MEDI-CAL COMPANION GUIDE

California Medicaid (Medi-Cal)

Standard Companion Guide Transaction Information Instructions Related to Transactions Based on ASC X12 Implementation Guides, Version 005010

Companion Guide Version Number: 1.2 Published: June 2012

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This Companion Guide is Copyright 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12.

2011 Companion Guide copyright by California Department of Health Care Services

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Preface
The Companion Guide (CG) may contain two types of data, instructions for electronic communications with the publishing entity (Communications/Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document. The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASC X12s copyrights and Fair Use statement.

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Table of Contents
1 TI Introduction .......................................................................................................... 5
1.1 Background ...................................................................................................................5 1.1.1 Overview of HIPAA Legislation ........................................................................... 5 1.1.2 Compliance according to HIPAA ......................................................................... 5 1.1.3 Compliance according to ASC X12 ..................................................................... 6 1.2 Intended Use.................................................................................................................6

2 Included ASC X12 Implementation Guides ............................................................ 6 3 Instruction Tables .................................................................................................... 7

3.1 3.2 3.3 3.4 3.5 3.6 3.7 005010X279A1 Health Care Eligibility Benefit Inquiry ...................................................7 005010X279A1 Health Care Eligibility Benefit Response ............................................ 10 005010X212 Health Care Claim Status Request .........................................................14 005010X212 Health Care Claim Status Response ......................................................15 005010X222A1 Health Care Claim: Professional ........................................................16 005010X223A2 Health Care Claim: Institutional ..........................................................26 005010X221A1 Health Care Claim Payment/Advice ................................................... 34

4 TI Additional Information ...................................................................................... 37

4.1 4.2 4.3 4.4 Business Scenarios.....................................................................................................37 Payer-Specific Business Rules and Limitations ...........................................................37 Frequently Asked Questions .......................................................................................37 Other Resources .......................................................................................................388

5 TI Change Summary .............................................................................................. 38 6 Appendix A Communication/Connectivity Instructions (CCI)......................... 38

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Transaction Instruction (TI)

1 TI Introduction
1.1 Background
1.1.1 Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs

1.1.2 Compliance According to HIPAA The HIPAA regulations at 45 CFR 162.915 require that covered entities not enter into a trading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in a standard Add any data elements or segments to the maximum defined data set Use any code or data elements that are marked not used in the standards implementation specifications or are not in the standards implementation specification(s) Change the meaning or intent of the standards implementation specification(s)

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1.1.3 Compliance According to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory or clarifying content contained in the implementation guide Modifying any requirement contained in the implementation guide

1.2 Intended Use

The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12s Fair Use and Copyright statements.

2 Included ASC X12 Implementation Guides

This table lists the X12N Implementation Guides for which specific transaction instructions apply and which are included in Section 3 of this document.
Unique ID 005010X279A1 005010X212 005010X222A1 005010X223A2 005010X221A1 Name Health Care Eligibility Benefit Inquiry and Response (270/271) Health Care Claim Status Request and Response (276/277) Health Care Claim: Professional (837) Health Care Claim: Institutional (837) Health Care Claim Payment/Advice (835)

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3 Instruction Tables
These tables contain one or more rows for each segment for which a supplemental instruction is needed.

Legend SHADED rows represent segments in the X12N implementation guide. NON-SHADED rows represent data elements in the X12N implementation guide.

3.1 005010X279A1 Health Care Eligibility Benefit Inquiry

Loop ID 2100A 2100A Reference NM1 NM109 Name Information Source Name Identification Code Medi-Cal expects to receive: 610442 2100B 2100B NM1 NM101 Information Receiver Name Entity Identifier Code 1P Medi-Cal expects to receive the value listed in the codes column Medi-Cal expects to receive one of the values listed in the codes column Codes Notes/Comments

NM108

Identification Code Qualifier

SV XX

2100B 2100B

REF REF01

Information Receiver Additional Identification Reference Identification Qualifier Information Receiver Address 4A For Batch, Medi-Cal expects to receive the value listed in the codes column This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system Medi-Cal expects to receive the following: For Leased-Line and Dial-Up: 3 For Batch: Increment this for each Subscriber entered, from three and up to 99 Subscribers

2100B

N3

2100B

N4

Information Receiver City, State and ZIP Code Information Receiver Provider Information Subscriber Level Hierarchical ID Number

2100B

PRV

2000C 2000C

HL HL01

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Loop ID 2100C 2100C

Reference NM1 NM108

Name Subscriber Name Identification Code Qualifier

Codes

Notes/Comments

MI

Medi-Cal expects to receive the value listed in the codes column

2100C 2100C

REF REF01

Subscriber Additional Identification Reference Identification Qualifier 18 1L 1W 6P EA EJ IG N6 NQ Medi-Cal expects to receive one of the code values listed in the codes column

2100C

N3

Subscriber Address

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2100C

N4

Subscriber City, State, and ZIP Code Provider Information

2100C

PRV

2100C

INS

Multiple Birth sequence Number Subscriber Health Care Diagnosis Code Subscriber Eligibility or Benefit Inquiry Information Product/Service ID Qualifier CJ HC ID IV N4 ZZ

