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Encounter Data System
Standard Companion Guide Transaction Information
Instructions related to the 837 Health Care Claim: Professional Transaction based
on ASC X12 Technical Report Type 3 (TR3), Version 005010X222A1
Companion Guide Version Number: 29.0
Created: May 2014
837 Professional Companion Guide Version 29.0/May 2014
1
Preface
The Encounter Data System (EDS) Companion Guide contains information to assist Medicare Advantage
Organizations (MAOs) and other entities in the submission of encounter data. The EDS Companion Guide is
under development and the information in this version reflects current decisions and will be modified on a
regular basis. All of the EDS Companion Guides are identified with a version number, which is located in the
version control log on the last page of the document. Users should verify that they are using the most
current version.
Questions regarding the contents of the EDS Companion Guide should be directed to
[email protected].
837 Professional Companion Guide Version 29.0/May 2014
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Table of Contents
1.0
Introduction
1.1
Scope
1.2
Overview
1.3
Major Updates
1.3.1 EDS Acronyms
1.4
References
2.0
Contact Information
2.1
CSSC
2.2
Applicable Websites/Email Resources
3.0
File Submission
3.1
File Size Limitations
3.2
File Structure
4.0
Control segments/envelopes
4.1
ISA/IEA
4.2
GS/GE
4.3
ST/SE
5.0
Transaction Specific Information
5.1
837-P Transaction Specific Table
6.0
Acknowledgements and/or Reports
6.1
TA1
6.2
999
6.3
277CA
6.4
MAO-001 Encounter Data Duplicates Report
6.5
MAO-002 – Encounter Data Processing Status Report
6.6
File Naming Conventions
6.6.1 Testing
6.6.2 Production
6.7
EDFES Notifications
7.0
Front-End Edits
7.1.
Deactivated Front-end Edits
7.2
Temporarily Deactivated Front-End Edits
8.0
Duplicate Logic
8.1
Header Level
8.2
Detail Level
837 Professional Companion Guide Version 29.0/May 2014
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Table of Contents
9.0
Business Cases
9.1
Standard Professional Encounter
9.2
Capitated Professional Encounter
9.3
Chart Review Professional Encounter – No Linked ICN
9.4
Chart Review Professional Encounter – Linked ICN
9.5
Complete Replacement Professional Encounter
9.6
Complete Deletion Professional Encounter
9.7
Atypical Provider Professional Encounter
9.8
Paper Generated Professional Encounter
9.9
True Coordination of Benefits Professional Encounter
9.10 Bundled Professional Encounter
10.0
Encounter Data Professional Processing and Pricing System Edits
10.1 EDPPPS Enhancements Implementation Dates
10.2 EDPS Edits Prevention and Resolution Strategies
10.2.1 EDPS Edits Prevention and Resolution Strategies – Phase I
10.2.2 EDPS Edits Prevention and Resolution Strategies – Phase II
10.2.3 EDPS Edits Prevention and Resolution Strategies – Phase III
11.0
Submission of Default Data in a Limited Set of Circumstances
11.1 Default Data Reason Codes
12.0
Tier II Testing
13.0
EDS Acronyms
837 Professional Companion Guide Version 29.0/May 2014
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1.0
Introduction
1.1
Scope
The CMS Encounter Data System (EDS) 837-P Companion Guide addresses how MAOs and other entities
conduct Professional claims Health Information Portability and Accountability Act (HIPAA) standard
electronic transactions with CMS. The CMS EDS supports transactions adopted under HIPAA, as well as
additional supporting transactions described in this guide.
The CMS EDS 837-P Companion Guide must be used in conjunction with the associated 837-P
Implementation Guide (TR3) and the Encounter Data Front-End System (EDFES) CEM Edits Spreadsheets.
The instructions in the CMS EDS 837-P Companion Guide are not intended for use as a stand-alone
requirements document.
1.2
Overview
The CMS EDS 837-P Companion Guide includes information required to initiate and maintain
communication exchange with CMS. The information is organized in the sections listed below:
•
Contact Information: Includes telephone numbers and email addresses for EDS contacts.
•
Control Segments/Envelopes: Contains information required to create the ISA/IEA, GS/GE, and
ST/SE control segments in order for the EDS to support these transactions.
•
Acknowledgements and Reports: Contains information for all transaction acknowledgements and
reports sent by the EDS.
•
Transaction Specific Information: Describes the details of the HIPAA X12 Implementation Guides
(IGs), using a tabular format. The tables contain a row for each segment with CMS and IG specific
information. That information may contain:
o Limits on the repeat of loops or segments
o Limits on the length of a simple data element
o Specifics on a sub-set of the IG’s internal code listings
o Clarification of the use of loops, segments, and composite or simple data elements
o Any other information tied directly to a loop, segment, and composite or simple data
element pertinent to trading electronically with CMS.
In addition to the row for each segment, one (1) or more additional rows describe the EDS’ usage for
composite or simple data elements and for any other information.
1.3 Major Updates
1.3.1
EDS Acronyms
MAOs and other entities may reference Section 13.0, Table 19 for additional acronyms frequently used by
the EDS.
