NPI: 1548202641 TAXONOMY CODE: 261QM2500X ADDRESS: 111 ABC Drive, Boston, MA 02215-1234 TIN: 012-34-5678 PRIMARY SUBSCRIBER: First Last MEDICAID ID: 010101010111 ADDRESS: 222 Def Street, Framingham, MA 01701 SEX: Female DOB: 06/30/1946 PAYER: MassHealth PAYOR ID: DMA7384 ADDRESS: 333 Ghi Street, Boston, MA 02110 ATTENDING PHYSICIAN: One Doctor NPI: 1234567890 CLAIM INFORMATION SUBMITTER ID: Sample AMOUNT: $10.00 DISCHARGE TIME: 10:00 STATEMENT DATES: 06/25/2011-06/25/2011 PLACE OF SERVICE: Outpatient Hospital ADMISSION DATE and TIME: 06/25/2011 10:00 DATE OF SERVICE: 06/25/2011 ADMISSION TYPE CODE: 3 POINT OF ORIGIN CODE: 1 PATIENT STATUS CODE: 01 PRINCIPAL DIAGNOSIS CODE: 71159, Present on Admission ADMITTING DIAGNOSIS CODE: 71159 PATIENT’S REASON FOR VISIT CODE: 71159 SERVICES: INSTITUTIONAL SERVICES RENDERED REVENUE CODE: 250 HCPCS Procedure Code J9250, Price: $10.00, Units: 1 PHARMACY: Prescription: 698, NDC: 11694089408, Units: 1 SUPPLEMENTAL CLAIM INFORMATION ATTACHMENT TYPE: Report Justifying Treatment Beyond Utilization Guidelines ATTACHMENT CODE: Available on Request at Provider Site C. Transmission Examples This appendix contains actual data streams. The business scenarios linked to the data streams are included in Appendix B. 1. Example of a 5010 MassHealth 837I Transaction with NDC information being billed: ISA*00* *00* *ZZ*999999999A *ZZ*DMA7384 *110701*1030*^*00501*789113000*0*T*>~ GS*HC*999999999A*DMA7384*20110701*1030*7001*X*005010X223A2~ ST*837*60002*005010X223A2~ BHT*0019*00*000001*20110701*1030*CH~ NM1*41*2*OUTPATIENT CLAIM*****46*999999999A~ PER*IC*EDI DEPT*TE*8605551124~ NM1*40*2*MASSHEALTH*****46*DMA7384~ HL*1**20*1~ PRV*BI*PXC*261QM2500X~ NM1*85*2*BILLING AGENT*****XX*1548202641~ N3*111 ABC DRIVE~ N4*BOSTON*MA*022151234~ REF*EI*012345678~ HL*2*1*22*0~ SBR*P*18*******MC~ NM1*IL*1*LAST*FIRST****MI*010101010111~ N3*222 DEF ST~ N4*FRAMINGHAM*MA*01701~ DMG*D8*19460630*F~ NM1*PR*2*MASSHEALTH*****PI*DMA7384~ N3*333 GHI ST~ N4*BOSTON*MA*02110~ CLM*SAMPLE*10***13>A>1**A*Y*Y~ DTP*096*TM*1000~ DTP*434*RD8*20110625-20110625~ DTP*435*DT*201106251000~ CL1*3*1*01~ HI*BK>71159>>>>>>>Y~ HI*BJ>71159~ HI*PR>71159~ NM1*71*1*DOCTOR*ONE****XX*1234567890~ LX*1~ SV2*250*HC>J9250>UD*10*UN*1~ PWK*03*AA~ DTP*472*D8*20110625~ LIN**N4*11694089408~ CTP****1*UN~ REF*XZ*698~ SE*37*60002~ GE*1*7001~ IEA*1*789113000~ 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: MassHealth has allowed outpatient departments that perform dental procedures to use the CDT codes and the CPT codes for oral surgery services. The 837D Implementation Guide states that CDT codes are the only service codes allowed when filing an electronic claim. What is the process for an outpatient department to submit claims for oral surgery services using a CPT code? A: A: Outpatient departments should submit oral surgery claims with CPT codes using the 837I claim format, and all other dental services using the 837D format. Q: Hospitals billing on the paper UB-04 claim form are required to enter revenue code 0001 indicating “Total Charge” when submitting claims to MassHealth. Should this revenue code be entered on an 837I transaction? A: No. Revenue code 0001 is not required on the 837I transaction, but continues to be required on the paper UB-04 claim form. Q: If I identify other insurance that is not on file with MassHealth, how do I submit the claim? A: Follow the standard process for any COB claim. To obtain the MassHealth-assigned carrier code, cross-reference the insurance name with the appropriate carrier code in Appendix C: Third Party Liability Codes of your MassHealth provider manual, and enter the seven-digit code on your 837 transaction. Concurrently, you should request that the MassHealth file be updated by sending all pertinent information to the appropriate address below. MassHealth Third Party Liability Unit P.O. Box 9212 Chelsea, MA 02150 Fax: 617-357-7604 MassHealth Medicare Unit Schraffts Center 529 Main Street, 3rd Floor Charlestown, MA 02129-1120 Fax: 617-886-8134 Note: Do not send claim forms to the above addresses. E. Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Version Date Section/Pages Description 3.0 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 837I Residential Care Homes Companion Guide October 2012, Version 3.0 iv MassHealth 005010 837I Residential Care Homes Companion Guide October 2012, Version 3.0 i October 2012, Version 3.0 29 MassHealth 005010 837I Residential Care Homes Companion Guide October 2012, Version 3.0 Appendix 5