2100C

HI

2110C 2110C

EQ EQ021

Medi-Cal expects to receive one of the code values listed in the codes column

2110C

III

Subscriber Eligibility or Benefit Additional Inquiry Information Subscriber Additional Information Subscriber Eligibility / Benefit Date

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2110C

REF

DTP

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Loop ID 2000D

Reference

Name Dependent Level

Codes

Notes/Comments This loop is not required for the payers adjudication system Medi-Cal patients/recipients are identified to the payer by a unique Identification Number All patients/recipients are considered the subscriber and must be identified in the Subscriber Loop

2100D

Dependent Name

This loop is not required for the payers adjudication system Medi-Cal patients/recipients are identified to the payer by a unique Identification Number All patients/recipients are considered the subscriber and must be identified in the Subscriber Loop

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3.2 005010X279A1 Health Care Eligibility Benefit Response

Loop ID 2000A 2000A Reference HL HL04 Name Information Source Level Hierarchical Child Code 1 Medi-Cal will populate this data element with value listed in the codes column Medi-Cal will populate this data element with: Medi-Cal NM109 Identification Code Medi-Cal will populate this data element with: 610442 2100A 2100A PER PER02 Information Source Contact Information Name Medi-Cal will populate this data element with: POS Help Desk Toll Free Number or Voice AEVS PER03 Communication Number Qualifier Information Receiver Level Hierarchical Child Code 1 Medi-Cal will populate this data element with value listed in the codes column TE Medi-Cal will populate this data element with value listed in the codes column Codes Notes/Comments

2100A 2100A

NM1 NM103

Information Source Name Name Last or Organization Name

2000B 2000B

HL HL04

2100B 2100B

NM1 NM101

Information Receiver Name Entity Identifier Code 1P Medi-Cal will populate this data element with value listed in the codes column Medi-Cal will populate this data element with values listed in the codes column Medi-Cal will not send this segment Medi-Cal will not send this segment

NM108

Identification Code Qualifier Information Receiver Additional Identification Information Receiver Provider Information Subscriber Level

XX SV

2100B 2100B 2100C

REF PRV HL

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Loop ID 2100C

Reference HL01

Name Hierarchical ID Number

Codes

Notes/Comments Medi-Cal will populate this data element with: For Leased-Line and Dial-Up: 3 For Batch: This will be incremented for each Subscriber, up to 99 Subscribers

HL04

Hierarchical Child Code

Medi-Cal will populate this data element with value listed in the codes column Medi-Cal will populate this data element with: 610442

2000C 2000C

TRN TRN03

Subscriber Trace Number Originating Company Identifier

2100C 2100C

NM1 NM108

Subscriber Name Identification Code Qualifier Subscriber Address Subscriber City, State, and ZIP Code Provider Information Subscriber Health Care Diagnosis Code Subscriber Date Date/Time Qualifier 102 291 307 458 472 Medi-Cal will populate this data element with values listed in the codes column MI Medi-Cal will populate this data element with value listed in the codes column Medi-Cal will not send this segment Medi-Cal will not send this segment Medi-Cal will not send this segment Medi-Cal will not send this segment

2100C 2100C 2100C 2100C 2100C 2100C

N3 N4 PRV HI DTP DTP01

2100C 2110C

MPI EB

Subscriber Military Personnel Information Subscriber Eligibility or Benefit Information

Medi-Cal will not send this segment

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Loop ID 2110C

Reference EB01

Name Eligibility or Benefit Information Code

Codes 1 6 CB E F I K MC N R V W Y 1 9 30 33 35 43 45 47 48 50 54 61 69 76 82 83 84 86 88 89 90 91 92 96 98 99 A0 A1 A2 A3 A8 AI AJ AK AL MH UC

Notes/Comments Medi-Cal will populate this data element with values listed in the codes column

EB03

Service Type Code

Medi-Cal will populate this data element with values listed in the codes column Refer to the Medi-Cal Provider Manual for more detailed information regarding services covered under the Medi-Cal program

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Loop ID

Reference EB04

Name Insurance Type Code

Codes MA MB MC OT

Notes/Comments Medi-Cal will populate this data element with values listed in the codes column

EB05

Plan Coverage Description

Medi-Cal will populate this data element with one of the following values: CCS CHDP CMSP FAMILY PACT FAMILY PACT BENEFITS GHPP HAP MEDICARE PART D

2110C 2110C

HSD DTP

Health Care Services Delivery Subscriber Eligibility/Benefit Date Date/Time Qualifier 102 291 307 458 472

Medi-Cal will not send this segment

2110C

DTP01

Medi-Cal will populate this data element with one of the values shown in the codes column

2110C 2110C

MSG MSG01

Message Text Free-form Message Text County Code will be included in the free form text, along with the eligibility information Medi-Cal will not send this segment

2115

III

Subscriber Eligibility or Benefit Additional Information

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3.3 005010X212 Health Care Claim Status Request

Loop ID 2100A 2100A Reference NM1 NM103 Name Payer Name Payer Name Medi-Cal expects to receive: Medi-Cal NM109 Payer Primary Identifier Medi-Cal expects to receive: 610442 2000D HL Dependent Loop Medi-Cal patients/recipients are identified to the payer by a unique Identification Number All patients/recipients are considered the subscriber and must be identified in the Subscriber Loop Codes Notes/Comments