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1.4
References
MAOs and other entities must use the ASC X12N IG adopted under the HIPAA Administrative Simplification
Electronic Transaction rule, along with CMS’ Encounter Data Participant Guides and EDS Companion Guides,
for development of the EDS transactions. These documents are accessible on the CSSC Operations website
at www.csscoperations.com.
Additionally, CMS publishes the EDS’ submitter guidelines and application, testing documents, 837 EDS
Companion Guides and Encounter Data Participant Guides on the CSSC Operations website.
MAOs and other entities must use the most current national standard code lists applicable to the 5010
transaction. The code lists is accessible at the Washington Publishing Company (WPC) website at
http://www.wpc-edi.com
The applicable code lists are as follows:
• Claim Adjustment Reason Code (CARC)
• Claim Status Category Codes (CSSC)
• Claim Status Codes (CSC)
CMS provides X12 5010 file format technical edit spreadsheets for the 837-P and 837-I. The edits included
in the spreadsheets are provided to clarify the WPC instructions or add Medicare specific requirements. In
order to determine the implementation date of the edits contained in the spreadsheet, MAOs and other
entities should initially refer to the spreadsheet version identifier. The version identifier is comprised of ten
(10) characters as follows:
•
•
•
•
Positions 1-2 indicate the line of business:
o EA – Part A (837-I)
o EB – Part B (837-P)
Positions 3-6 indicate the year (e.g., 2011)
Position 7 indicates the release quarter month
o 1 – January release
o 2 – April release
o 3 – July release
o 4 – October release
Positions 8-10 indicate the spreadsheet version iteration number (e.g., V01-first iteration, V02second iteration)
The effective date of the spreadsheet is the first calendar day of the release quarter month. The
implementation date is the first business Monday of the release quarter month. Federal holidays that
potentially occur on the first business Monday are considered when determining the implementation date.
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2.0
Contact Information
2.1
The Customer Service and Support Center (CSSC)
The Customer Service and Support Center (CSSC) personnel are available for questions from 8:00 A.M. –
7:00 P.M. EST, Monday-Friday, with the exception of federal holidays. MAOs and others entities are able to
contact the CSSC by phone at 1-877-534-CSSC (2772) or by email at [email protected].
2.2
Applicable Websites/Email Resources
The following websites provide information to assist in the EDS submission:
RESOURCE
WEB ADDRESS
EDS Bulletin
http://www.csscoperations.com/
EDS Inbox
[email protected]
EDS Participant Guides
http://www.csscoperations.com/
EDS User Group Materials
http://www.csscoperations.com/
ANSI ASC X12 TR3
http://www.wpc-edi.com/
Implementation Guides
Washington Publishing Company http://www.wpc-edi.com/
Health Care Code Sets
CMS Edits Spreadsheets
http://www.cms.gov/MFFS5010D0/20_TechnicalDocumentation.asp
3.0
File Submission
3.1
File Size Limitations
Due to system limitations, the combination of all ST/SE transaction sets per file cannot exceed certain
thresholds, dependent upon the connectivity method of the submitter. FTP and NDM users cannot exceed
85,000 encounters per file. Gentran/TIBCO users cannot exceed 5,000 encounters per file. For all
connectivity methods, the TR3 allows no more than 5000 CLMs per ST/SE segment. The following table
demonstrates the limits due to connectivity methods:
CONNECTIVITY
FTP/NDM
Gentran/TIBCO
MAXIMUM NUMBER OF
ENCOUNTERS
85,000
5,000
MAXIMUM NUMBER OF
ENCOUNTERS PER ST/SE
5,000
5,000
Note: Due to system processing overhead associated with smaller numbers of encounters within the ST/SE,
it is highly recommended that MAOs and other entities submit larger numbers of encounters within the
ST/SE, not to exceed 5,000 encounters.
In an effort to support and provide the most efficient processing system, and to allow for maximum
performance, CMS recommends that FTP submitters’ scripts upload no more than one (1) file per five (5)
minute intervals. Zipped files should contain one (1) file per transmission. MAOs and other entities should
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refrain from submitting multiple files within the same transmission. NDM and Gentran/TIBCO users may
submit a maximum of 255 files per day.
3.2
File Structure – NDM/Connect:Direct and Gentran/TIBCO Submitters Only
NDM/Connect:Direct and Gentran/TIBCO submitters must format all submitted files in an 80-byte fixed
block format. This means MAOs and other entities must upload every line (record) in a file with a length of
80 bytes/characters.
Submitters should create files with segments stacked, using only 80 characters per line. At position 81 of
each segment, MAOs and other entities must create a new line. On the new line starting in position 1,
continue for 80 characters, and repeat creating a new line in position 81 until the file is complete. If the last
line in the file does not fill to 80 characters, the submitter should space the line out to position 80 and then
save the file.
Note: If MAOs and other entities are using a text editor to create the file, pressing the Enter key will create
a new line. If MAOs and other entities are using an automated system to create the file, create a new line
by using a CRLF (Carriage Return Line Feed) or a LF (Line Feed).
