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HIPAA: 837 Institutional and Professional Claim Refresher FAQs

Q:
When sending Inpatient or Outpatient claims for multiple providers, which segments are involved and how? Please indicate how those segments are different than when you are submitting for a single provider.

A:
Refer to the Implementation Guide and Companion Guide to build an Inpatient or Outpatient transaction. Bolded elements are used in processing.

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Q:
In loop 2000B, what's the difference between the HL01 Hierarchical ID number and the HL02 parent ID number?

A:
The HL01 identifies the numerical order of the hierarchical order. The first HL01 begins with the numeral "1" and each subsequent HL01changes in increments of one. In loop 2000B, the HL02 identifies that this HL segment is subordinate (or later in order) to the 2000A HL (the parent). For more information on how the HL structure works, refer to Appendix A, section A.1.4.3 of the Implementation Guide.

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Q:
Under HIPAA law, we are required to bill with the appropriate CPT, HCPCS and ICD-9 code that is valid and effective at the time of service. When will Medi-Cal be ready to accept the new 2005 CPT codes?

A:
Medi-Cal continues to make beneficiary access to care and provider payment the highest priority while advancing toward HIPAA compliance. Due to the complexity of the changes and the coordination required to make these changes, Medi-Cal continues to perform the benefit, policy and technical remediation processes for the 2005 CPT-4 codes to ensure that there is no break in services or payments. As soon as a firm date to begin accepting these codes is available, we will publish the information in a future Medi-Cal Update.

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Q:
For Medi-Cal claim remarks, I was told that Medi-Cal only stores one NTE segment, although the Implementation Guide allows for more. Do you still store only one NTE segment? Does this hold true for both the 2300 and 2400 loops?

A:
Medi-Cal stores all iterations (repeats) of the NTE segments as allowed by the Implementation Guide. Refer to the Implementation Guide for the number of repeats allowed in the 2300 and 2400 loops.

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Q:
When will you have a 997 report available to download from your Internet Bulletin Board System (IBBS)?

A:
At this time, Medi-Cal has chosen to continue use of its proprietary acknowledgement, which provides more information than the standard 997.

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Q:
When will Long Term Care (LTC) claims be converted from accommodation codes to revenue codes?

A:
Medi-Cal has established a project for future conversion of accommodation codes to revenue codes for LTC claims. Watch your provider bulletins and the Medi-Cal Web site for information regarding the conversion of these codes.

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Q:
Your seminar assumes ability to complete the ASC X12N 837 v.4010A1 transactions. Do you have or know of a place to get additional training or help with the building of these transaction sets using the Companion Guide?

A:
Outside training is available. You may want to search the web for X12N training. However, Medi-Cal does not endorse any outside training products.

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Q:
In the 2300 HI segment, is Medi-Cal requiring the ICD-9 procedure codes on Outpatient claims in the 837 4010A1 transaction format?

A:
As stated in the Implementation Guide, ICD-9 procedure codes are only used on Inpatient claims. Outpatient procedure codes are reported as HCPCS codes in the SV2 segment at the service level.

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Q:
Will you be adding the ability to download the acknowledgement report from your IBBS? Are you going to have your acknowledgement report (not the 997) available on the IBBS?

A:
Submitters may perform a CMC Inquiry from Transaction Services to confirm acknowledgement of their electronic batch transmission(s). Watch future bulletins regarding ability to download the acknowledgement report on the IBBS.

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Q:
From the Medi-Cal billing guidelines: A mother's Medi-Cal Benefits Identification Card (BIC), whether for restricted or full-scope benefits, can be used to bill full-scope medical services rendered to her newborn during the month of delivery and the following month. When billing this type of claim in the 837 4010A1 format, what relationship code should be used since the patient is always the subscriber? Should this be billed with mother as subscriber and relationship as dependent?

A:
The patient is always the subscriber, so the relationship is "Self". Do not use "Dependent" for relationship.

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Q:
From the Medi-Cal billing guidelines: A mother's Medi-Cal Benefits Identification Card (BIC), whether for restricted or full-scope benefits, can be used to bill full-scope medical services rendered to her newborn during the month of delivery and the following month. When billing this type of claim in the 837 4010A1 format, what relationship code should be used since the patient is always the subscriber? Should this be billed with mother as subscriber and relationship as dependent?

A:
The patient is always the subscriber, so the relationship is "Self". Do not use "Dependent" for relationship.

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Q:
There are two types of notes for an 837 4010A1 Institutional claim:
Claim Note
ALG – Allergies
  DCP – Goals, rehabilitation potential or discharge plans
  DGN – Diagnosis description
  DME – Durable medical equipment and supplies
  MED – Medications
  NTR – Nutritional requirements
  RHB – Functional limitations, reason homebound or both
  RLH – Reasons patient leaves home
  RNH – Times and reasons patient not at home
  SET – Unusual home, social environment or both
  SFM – Safely measures
  SPT – Supplementary plan of treatment
  UPI – Updated Information
   
Billing Note
ADD – Addition information

      Where on the 837 4010A1 Institutional claim do you want us to move this new note for FPACT supplies?

A:
If the note doesn't fit into any of the claim notes listed, then place the note under ADD in the Billing Note area.

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Q:
We currently submit claims for LTC on the 25-1 form. Can we now eliminate the use of the 25-1 form and bill these claims in the 837 4010A1 format?

A:
Yes, you may bill in the 837 4010A1 format. If billing on paper continues, please use the Payment Request for Long Term Care (25-1) claim form.

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Q:
To my knowledge, I am using an ASC X12N 4010A1 but I'm not sure if it's the 837 version. How will I know?

A:
You need to complete the Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHS 6153) and test in the 837 4010A1 format. If you have not done so, you may still be using the proprietary format.