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3.4 005010X212 Health Care Claim Status Response

Loop ID 2100A 2100A Reference NM1 NM103 Name Payer Name Payer Name Medi-Cal will populate this segment with: Medi-Cal NM109 Payer Primary Identifier Medi-Cal will populate this segment with: 610442 2000D HL Dependent Loop All patients/recipients are considered the subscriber and must be identified in the Subscriber Loop Codes Notes/Comments

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3.5 005010X222A1 Health Care Claim: Professional

Loop ID 1000A 1000A 1000A Reference NM1 NM109 PER Name Payer Identification Submitter Identifier Submitter EDI Contact Information Medi-Cal expects to receive the Submitter ID This segment is not required for the payers adjudication system In the event communication is required related to this transaction, Medi-Cal will use the contact information submitted in the Billing Provider Contact Information in Loop 2010AA 1000B 1000B NM1 NM103 Receiver Name Receiver Name Medi-Cal expects to receive: Medi-Cal NM109 Receiver Primary Identifier Medi-Cal expects to receive: 610442 2000A CUR Foreign Currency Information This segment is not required for the payers adjudication system All amounts within Medi-Cal electronic transactions represent U.S. currency 2010AA N3 Billing Provider Address Medi-Cal will use the Provider Address in the internal Provider Master File for mailing of check or other documents related to this claim Medi-Cal will use the Provider Address in the internal Provider Master File for mailing of check or other documents related to this claim Medi-Cal will use the Tax Identification Number (TIN) on file in the internal Provider Master File for income reporting on the 1099 forms Codes Notes/Comments

2010AA

N4

Billing Provider City, State and ZIP Code

2010AA

REF

Billing Provider Tax Identification

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Loop ID 2010AA

Reference REF

Name Billing Provider UPIN/License Information

Codes

Notes/Comments This segment is not required for the payers adjudication system Medi-Cal only accepts the NPI and Medi-Cal Provider Number to identify providers in our adjudication system

2010AA 2010AA

PER PER03

Billing Provider Contact Information Communication Number Qualifier TE Medi-Cal expects to receive the value shown in the codes column In the event communication is required related to this transaction, Medi-Cal will contact you by telephone

2010AB

Pay-to Address Name

This loop is not required for the payers adjudication system Medi-Cal will use the Provider Address in the internal Provider Master File for mailing of check or other documents related to this claim

2010AC

Pay-to Plan Name

This loop is not required for the payers adjudication system Medi-Cal does not currently process subrogation payment requests

2010BA 2010BA

NM1 NM108

Subscriber Name Identification Code Qualifier Subscriber Secondary Identification Property and Casualty Claim Number Property and Casualty Subscriber Contact Information MI Medi-Cal expects to receive the value shown in the codes column This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the Payer adjudication system

2010BA

REF

2010CA

REF

2010CA

PER

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Loop ID 2010BB 2010BB

Reference NM1 NM103

Name Payer Name Payer Name

Codes

Notes/Comments

Medi-Cal expects to receive: Medi-Cal

NM109

Payer Identifier

Medi-Cal expects to receive: 610442

2010BB

N3

Payer Address

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment should be submitted for atypical Medi-Cal providers who are not eligible to receive an NPI Medi-Cal expects to receive the Medi-Cal Provider Number in this segment for Blood Bank, Christian Science Practitioner and MSSP providers who are not eligible for an NPI These providers are considered atypical providers and must bill the Medi-Cal program using their Medi-Cal Provider Number

2010BB

N4

Payer City, State and ZIP Code Payer Secondary Identification Billing Provider Secondary Identification

2010BB

REF

2010BB

REF

2010BB

REF01

Billing Provider Secondary Identifier Patient Hierarchical Level

G2

Medi-Cal expects to receive the value shown in the codes column This segment is not required for the payers adjudication system Medi-Cal recipients are all identified to the payer by a unique Identification Number All patients/recipients are considered the subscriber and must be identified at the Subscriber Level

2000C

HL

2300

DTP

Date Initial Treatment Date Date Last Seen Date

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

DTP

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Loop ID 2300

Reference DTP

Name Date Acute Manifestation Date Last Menstrual Period Date Last X-ray

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

DTP

2300

DTP

2300

DTP

Date Disability Dates

2300

DTP

Date Last Worked

2300

DTP

Date Authorized Return to Work Date - Assumed and Relinquished Care Dates Date Property and Casualty Date of First Contact Date Repricer Received Date

2300

DTP

2300

DTP

2300

DTP

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Loop ID 2300

Reference PWK

Name Claim Supplemental Information

Codes

Notes/Comments 1. Only the first iteration of the PWK segment at the header will be considered in the claim adjudication process Attachments associated with a PWK segment should be sent at the same time the 837 claim transaction is sent. Medi-Cals business practice is that additional documentation received more than 30 days after the receipt of your 837 claim transmission will not be considered in adjudication of your claim An Attachment Control Form must be used when submitting supplemental information in support of an electronic claim. The Attachment Control Number on this form must match the control number submitted in the PWK06 data element. That control number is assigned by the provider or the providers system

2.