For example, the ISA record is 106 characters long:
ISA*00*
*00*
*ZZ*ENH9999
4*^*00501*000000031*1*P*:~
*ZZ*80882
*120430*114
The first line of the file will contain the first 80 characters of the ISA segment; the last 26 characters of the
ISA segment will continue on the second line. The next segment will start in the 27th position and continue
until column 80.
Note to NDM/Connect:Direct Users: If a submitter has not established a sufficient number of Generated
Data Groups (GDGs) to accommodate the number of files returned from the EDFES, not all of the EDFES
Acknowledgement reports will be stored in the submitter’s system. To prevent this situation,
NDM/Connect:Direct submitters should establish a limit of 255 GDGs in their internal processing systems.
4.0
Control Segments/Envelopes
4.1
ISA/IEA
The term interchange denotes the transmitted ISA/IEA envelope. Interchange control is achieved through
several “control” components, as defined in Table 1. The interchange control number is contained in data
element ISA13 of the ISA segment. The identical control number must also occur in data element IEA02 of
the IEA segment. MAOs and other entities must populate all elements in the ISA/IEA interchange. There
are several elements within the ISA/IEA interchange that must be populated specifically for encounter data
purposes. Table 1 below provides EDS Interchange Control (ISA/IEA) specific elements.
Note: Table 1 presents only those elements that provide specific details relevant to encounter data. When
developing the encounter data system, users should base their logic on the highest level of specificity. First,
consult the WPC/TR3. Second, consult the CMS edits spreadsheets. Third, consult the CMS EDS 837-P
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Companion Guide. If the options expressed in the WPC/TR3 or the CEM edits spreadsheet are broader than
the options identified in the CMS EDS 837-P Companion Guide, MAOs and other entities must use the rules
identified in the Companion Guide.
Legend
SHADED rows represent segments in the X12N Implementation Guide
NON-SHADED rows represent data elements in the X12N Implementation Guide
LOOP ID
ISA
REFERENCE
ISA01
ISA02
ISA03
ISA04
ISA05
ISA06
ISA07
ISA08
ISA11
ISA13
ISA14
ISA
ISA15
IEA
IEA02
4.2
TABLE 1 – ISA/IEA INTERCHANGE ELEMENTS
NAME
CODES
NOTES/COMMENTS
Interchange Control Header
Authorization Information Qualifier 00
No authorization information present
Authorization Information
Use 10 blank spaces
Security Information Qualifier
00
No security information present
Security Information
Use 10 blank spaces
Interchange ID Qualifier
ZZ
CMS expects to see a value of “ZZ” to
designate that the code is mutually defined
Interchange Sender ID
EN followed by Contract ID Number
Interchange ID Qualifier
ZZ
CMS expects to see a value of “ZZ” to
designate that the code is mutually defined
Interchange Receiver ID
80882
Repetition Separator
^
Interchange Control Number
Must be a fixed length with nine (9)
characters and match IEA02
Used to identify file level duplicate
collectively with GS06, ST02, and BHT03
Acknowledgement Requested
1
Interchange Acknowledgement Requested
(TA1)
A TA1 will be sent if the file is syntactically
incorrect, otherwise only a ‘999’ will be sent
Interchange Control Header
Usage Indicator
T
Test
P
Production
Interchange Control Trailer
Interchange Control Number
Must match the value in ISA13
GS/GE
The functional group is outlined by the functional group header (GS segment) and the functional group
trailer (GE segment). The functional group header starts and identifies one or more related transaction sets
and provides a control number and application identification information. The functional group trailer
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defines the end of the functional group of related transaction sets and provides a count of contained
transaction sets.
MAOs and other entities must populate elements in the GS/GE functional group. There are several
elements within the GS/GE that must be populated specifically for encounter data collection. Table 2
provides EDS functional group (GS/GE) specific elements.
Note: Table 2 presents only those elements that require explanation.
LOOP ID
GS
REFERENCE
GS02
GS03
GS06
TABLE 2 - GS/GE FUNCTIONAL GROUP ELEMENTS
NAME
CODES
NOTES/COMMENTS
Functional Group Header
EN followed by Contract ID Number
Application Sender’s Code
Application Receiver’s Code
Group Control Number
80882
This value must match the value in ISA06
This value must match the value is ISA08
This value must match the value in GE02
Used to identify file level duplicates
collectively with ISA13, ST02, and BHT03
GS08
GE
GE02
4.3
Version/Release/Industry
Identifier code
Functional Group Trailer
Group Control Number
005010X222A1
This value must match the value in GS06
ST/SE
The transaction set (ST/SE) contains required, situational loops, unused loops, segments, and data
elements. The transaction set is outlined by the transaction set header (ST segment) and the transaction
set trailer (SE segment). The transaction set header identifies the start and identifies the transaction set.
The transaction set trailer identifies the end of the transaction set and provides a count of the data
segments, which includes the ST and SE segments. Several elements that must be populated specifically for
encounter data purposes. Table 3 provides EDS’ transaction set (ST/SE) specific elements.
Note: Table 3 presents only those elements that require explanation.