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Q:
You stated that you are not going to support the increased line limits (999). How many lines are you going to support (for example, how many lines can we submit in an 837 transaction)? According to ADP and DMH, they will accept up to 50 service lines (2400 LX). Your slide number 54 states that Medi-Cal will only accept a maximum of six.

A:
Currently, Medi-Cal supports the following number lines:
  • Inpatient: 22 (Institutional)
  • Outpatient: 22 (Institutional)
  • LTC: 1 (Institutional)
  • Vision: 6 (Professional)
  • Professional Medical: 6 (Professional)
A future project (exact date to be determined) will increase the number of lines accepted.

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Q:
Is the Patient Paid Amount data element captured only on the Institutional and not Professional format?

A:
The Patient Paid Amount is captured on both the Institutional and Professional 837 4010A1 formats. Please see page 182 of the Institutional Implementation Guide and page 220 of the Professional Implementation Guide for more information.

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Q:
Are the diagnosis descriptions in the NTE segments required in the 837 4010A1 transaction?

A:
Medi-Cal policy requires the description of the diagnosis in order to appropriately adjudicate claims.

Medi-Cal captures this information on the electronic format in the NTE segment so that this information does not have to be supplied in an attachment.

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Q:
Should we send revenue codes along with HCPCS codes on SV2 items for 837 4010A1 Institutional Outpatient claims? If not, should we send 0023 as revenue code for an HIPPS code line?

A:
Medi-Cal currently does not use revenue codes for Outpatient claims, which means revenue codes will not impact adjudication. However, data element SV202 service line revenue code is a required element per HIPAA; therefore, the submitter must send a revenue code they feel is appropriate for the services rendered even if Medi-Cal does not use it.

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Q:
What is the NTE remark?

A:
The NTE field allows providers to submit information not otherwise captured in discreet fields on the 837 4010A1 transaction. Medi-Cal uses this field to capture additional information for some conditions (such as emergency statements and diagnosis descriptions) so that providers do not have to submit attachments containing this data.

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Q:
You indicate that Medi-Cal is not currently able to support Coordination of Benefits (COB) claims, adjustment claims, electronic claims requiring attachments and claims with the HIPAA-allowed number of service lines. What is Medi-Cal's plan specifically for bringing COB claims up in production and for accepting claims with the increased service lines allowed under the 837 4010A1 format?

A:
Medi-Cal plans to support COB claims by October 2005. Increasing service lines will be a future project.

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Q:
We do not send codes on Outpatient claims in our current submission format. Are they required on Outpatient claims in the 837 4010A1 format?

A:
HCPCS codes and revenue codes are required for Outpatient claims in SV202 on the 837 4010A1 format.

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Q:
Should Outpatient 837 4010A1 Institutional claims use the AMT02 segment?

A:
Yes, the AMT02 segment is the net billed amount.

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Q:
Do you have a timeline for all of the items listed on slides 72 and 73 referring to future projects?

A:
Not at this time. Updated information will be published on both the DHS and Medi-Cal Web sites as soon as information is available.

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Q:
Where can we find the current Medi-Cal provider manual on the Web site?

A:
Provider manuals can be found in the Publications section.

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Q:
Currently when we bill claims with a date of service greater than one year from the current date, we submit the claim on paper with an “Over One Year” letter (MC180). Is this still required if we are billing in the 837 4010A1 format?

A:
Currently, you must submit on paper with the hard copy attachment if an attachment is required (MCISO). May 23, 2005, Medi-Cal will implement a solution that links paper attachments to electronic claims. Watch Medi-Cal Updates and Web notices for new information.

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Q:
Do we put information in Notes?

A:
Any information you formerly put in Remarks would be put in Notes.

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Q:
If we bill the LTC claims on the 837 4010A1 format, will Medi-Cal be looking for one SV2 segment in Loop 2400 or will Medi-Cal accept up to 22 SV2 segments on these claims as well?

A:
Medi-Cal policy only allows one service line per recipient (subscriber) for LTC claims; therefore, only one service line per subscriber should be billed to Medi-Cal on the 837 4010A1 format.

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Q:
What are the allowed modifiers for hospital Outpatient surgical claims with multiple procedures?

A:
The number of allowed modifiers can be found on page 3 of Surgery: Billing with Modifiers in the Part 2 manual.

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Q:
For Outpatient hospital surgery claims, what revenue codes are allowed for the procedure, such as 360, 460, 710, 750 and 760?

A:
You determine the appropriate revenue code based on the provider and services provided. Medi-Cal does not currently use revenue codes from outpatient claims for adjudication.

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Q:
Should I send more than one Resident Assessment Protocol (RAP) and one final claim in order for Medi-Cal to get all the service lines rendered to the patient?

A:
Only one RAP is needed per claim.

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Q:
What does it mean when I try to log into Transaction Services using my using my sub ID and there is no selection for submitter status on the left-hand side of the page?

A:
If you are looking for the status of your Submitter ID (and not the status of your submissions), you can only see that option on sysdev.medi-cal.ca.gov, not on the production site. The exact wording is “View CMC Status”. For claim submission status, follow the instructions on the CMC Submission Instructions page.

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Q:
Do you have to log in separately for each different provider number on which you're checking the status of claims?

A:
To check status of claims submitted for a particular provider number, you must log in with that provider number and PIN. To check claim submission status, you must log in with the submitter ID and password.

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Q:
Regarding the Dependent loops: what about mom/baby claims where baby is less than 90 days old?

A:
For Medi-Cal, the patient is always the Subscriber. See the billing guidelines in Obstetrics: UB-92 Billing Examples for Inpatient Services in the Part 2 manual. The same billing rule applies to the 837I claim, with the only difference being that the relationship code will always be “18” for Self when billing for baby with Mother’s ID.

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