3.

2300

PWK02

Attachment Transmission Code

BM EL FX

Medi-Cals processing and policy procedures support the methods for transmission of attachments shown in the codes column This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

CN1

Contract Information

2300

REF

Service Authorization Exception Code Mandatory Medicare (Section 4081) Crossover Indicator Mammography Certification Number Referral Number

2300

REF

2300

REF

2300

REF

2300

REF

Payer Claim Control Number

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Loop ID 2300

Reference REF

Name Clinical Laboratory Improvement Amendment (CLIA) Certificate Number Repricer Claim Number

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system. This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system Medi-Cal uses one of the occurrences of this segment to convey the Emergency Certification Statement as defined by Medi-Cal policy Medi-Cal expects to receive CER when submitting Emergency Certification Statement information

2300

REF

2300

REF

Adjusted Repricer Claim Number Investigation Device Exception Number Claim Identifiers for Transmission Intermediaries Medical Record Number

2300

REF

2300

REF

2300

REF

2300

REF

Demonstration Project Identifiers Care Plan Oversight

2300

REF

2300

K3

File Information

2300 2300

NTE NTE01

Claim Note Attachment Transmission Code

2300

CR1

Ambulance Transport Information Spinal Manipulation Service Information Homebound Indicator

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

CR2

2300

CRC

2300

CRC

EPSDT Referral

2300

HI

Health Care Diagnosis Codes

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Loop ID 2300 2300

Reference HI HI012 and HI122

Name Health Care Diagnosis Code Diagnosis Code

Codes

Notes/Comments

Medi-Cal will accept 12 diagnosis codes Only the first two diagnosis codes submitted in this segment will be used in the adjudication process

2300

HI

Anesthesia Related Procedure Claim Pricing/Repricing Information Service Facility Contact Information Supervising Provider Name Coordination of Benefits (COB) Total Non-Covered Amount Other Insurance Coverage Information Medicare Outpatient Adjudication Information Other Subscriber Name Identification Code Qualifier Other Subscriber Address MI

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

HCP

2310C

PER

2310D

NM

2320

AMT

2320

OI

2320

MOA

2330A 2330A

NM1 NM108

Medi-Cal expects to receive the value shown in the codes column This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system
22

2330A

N3

2330A

N4

Other Subscriber City, State and ZIP Other Subscriber Secondary Identifier Other Payer Address

2330A

REF

2330B

N3

2330B

N4

Other Payer City, State and ZIP Other Payer Secondary Identification

2330B

REF

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Loop ID 2330B

Reference REF

Name Other Payer Referral Number Other Payer Adjustment Indicator Other Payer Referring Provider Other Payer Rendering Provider Name Other Payer Service Facility Location Other Payer Supervising Provider Other Payer Billing Provider

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system Medi-Cal will accept and process 6 Claim Service Lines for Professional Claims Medi-Cal expects to receive the value shown in the codes column Medi-Cal will accept 4 Procedure Modifiers but only the first two will be utilized in the adjudication process See the Medi-Cal Provider Manual for the appropriate usage of Modifier Codes

2330B

REF

2330C

2330D

2330E

2330F

2330G

2400

LX

Service Line Number

2400 2400

SV1 SV1011

Professional Services Product or Service ID Qualifier Procedure Modifier HC

SV1013 thru SV1016

2400

SV5

Durable Medical Equipment Service Line Supplemental Information Durable Medical Equipment Certificate of Medical Necessity Indicator Ambulance Transport Information Durable Medical Equipment Certification

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2400

PWK

2400

PWK

2400

CR1

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2400

CR3

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Loop ID 2400

Reference DTP

Name Date Certification Revision/Recertification Date Begin Therapy Date

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2400

DTP

2400

DTP

Date Last Certification Date Date Last Seen Date

2400

DTP

2400

DTP

Date Test Date

2400

DTP

Date Last X-ray Date

2400

DTP

Date Initial Treatment Date Ambulance Patient Count

2400

QTY

2400

QTY

Obstetrical Anesthesia Additional Units Test Results

2400

MEA

2400

CN1

Contract Information

2400

REF

Repriced Line Item Reference Number Adjusted Repriced Line Item Reference Number
Mammography Certification Number Clinical Laboratory Improvement Amendment (CLIA) Number Referring Clinical Laboratory Improvement Amendment (CLIA) Facility Immunization Batch Number

2400

REF

2400

REF

2400

REF

2400

REF

2400

REF

This segment is not required for the payers adjudication system

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Loop ID 2400

Reference REF

Name Referral Number

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This segment is not required for the payers adjudication system This loop is not required for the payers adjudication system

2400

AMT

Postage Claimed Amount

2400

K3

File Information

2400

NTE

Third Party Organization Note Purchase Service Information Line Pricing/Repricing Information Purchase Service Provider

2400

PS1

2400

HCP

2420B

2420D

Supervising Provider Name Ordering Provider Name

2420E

2430

AMT

Remaining Patient Liability

2440

Form Identification Code

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3.6

005010X223A2 Health Care Claim: Institutional

Reference NM1 NM109 Name Submitter Name Submitter Identifier Medi-Cal expects to receive: Submitter ID Codes Notes/Comments