LOOP ID
ST
REFERENCE
ST01
ST02
TABLE 3 - ST/SE TRANSACTION SET HEADER AND TRAILER ELEMENTS
NAME
CODES
NOTES/COMMENTS
Transaction Set Header
Transaction Set Identifier
837
Code
This value must match the value in SE02
Transaction Set Control
Number
Used to identify file level duplicates
collectively with ISA13, GS06, and BHT03
ST03
Implementation Convention
Reference
005010X222A1
837 Professional Companion Guide Version 29.0/May 2014
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LOOP ID
SE
TABLE 3 - ST/SE TRANSACTION SET HEADER AND TRAILER ELEMENTS (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
Transaction Set Trailer
SE01
Number of Included
Must contain the actual number of
Segments
segments within the ST/SE
SE02
Transaction Set Control
This value must be match the value in
Number
ST02
5.0
Transaction Specific Information
5.1
837 Professional: Data Element Table
Within the ST/SE transaction set, there are multiple loops, segments, and data elements that provide billing
provider, subscriber, and patient level information. MAOs and other entities should reference www.wpcedi.com to obtain the most current Implementation Guide. MAOs and other entities must submit EDS
transactions using the most current transaction version.
The 837 Professional Data Element table identifies only those elements within the X12N Implementation
Guide that require comment within the context of the EDS’ submission. Table 4 identifies the 837
Professional Implementation Guide by loop name, segment name, segment identifier, data element name,
and data element identifier for cross reference. Not all data elements listed in the table below are
required, but if they are used, the table reflects the values CMS expects to see.
LOOP ID
REFERENCE
BHT
BHT03
1000A
1000A
BHT06
NM1
NM102
NM109
PER
PER03
PER05
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM
NAME
CODES
NOTES/COMMENTS
Beginning of Hierarchical
Transaction
Originator Application
Must be a unique identifier across all files
Transaction Identifier
Used to identify file level duplicates
collectively with ISA13, GS06, and ST02
Claim Identifier
CH
Chargeable
Submitter Name
Entity Type Qualifier
2
Non-Person Entity
Submitter Identifier
EN followed by Contract ID Number
Submitter EDI Contact
Information
Communication Number
TE
It is recommended that MAOs and other
Qualifier
entities populate the submitter’s
telephone number
Communication Number
EM
It is recommended that MAOs and other
Qualifier
entities populate the submitter’s email
address
837 Professional Companion Guide Version 29.0/May 2014
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LOOP ID
1000A
1000B
2010AA
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
PER
Submitter EDI Contact
Information
PER07
Communication Number
FX
It is recommended that MAOs and other
Qualifier
entities populate the submitter’s fax
number
NM1
Receiver Name
NM102
Entity Type Qualifier
2
Non-Person Entity
NM103
Receiver Name
EDSCMS
NM109
Receiver ID
80882
Identifies CMS as the receiver of the
transaction and corresponds to the value
in ISA08 Interchange Receiver ID
NM1
Billing Provider Name
NM108
Billing Provider ID Qualifier
XX
NPI Identifier
NM109
Billing Provider Identifier
1999999984 Must be populated with a ten digit
number, must begin with the number 1
Professional provider default NPI when
the provider has not been assigned an NPI
2010AA
N4
N403
2010AA
REF
SBR09
Billing Provider Tax
Identification
Reference Identification
Qualifier
Reference Identification
Subscriber Information
Payer Responsibility
Number Code
Claim Filing Indicator Code
NM1
NM108
Subscriber Name
Subscriber Id Qualifier
REF01
2000B
2010BA
Billing Provider City, State,
Zip Code
Zip Code
REF02
SBR
SBR01
The full nine (9) digits of the ZIP Code are
required. If the last four (4) digits of the
ZIP code are not available, populate a
default value of “9998”
EI
Employer’s Identification Number
199999998
Atypical professional provider default EIN
S
EDSCMS is considered the destination
(secondary) payer
Must be populated with a value of MB –
Medicare Part B
MB
MI
837 Professional Companion Guide Version 29.0/May 2014
Must be populated with a value of MI –
Member Identification Number
12
LOOP ID
2010BB
2010BB
2010BB
2010BB
2300
2300
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
NM109
Subscriber Primary Identifier
This is the subscriber’s Health Insurance
Claim (HIC) number. Must match the value
in Loop 2330A, NM109
NM1
Payer Name
NM103
Payer Name
EDSCMS
NM108
Payer ID Qualifier
PI
Must be populated with the value of PI –
Payer Identification
NM109
Payer Identification
80882
N3
Payer Address
N301
Payer Address Line
7500
Security
Blvd
N4
Payer City, State, ZIP Code
N401
Payer City Name
Baltimore
N402
Payer State
MD
N403
Payer ZIP Code
212441850
REF
Other Payer Secondary
Identifier
REF01
Contract ID Identifier
2U
REF02
Contract ID Number
MAO or other entity’s Contract ID Number
CLM
Claim Information
CLM02
Total Claim Charge Amount
CLM05-3
Claim Frequency Type Code
1
1=Original claim submission
7
7=Replacement
8
8=Deletion
PWK
Claim Supplemental
Information
PWK01
Report Type Code
09
Populated for chart review submissions
only
OZ
Populated for encounters generated as a
AM
result of paper claims only
PY
Populated on ambulance encounters when
the true ambulance pick-up and drop-off
complete addresses are not available and
the Rendering or Billing Provider street
address, city, state, and ZIP Code is
populated in 2310E and 2310F.