Loop ID 1000A

1000B

NM1 NM103

Receiver Name Receiver Name Medi-Cal expects to receive: Medi-Cal

NM109

Receiver Primary Identifier

Medi-Cal expects to receive: 610442

2000A

CUR

Foreign Currency Information

This loop is not required for the payers adjudication system All amounts within Medi-Cal electronic transactions represent U.S. currency

2010AA

N3

Billing Provider Address

Medi-Cal will use the Provider Address from the internal Provider Master File for mailing of check or other documents related to this claim Medi-Cal will use the Provider Address from the internal Provider Master File for mailing of check or other documents related to this claim Medi-Cal will use the Tax Identification Number (TIN) on file from the internal Provider Master File for income reporting on the 1099 forms This loop is not required for the payers adjudication system Medi-Cal will use the Provider Address from the internal Provider Master File for mailing checks or other documents related to this claim

2010AA

N4

Billing Provider City, State and ZIP Code

2010AA

REF

Billing Provider Tax Identification

2010AB

Pay-to Address Name

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Loop ID 2010AC

Reference

Name Pay-to Plan Name

Codes

Notes/Comments This loop is not required for the payers adjudication system Medi-Cal does not currently process subrogation payment requests

2010BB

NM1 NM103

Payer Name Payer Name Medi-Cal expects to receive one of the following based on the claim type for: Long Term Care MEDI-CAL LTC Outpatient MEDI-CAL OP Inpatient MEDI-CAL IP

NM109

Payer Identifier

Medi-Cal expects to receive: 610442

2010BB

REF

Billing Provider Secondary Identification

This segment should be submitted for atypical Medi-Cal providers who are not eligible to receive an NPI Medi-Cal expects to receive the Medi-Cal Provider Number in this segment for Blood Bank, Christian Science Practitioner and MSSP providers who are not eligible for an NPI These providers are considered atypical providers and must bill the Medi-Cal program using their Medi-Cal Provider Number

2000C

Patient Hierarchical Level

This loop is not required for the payers adjudication system Medi-Cal patients/recipients are identified to the payer by a unique Identification Number Medi-Cal patients/recipients are considered the subscriber and must be identified at the Subscriber Level

2300

DTP

Date Initial Treatment Date

This segment is not required for the payers adjudication system

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Loop ID 2300

Reference DTP

Name Date Last Seen Date

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

DTP

Date Acute Manifestation Date Last Menstrual Period Date Last X-ray

2300

DTP

2300

DTP

2300

DTP

Date Disability Dates

2300

DTP

Date Last Worked

2300

DTP

Date Authorized Return to Work Date - Assumed and Relinquished Care Dates Date Property and Casualty Date of First Contact Date Repricer Received Date

2300

DTP

2300

DTP

2300

DTP

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Loop ID 2300

Reference PWK

Name Claim Supplemental Information

Codes

Notes/Comments 1. Attachments associated with a PWK segment should be sent at the same time the 837 claim transaction is sent. Medi-Cals business practice is that additional documentation received more than 30 days after the receipt of your 837 claim transmission will not be considered in adjudication of your claim An Attachment Control Form (ACF) must be used when submitting supplemental information in support of an electronic claim The Attachment Control Number (ACN) on this form must match the control number submitted in the PWK06 data element. That control number is assigned by the provider or the providers system

2.

3.

PWK02

Attachment Transmission Code

BM EL FX

Medi-Cals processing and policy procedures support the methods for transmission of attachments shown in the codes column This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

CN1

Contract Information

2300

REF

Service Authorization Exception Code Mandatory Medicare (Section 4081) Crossover Indicator Mammography Certification Number Referral Number

2300

REF

2300

REF

2300

REF

2300

REF

Payer Claim Control Number Clinical Laboratory Improvement Amendment (CLIA) Certificate Number

2300

REF

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Loop ID 2300

Reference REF

Name Repricer Claim Number

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the Payers adjudication process. OP and IP Claims Only Medi-Cal expects to receive DGN in the first and second occurrence of this segment

2300

REF

Adjusted Repricer Claim Number Investigation Device Exception Number Claim Identifiers for Transmission Intermediaries Medical Record Number

2300

REF

2300

REF

2300

REF

2300

REF

Demonstration Project Identifiers PRO Approval Number

2300

REF

2300

K3

File Information

2300 2300

NTE NTE01

Claim Note Note Reference Code

NTE02

Claim Note Text

OP and IP Claims Only Medi-Cal expects to receive the Primary and Secondary Diagnosis Code Description in the first and second occurrence of this segment

2300 2300

NTE NTE02

Billing Note Billing Note Text OP and IP Claims only: Medi-Cal will use this segment to convey the Emergency Certification Statement as defined by Medi-Cal policy Medi-Cal expects to receive EMCER in the first five characters followed by the Emergency Certification documentation If the Emergency Certification Statement is not needed, other additional information may be submitted in this segment

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Loop ID 2300

Reference CRC

Name EPSDT Referral

Codes

Notes/Comments This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system Medi-Cal will accept up to 12 Diagnosis codes and their associated elements in this segment but will only use one additional Diagnosis Code in the adjudication process Medi-Cal will accept up to 12 Other Procedure Codes and their associated elements in this segment but will only use one additional Procedure Code in the adjudication process This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This loop is not required for the payers adjudication system. This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2300