Populated for encounters generated as a
result of 4010 submission only
837 Professional Companion Guide Version 29.0/May 2014
13
LOOP ID
2300
2300
2300
2300
2310E
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
Populated for chart review, paper
PWK02
Attachment Transmission
AA
generated encounters, 4010 generated
Code
encounters, or ambulance encounters
when the true ambulance pick-up and dropoff locations are not available and the
Rendering Provider or Billing Provider street
address, city, state, and ZIP Code is
populated in Loops 2310E and 2310F
CN1
Contract Information
CN101
Contract Type Code
05
Populated for capitated arrangements
REF
Payer Claim Control Number
REF01
Original Reference Number
F8
REF02
Payer Claim Control Number
Identifies ICN from original claim when
submitting adjustment or chart review data
REF
Medical Record Number
REF01
Medical Record Identification EA
Number
REF02
Medical Record Identification 8
Chart review delete diagnosis code
Number
submissions only – Identifies the diagnosis
code populated in Loop 2300, HI must be
deleted from the encounter ICN in Loop
2300, REF02
Deleted
Chart review add and delete specific
Diagnosis
diagnosis codes on a single encounter
Code(s)
submissions only – Identifies the diagnosis
code(s) that must be deleted from the
encounter ICN in Loop 2300, REF02
NTE
Claim Note
NTE01
Note Reference Code
ADD
NTE02
Claim Note Text
See Section 11.0 for the use and message
requirements of default data information
N3
Ambulance Pick-Up Location
Address
N301
Ambulance Pick-Up Location
Provide the address line for the Rendering
Address Line
Provider if the true ambulance pick-up
address line is not available
Provide the address line for the Billing
Provider if the Rendering Provider is the
same as the Billing Provider and the true
ambulance pick-up address line is not
available
837 Professional Companion Guide Version 29.0/May 2014
14
LOOP ID
2310E
2310E
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
N4
Ambulance Pick-Up Location
City, State, and ZIP Code
N402
Ambulance Pick-Up State
Provide the state name for the Rendering
Name
Provider if the true ambulance pick-up
state name is not available
N403
Ambulance Pick-Up Zip Code
Provide the state name for the Billing
Provider if the Rendering Provider is the
same as the Billing Provider and the true
ambulance pick-up state name is not
available
Provide the ZIP code for the Rendering
Provider if the true ambulance pick-up ZIP
code is not available
Provide the ZIP code for the Billing Provider
if the Rendering Provider is the same as the
Billing Provider and the true ambulance
pick-up ZIP code is not available
2310F
N3
N301
Ambulance Drop-Off
Location Address
Ambulance Drop-Off
Location Address Line
Provide the address line for the Rendering
Provider if the true ambulance drop-off
address line is not available
Provide the address line for the Billing
Provider if the Rendering Provider is the
same as the Billing Provider and the true
ambulance drop-off address line is not
available
2310F
N4
N401
Ambulance Drop-Off
Location City, State, and ZIP
Code
Ambulance Drop-Off City
Name
Provide the city name for the Rendering
Provider if the true ambulance drop-off city
name is not available
Provide the city name for the Billing
Provider if the Rendering Provider is the
same as the Billing Provider and the true
ambulance drop-off city name is not
available
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15
LOOP ID
2310F
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
N4
Ambulance Drop-Off
Location City, State, and ZIP
Code
N402
Ambulance Drop-Off State
Provide the state name for the Rendering
Name
Provider if the true ambulance drop-off
state name is not available
N403
Provide the state name for the Billing
Provider if the Rendering Provider is the
same as the Billing Provider and the true
ambulance drop-off state name is not
available
Provide the ZIP code for the Rendering
Provider if the true ambulance drop-off ZIP
code is not available
Ambulance Drop-Off Zip
Code
Provide the ZIP code for the Billing Provider
if the Rendering Provider is the same as the
Billing Provider and the true ambulance
drop-off ZIP code is not available
2320
SBR
Other Subscriber
Information
Payer Responsibility
Sequence Number Code
P
T
SBR09
Claim Filing Indicator Code
16
CAS
CAS02
Claim Adjustment
Adjustment Reason Code
AMT
AMT02
OI
OI03
COB Payer Paid Amount
Payer Paid Amount
Coverage Information
Benefits Assignment
Certification Indicator
SBR01
2320
2320
2320
837 Professional Companion Guide Version 29.0/May 2014
P=Primary (when MAOs or other entities
populate the payer paid amount)
T=Tertiary (when MAOs or other entities
populate a true COB
Health Maintenance Organization (HMO)
Medicare Risk
If a claim is denied in the MAO or other
entities’ adjudication system, the denial
reason must be populated
MAO and other entity’s paid amount
Must match the value in Loop 2300, CLM08
16
LOOP ID
2330A
2330B
2330B
2330B
2400
2430
2430
2430
TABLE 4 - 837 PROFESSIONAL HEALTH CARE CLAIM (CONTINUED)
REFERENCE
NAME
CODES
NOTES/COMMENTS
NM1
Other Subscriber Name
NM108
Identification Code Qualifier MI
NM109
Subscriber Primary
Must match the value in Loop 2010BA,
Identifier
NM109
NM1