HI

Admitting Diagnosis

2300

HI

Patient's Reason for Visit

2300

HI

External Cause of Injury

2300

HI

DRG Information

2300

HI

Other Diagnosis Information

2300

HI

Other Procedure Information

2300

HI

Occurrence Span Information Treatment Code Information Claim Pricing/Repricing Information Other Operating Physician

2300

HI

2300

HI

2310C

NM1

2320

AMT

Remaining Patient Liability

2320

AMT

COB Total Non-Covered Amount Other Insurance Coverage Information Inpatient Adjudication Information

2320

OI

2320

MIA

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Loop ID 2320

Reference MOA

Name Outpatient Adjudication Information Other Subscriber Name Identification Code Qualifier Other Subscriber Address

Codes

Notes/Comments This segment is not required for the payers adjudication system

2330A 2330A

NM1 NM108

MI

Medi-Cal expects to receive the value shown in the codes column This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system This loop is not required for the payers adjudication system

2330A

N3

2330A

N4

Other Subscriber City, State and ZIP code Other Subscriber Secondary Identifier Other Payer Address

2330A

REF

2330B

N3

2330B

N4

Other Payer City, State and ZIP code Other Payer Secondary Identification Other Payer Referral Number Other Payer Adjustment Indicator Other Payer Attending Provider Other Payer Operating Physician Other Payer Other Operating Physician Other Payer Service Facility Location Other Payer Rendering Provider Name Other Payer Referring Provider Other Payer Billing Provider

2330B

REF

2330B

REF

2330B

REF

2330C

2330D

2330E

2330F

2330G

2330H

2330I

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Loop ID 2400

Reference LX

Name Service Line Number

Codes

Notes/Comments Medi-Cal accepts and processes the following number of claim service lines for the document types indicated: 1. 2. 3. Inpatient 22 lines Outpatient 22 lines Long Term Care 1 line

2400

PWK

Line Supplemental Information Line Item Control Number

This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2400

REF

2400

REF

Repriced Line Item Reference Number Adjusted Repriced Line Item Reference Number Facility Tax Amount

2400

REF

2400

AMT

2400

NTE

Third Party Organization Notes Line Pricing/Repricing Information Prescription of Compound Drug Association Number Reference Identification Number
Operating Physician Name XZ

2400

HCP

2410

REF

2410

REF01

Medi-Cal expects to receive the value shown in the codes column This loop is not required for the payers adjudication system This segment is not required for the payers adjudication system This segment is not required for the payers adjudication system

2420A

2420B

Other Operating Physician Name AMT Remaining Patient Liability

2430

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3.7

005010X221A1 Health Care Claim Payment/Advice

Reference BPR BPR01 Name Financial Information Transaction Handling Code I Medi-Cal will populate this data element with the value shown in the codes column This transaction contains remittance information only. Medi-Cal will always send the Payment and Remittance information separately BPR03 Credit/Debit Flag Code Payment Method Code Payment Format Code C Medi-Cal will populate this data element with the code value shown in the codes column Medi-Cal will populate this data element with one of the values shown in the codes column Data Elements BPR05 BPR15 are only populated when BPR04 is ACH Medi-Cal will populate this data element with the code value shown in the codes column BPR07 Sender DFI Identification Medi-Cal will populate this data element with the value: 121000358 BPR08 Account Number Qualifier Sender Bank Acct. number DA Medi-Cal will populate this data element with the code value shown in the codes column Medi-Cal will populate this data element with the code value: 1436100418 BPR10 Payer Identifier (Tax ID) Medi-Cal will populate this data element with the code value: 1680217053 BPR12 (DFI) ID Number Qualifier Check Number Payer Identifier Medi-Cal will populate this data element with the code value: 1680217053 01 Medi-Cal will populate this data element with the code value shown in the codes column Codes Notes/Comments

Loop ID Header Header

BPR04

ACH CHK CCP

BPR05

BPR09

Header Header

TRN TRN03

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Loop ID

Reference TRN04

Name Reference Identification

Codes 1 2 4 5 6 7 A M N L

Notes/Comments Medi-Cal will send this information to identify the financial program payment association. Medi-Cal will populate this data element with one of the values shown in the codes column

Header

CUR

Foreign Currency Information Version Identifier Payer Name Payer Name

This segment will not be sent. All Medi-Cal payments are made in US dollars This segment will not be sent Medi-Cal will populate this data element with: State of California Department of Health Care Services

Header 1000A 1000A

REF N1 N102

1000A 1000A

N3 N301

Payer Address Address Information Medi-Cal will populate this data element with: 714 P Street RM 950

N302

Address Information

Medi-Cal will populate this data element with: P.O. Box 942732

1000A 1000A

N4 N401

Payer City, State and ZIP Code City Name Medi-Cal will populate this data element with: Sacramento

N402

State or Province Code

Medi-Cal will populate this data element with: CA

N403

Postal Code

Medi-Cal will populate this data element with: 942347320

1000A 1000A 1000A 1000A

REF PER PER PER02

Additional Payer Identification Payer Business Contact Information Payer Technical Contact Information Payer Contact Name