Other Payer Name
NM108
Identification Code Qualifier XV
NM109
Other Payer Primary
Payer01
MAO or other entity’s Contract ID Number
Identifier
Only populated if there is no Contract ID
Number available for a true other payer
N3
Other Payer Address
N301
Other Payer Address Line
MAO or other entity’s address
N4
Other Payer City, State, ZIP
Code
N401
Other Payer City Name
MAO or other entity’s City Name
N402
Other Payer State
MAO or other entity’s State
N403
Other Payer ZIP Code
MAO or other entity’s ZIP Code
CN1
Contract Information
CN101
Contract Type Code
05
Populated for each capitated/ staff service
line
SVD
Line Adjudication
Information
SVD01
Other Payer Primary
Must match the value in Loop 2330B,
Identifier
NM109
CAS
Line Adjustments
CAS02
Adjustment Reason Code
If a service line is denied in the MAO or
other entities’ adjudication system, the
denial reason must be populated
DTP
Line Check or Remittance
Date
DTP03
Populate the claim receipt date minus one
(1) day as the default primary payer
adjudication date only in the instance that
the primary payer adjudication date is not
available
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6.0
Acknowledgements and Reports
6.1
TA1 – Interchange Acknowledgement
The TA1 report enables the receiver to notify the sender when there are problems with the interchange
control structure. As the interchange envelope enters the EDFES, the EDI translator performs TA1
validation of the control segments/envelope. The sender will only receive a TA1 if there are syntax errors in
the submitted file. Errors found in this stage will cause the entire X12 interchange to reject with no further
processing.
MAOs and other entities will receive a TA1 interchange report acknowledging the syntactical inaccuracy of
an X12 interchange header ISA and trailer IEA and the envelope’s structure. Encompassed in the TA1 is the
interchange control number, interchange date and time, interchange acknowledgement code and
interchange note code. The interchange control number, date, and time are identical to those populated
on the original 837-I or 837-P ISA line, which allows for MAOs and other entities to associate the TA1 with a
specific file previously submitted.
Within the TA1 segment, MAOs and other entities will be able to determine if the interchange rejected by
examining the interchange acknowledgement code (TA104) and the interchange note code (TA105). The
interchange acknowledgement code stipulates whether the interchange (ISA/IEA) rejected due to
syntactical errors. An “R” will be the value in the TA104 data element if the interchange rejected due to
errors. The interchange note code is a numeric code that notifies MAOs and other entities of the specific
error. If a fatal error occurs, the EDFES generates and returns the TA1 interchange acknowledgement
report within 24 hours of the interchange submission. If a TA1 interchange control structure error is
identified, MAOs and other entities must correct the error and resubmit the interchange file.
6.2
999 – Functional Group Acknowledgement
After the interchange passes the TA1 edits, the next stage of editing is to apply Implementation Guide (IG)
edits and verify the syntactical correctness of the functional group(s) (GS/GE). Functional groups allow for
organization of like data within an interchange; therefore, more than one (1) functional group with multiple
claims within the functional group can be populated in a file. The 999 acknowledgement report provides
information on the validation of the GS/GE functional group(s) and the consistency of the data. The 999
report provides MAOs and other entities information on whether the functional group(s) were accepted or
rejected.
If a file has multiple GS/GE segments and errors occurred at any point within one of the syntactical and IG
level edit validations, the GS/GE segment will reject, and processing will continue to the next GS/GE
segment. For instance, if a file is submitted with three (3) functional groups and there are errors in the
second functional group, the first functional group will accept, the second functional group will reject, and
processing will continue to the third functional group.
The 999 transaction set is designed to report on adherence to IG level edits and CMS standard syntax errors
as depicted in the CMS edit spreadsheet. Three (3) possible acknowledgement values are:
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•
•
•
“A” – Accepted
“R” – Rejected
“P” - Partially Accepted, At Least One Transaction Set Was Rejected
When viewing the 999 report, MAOs and other entities should navigate to the IK5 and AK9 segments. If an
“A” is displayed in the IK5 and AK9 segments, the claim file is accepted and will continue processing. If an
“R” is displayed in the IK5 and AK9 segments, an IK3 and an IK4 segment will be displayed. These segments
indicate what loops and segments contain the error that needs correcting so the interchange can be
resubmitted. The third element in the IK3 segment identifies the loop that contains the error. The first
element in the IK3 and IK4 indicates the segment and element that contain the error. The third element in
the IK4 segment indicates the reason code for the error.
6.3
277CA – Claim Acknowledgement
After the file accepts at the interchange and functional group levels, the third level of editing occurs at the
transaction set level within the CEM in order to create the Claim Acknowledgement Transaction (277CA)
report. The CEM checks the validity of the values within the data elements. For instance, data element
N403 must be a valid nine (9)-digit ZIP code. If a non-existent ZIP code is populated, the CEM will reject the
encounter. The 277CA is an unsolicited acknowledgement report from CMS to MAOs and other entities.
The 277CA is used to acknowledge the acceptance or rejection of encounters submitted using a hierarchical
level (HL) structure. The first level of hierarchical editing is at the Information Source level. This entity is
the decision maker in the business transaction receiving the X12 837 transactions (EDSCMS). The next level
is at the Information Receiver level. This is the entity expecting the response from the Information Source.
The third hierarchal level is at the Billing Provider of Service level; and the fourth and final level is done at
the Patient level. Acceptance or rejection at this level is based on the WPC and the CMS edits spreadsheet.
Edits received at any hierarchical level will stop and no further editing will take place. For example, if there
is a problem with the Billing Provider of Service submitted on the 837, individual patient edits will not be
performed. For those encounters not accepted, the 277CA will detail additional actions required of MAOs
and other entities in order to correct and resubmit those encounters.
If an MAO or other entity receives a 277CA indicating an encounter rejected, the MAO or other entity must
resubmit the encounter until the 277CA indicates no errors were found.
If an encounter is accepted, the 277CA will provide the ICN assigned to that encounter. The ICN segment
for the accepted encounter will be located in 2200D REF segment, REF01=IK and REF02=ICN. The ICN is a
unique 13-digit number.
If an encounter rejects, the 277CA will provide edit information in the STC segment. The STC03 data
element will convey whether the HL structures accepted or rejected. The STC03 is populated with a value
of “WQ”, if the HL was accepted. If the STC03 data element is populated with a value of “U”, the HL rejects
and the STC01 data element will list the acknowledgement code.
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6.4
MAO-001 – Encounter Data Duplicates Report
When the MAO-002 Encounter Data Processing Status Report is returned to an MAO or other entity, and
contains edit 98325 – Service Line(s) Duplicated, the EDPS will also generate and return the MAO-001
Encounter Data Duplicates Report. MAOs and other entities will not receive the MAO-001 report if there
are no duplicate errors received on submitted encounters.
The MAO-001 report is a fixed length report available in flat file and formatted report layouts. It provides
information for encounters and service lines that receive a status of “reject” and the specific error message
of 98325 – Service Line(s) Duplicated. MAOs and other entities must correct and resubmit only those
encounters containing service lines that received edit 98325. The MAO-001 report allows MAOs and other
entities the opportunity to more easily reconcile these duplicate encounters and service lines.
6.5
MAO-002 – Encounter Data Processing Status Report
After a file accepts through the EDFES, the file is transmitted to the Encounter Data Processing System
(EDPS) where further editing, processing, pricing, and storage occurs. As a result of EDPS editing, the EDPS
will return the MAO-002 – Encounter Data Processing Status Report.
The MAO-002 report is a fixed length report available in flat file and formatted report layouts that provide
encounter and service line level information. The MAO-002 reflects two (2) statuses at the encounter and
service line level: “accepted” and “rejected”. Lines that reflect a status of “accept” yet contain an error
message in the Edit Description column are considered “informational” edits. MAOs and other entities are
not required to take further action on “informational” edits.
The ‘000’ line on the MAO-002 report identifies the header level and indicates either “accepted” or
“rejected” status. If the ‘000’ header line is rejected, the encounter is considered rejected and MAOs and
other entities must correct and resubmit the encounter. If the ‘000’ header line is “accepted” and at least
one (1) other line (i.e., 001 002 003 004) is accepted, then the overall encounter is accepted.
6.6
Reports File Naming Conventions
In order for MAOs and other entities to receive and identify the EDFES acknowledge reports (TA1, 999, and
277CA) and EDPS MAO-002 Encounter Data Processing Status Report, specific reports file naming
conventions have been used. The file name ensures that the specific reports are appropriately distributed
to each secure, unique mailbox. The EDFES and EDPS have established unique file naming conventions for
reports distributed during testing and production.
6.6.1
Testing Reports File Naming Convention
Table 5 below provides the EDFES reports file naming conventions according to connectivity method.
MAOs and other entities should note that Connect:Direct (NDM) users’ reports file naming conventions are
user defined.
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20
REPORT TYPE
EDFES Notifications
TA1
999
999
277CA
TABLE 5 – TESTING EDFES REPORTS FILE NAMING CONVENTIONS
GENTRAN/TIBCO MAILBOX
FTP MAILBOX
T.xxxxx.EDS_RESPONSE.pn
RSPxxxxx.RSP.REJECTED_ID
T.xxxxx.EDS_REJT_IC_ISAIEA.pn
X12xxxxx.X12.TMMDDCCYYHHMMS
T.xxxxx.EDS_REJT_FUNCT_TRANS.pn
999#####.999.999
T.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn
999#####.999.999
T.xxxxx.EDS_RESP_CLAIM_NUM.pn
RSPxxxxx.RSP_277CA
Table 6 below provides the EDPS reports file naming convention by connectivity method. MAOs and other
entities should note that Connect:Direct (NDM) users’ reports file naming conventions are user defined.