This segment will not be sent This segment will not be sent

Medi-Cal will populate this data element with: State of California Medi-Cal Department

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Loop ID

Reference PER04

Name Payer Contact Communication Number Payer Contact Communication Number Payer Website Payee Identification Identification Code Qualifier Remittance Delivery Method Provider Summary Information Provider Supplemental Summary Information Claims Payment Information Claim Status Code

Codes

Notes/Comments Medi-Cal will populate this data element with: 8005415555

PER06

Medi-Cal will populate this data element with: www.medi-cal.ca.gov

1000A 1000B 1000B

PER N1 N103

This segment will not be sent

XX FI

Medi-Cal will populate this data element with one of the values shown in the codes column This segment will not be sent This segment will not be sent This segment will not be sent

1000B 2000 2000

RDM TS3 TS2

2100 2100

CLP CLP02

1 2 3 4 22 MC

Medi-Cal will populate this data element with one of the values shown in the codes column

CLP06

Claim Filing Indicator Code Patient Name Identification Code Qualifier Insured Name Crossover Carrier Name Service Provider Name Identification Code Qualifier Crossover Carrier Name Corrected Priority Payer Name Identification Code Qualifier Other Subscriber Name

Medi-Cal will populate this data element with value shown in codes column Medi-Cal will populate this data element with value shown in codes column Medi-Cal will not send this segment Medi-Cal will not send this segment

2100 2100

NM1 NM108

MR

2100 2100 2100 2100

NM1 NM1 NM1 NM108

XX MC

Medi-Cal will populate this data element with one of the values shown in the codes column Medi-Cal will not send this segment

2100 2100 2100

NM1 NM1 NM108

PI

Medi-Cal will populate this data element with value shown in codes column Medi-Cal will not send this segment

2100

NM1

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Loop ID 2100 2100 2100 2100 2100 2110 2110

Reference MIA REF PER AMT QTY SVC SVC011

Name Inpatient Adjudication Information Rendering Provider Information Claim Contact Information Claim Supplemental Information Claim Supplemental Information Quantity Product/Service ID Qualifier Service Date Service Identification Rendering Provider Information Reference Identification Qualifier Health Care Policy Identification Service Supplemental Amount Amount Qualifier Code Service Supplemental Quantity Health Care Remarks Code

Codes

Notes/Comments Medi-Cal will not send this segment Medi-Cal will not send this segment Medi-Cal will not send this segment Medi-Cal will not send this segment Medi-Cal will not send this segment

NU HC N4

Medi-Cal will populate this data element with one of the values shown in the codes column Medi-Cal will not send this segment Medi-Cal will not send this segment

2110 2110 2110 2110

DTM REF REF REF01

1D

Medi-Cal will populate this data element with value shown in the codes column Medi-Cal will not send this segment

2110 2110 2110

REF AMT AMT01

T T2

Medi-Cal will populate this data element with values shown in the codes column Medi-Cal will not send this segment Medi-Cal will not send this segment

2110 2110

QTY LQ

4 TI Additional Information
4.1 Business Scenarios
There is currently no additional information to report in this section.

4.2 Payer-Specific Business Rules and Limitations

There is currently no additional information to report in this section.

4.3 Frequently Asked Questions

There is currently no additional information to report in this section.
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4.4 Other Resources

https://www.Medi-Cal.ca.gov/signup.asp http://files.Medi-Cal.ca.gov/pubsdoco/CTM_manual.asp http://files.Medi-Cal.ca.gov/pubsdoco/Manuals_menu.asp http://www.wpc-edi.com/

5 TI Change Summary

Version Number
1.0 1.1

Date
7/8/2011 8/11/2011

Reason for Revision

Initial Version ACS and IV&V edits captured throughout document Removed hyphens in Loop 1000A (PER02 and PER04); removed X and Y from ISA04 codes column

Notes/Comments

1.2

6/14/2012

Updated comments for ISA04

6 Appendix A Communication/Connectivity Instructions (CCI)

Envelope segments for inbound transaction 005010X279 (270)
Loop ID Header Header Reference ISA ISA02 Name Interchange Control Header Authorization Information Submitters must enter (left justified) their three-character Submitter (software vendor) ID, followed by their four-character Software Version Number, and with trailing spaces Codes Notes/Comments

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Loop ID

Reference ISA03

Name Security Information Qualifier

Codes 00 01

Notes/Comments For Leased-Line and Dial-Up Medi-Cal expects to receive: 00 For Batch, Medi-Cal expects to receive: 01

ISA04

Security Information

For Leased-Line and Dial-Up: Required Submitter PIN/Password, left justified and with trailing spaces For Batch: leave blank, PIN is validated against the Medi-Cal website login password

ISA05

ZZ

For Leased-Line and Dial-Up: Use the Provider Number as is in NM109 Receiver Level For Batch: Use the Submitter ID as used when you logged onto the Medi-Cal website

ISA06

Interchange Sender ID

For Leased-Line and Dial-Up: NPI or Medi-Cal Provider number For all types of providers, left justify and with trailing spaces For Batch: Enter the Submitter ID as used when you logged onto the Medi-Cal website

ISA07

Interchange ID Qualifier

ZZ

Medi-Cal expects to receive the value shown in the codes column For Leased-Line and Dial-Up: 610442ACS214, left justify and with trailing spaces For Batch: 610442

ISA08

Interchange Receiver ID

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Loop ID

Reference ISA14

Name Acknowledgment Requested

Codes 0 1

Notes/Comments For Leased-Line and Dial-Up Medi-Cal expects to receive: 0 No Acknowledgment Requested

For Batch, Medi-Cal expects to receive: 1 Interchange Acknowledgment Requested

ISA16

Component Element Separator Functional Group Header Application Sender's Code

Medi-Cal expects to receive: ~ as component separator For Leased-Line and Dial-Up Medi-Cal expects to receive: NPI or Medi-Cal provider number For Batch, Medi-Cal expects to receive: Submitter ID

Header Header

GS GS02

GS03

Application Receiver's Code

Medi-Cal expects to receive: 610442

Envelope segments for outbound transaction 005010X217 (271)

Loop ID Header Header Reference ISA ISA01 Name Interchange Control Header Authorization Information Qualifier 00 Medi-Cal will populate this data element with: 00 ISA03 Security Information Qualifier 00 No Authorization Information Present Codes Notes/Comments

Medi-Cal will populate this data element with the value shown in the codes column Medi-Cal will populate this data element with the value shown in the codes column Medi-Cal will populate this data element with: 610442

ISA05

ZZ

ISA06

Interchange Sender ID

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Loop ID

Reference ISA07

Name Interchange ID Qualifier

Codes ZZ

Notes/Comments Medi-Cal will populate this data element with the value shown in the codes column Medi-Cal will populate this data element with: For Leased-Line and Dial-Up: Medi-Cal Provider Number or NPI For Batch: Sender ID

ISA08

Interchange Receiver ID

ISA13

Interchange Control Number Acknowledgment Requested Functional Group Header Application Sender's Code

000000001

Medi-Cal will populate this data element with the value shown in the codes column Medi-Cal will populate this data element with the value shown in the codes column Medi-Cal will populate this data element with: 610442

ISA14

Header Header

GS GS02

GS03

Application Receiver's Code

Medi-Cal will populate this data element with: For Leased-Line and Dial-Up: Medi-Cal Provider Number or NPI For Batch: Submitter ID

Envelope segments for inbound transaction 005010X222A1 (837P)

Loop ID Header Reference ISA Name Interchange Control Header Header ISA04 ISA06 Media Indicator Interchange Sender ID Medi-Cal will populate this data element with values X or Y Medi-Cal expects to receive: Submitter ID Codes Notes/Comments

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Loop ID

Reference ISA08

Name Interchange Receiver ID

Codes

Notes/Comments Medi-Cal expects to receive: 610442

Header Header

GS GS02

Functional Group Header Application Senders Code Medi-Cal expects to receive: Submitter ID

GS03

Application Receiver Code

Medi-Cal expects to receive: 610442

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Envelope segments for inbound transaction 005010X223A2 (837I)

Loop ID Header Reference ISA Name Interchange Control Header Header ISA04 ISA06 Media Indicator Interchange Sender ID Medi-Cal will populate this data element with values X or Y Medi-Cal expects to receive: Submitter ID ISA08 Interchange Receiver ID Medi-Cal expects to receive: 610442 Header GS GS02 Functional Group Header Application Senders Code Application Receiver Code Medi-Cal expects to receive: Submitter ID GS03 Medi-Cal expects to receive: 610442 Codes Notes/Comments

Envelope segments for inbound transaction 005010X223A2 (837I)

Loop ID Header Reference ISA Name Interchange Control Header Header ISA06 Interchange Sender ID Medi-Cal expects to receive: Submitter ID, NPI or Medi-Cal Provider Number ISA08 Interchange Receiver ID Medi-Cal expects to receive: 610442 Header Header GS GS02 Functional Group Header Application Senders Code Medi-Cal expects to receive: Submitter ID, NPI or Medi-Cal Provider Number GS03 Application Receiver Code Medi-Cal expects to receive: 610442 Codes Notes/Comments

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Envelope segments for inbound transaction 005010X223A2 (837I)

Loop ID Header Reference ISA Name Interchange Control Header Header ISA06 Interchange Sender ID Medi-Cal will populate this segment with: Submitter ID ISA08 Interchange Receiver ID Medi-Cal will populate this segment with: 610442 Header Header GS GS02 Functional Group Header Application Senders Code Medi-Cal will populate this segment with: Submitter ID GS03 Application Receiver Code Medi-Cal will populate this segment with: 610442 Codes Notes/Comments

Envelope segments for outbound transaction 005010X221A1 (835)

Loop ID Header Reference ISA Name Interchange Control Header Header ISA06 Interchange Sender ID Medi-Cal will populate this segment with: Submitter ID ISA08 Interchange Receiver ID Medi-Cal will populate this segment with: 610442 Header Header GS GS02 Functional Group Header Application Senders Code Medi-Cal will populate this segment with: Submitter ID GS03 Application Receiver Code Medi-Cal will populate this segment with: 610442 Codes Notes/Comments

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