TABLE 6 – TESTING EDPS REPORTS FILE NAMING CONVENTIONS
CONNECTIVITY
METHOD
GENTRAN/
TIBCO
FTP
TESTING NAMING CONVENTION
FORMATTED REPORT
T .xxxxx.EDPS_001_DataDuplicate_Rpt
T.xxxxx.EDPS_002_DataProcessingStatus_Rpt
T .xxxxx.EDPS_004_RiskFilter_Rpt
T.xxxxx.EDPS_005_DispositionSummary_Rpt
T .xxxxx.EDPS_006_EditDisposition_Rpt
T .xxxxx.EDPS_007_DispositionDetail_Rpt
RPTxxxxx.RPT.EDPS_001_DATDUP_RPT
RPTxxxxx.RPT.EDPS_002_DATPRS_RPT
RPTxxxxx.RPT.EDPS_004_RSKFLT_RPT
RPTxxxxx.RPT.EDPS_005_DSPSUM_RPT
RPTxxxxx.RPT.EDPS_006_EDTDSP_RPT
RPTxxxxx.RPT.EDPS_007_DSTDTL_RPT
TESTING NAMING CONVENTION
FLAT FILE LAYOUT
T .xxxxx.EDPS_001_DataDuplicate_File
T.xxxxx.EDPS_002_DataProcessingStatus_File
T .xxxxx.EDPS_004_RiskFilter_File
T.xxxxx.EDPS_005_DispositionSummary_ File
T .xxxxx.EDPS_006_EditDisposition_ File
T .xxxxx.EDPS_007_DispositionDetail_ File
RPTxxxxx.RPT.EDPS_001_DATDUP_File
RPTxxxxx.RPT.EDPS_002_DATPRS_File
RPTxxxxx.RPT.EDPS_004_RSKFLT_ File
RPTxxxxx.RPT.EDPS_005_DSPSUM_ File
RPTxxxxx.RPT.EDPS_006_EDTDSP_ File
RPTxxxxx.RPT.EDPS_007_DSTDTL_ File
Table 7 below provides a description of the file name components, which will assist MAOs and other
entities in identifying the report type.
TABLE 7 –FILE NAME COMPONENT DESCRIPTION
FILE NAME
COMPONENT
RSPxxxxx
X12xxxxx
TMMDDCCYYHHMMS
999xxxxx
RPTxxxxx
EDPS_XXX
XXXXXXX
RPT/FILE
DESCRIPTION
The type of data ‘RSP’ and a sequential number assigned by the server ‘xxxxx’
The type of data ‘X12’ and a sequential number assigned by the server ‘xxxxx’
The Date and Time stamp the file was processed
The type of data ‘999’ and a sequential number assigned by the server ‘xxxxx’
The type of data ‘RPT’ and a sequential number assigned by the server ‘xxxxx’
Identifies the specific EDPS Report along with the report number (i.e., ‘002’, etc.)
Seven (7) characters available to be used as a short description of the contents of the file
Identifies if the file is a formatted report ‘RPT’ or a flat file ‘FILE’ layout
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6.6.2
Production Reports File Naming Convention
A different production reports file naming convention is used so that MAOs and other entities may easily
identify reports generated and distributed during production. Table 8 below provides the reports file
naming conventions per connectivity method for production reports.
TABLE 8 – PRODUCTION EDFES REPORTS FILE NAMING CONVENTIONS
REPORT TYPE
GENTRAN/TIBCO MAILBOX
FTP MAILBOX
EDFES Notifications
P.xxxxx.EDS_RESPONSE.pn
RSPxxxxx.RSP.REJECTED_ID
TA1
P.xxxxx.EDS_REJT_IC_ISAIEA.pn
X12xxxxx.X12.TMMDDCCYYHHMMS
999
P.xxxxx.EDS_REJT_FUNCT_TRANS.pn
999#####.999.999
999
P.xxxxx.EDS_ACCPT_FUNCT_TRANS.pn
999#####.999.999
277CA
P.xxxxx.EDS_RESP_CLAIM_NUM.pn
RSPxxxxx.RSP_277CA
Table 9 below provides the production EDPS reports file naming conventions per connectivity method.
TABLE 9 – PRODUCTION EDPS REPORTS FILE NAMING CONVENTIONS
CONNECTIVITY
METHOD
GENTRAN/
TIBCO
FTP
6.7
PRODUCTION NAMING CONVENTION
FORMATTED REPORT
P.xxxxx.EDPS_001_DataDuplicate_Rpt
P.xxxxx.EDPS_002_DataProcessingStatus_Rpt
P.xxxxx.EDPS_004_RiskFilter_Rpt
P.xxxxx.EDPS_005_DispositionSummary_Rpt
P.xxxxx.EDPS_006_EditDisposition_Rpt
P.xxxxx.EDPS_007_DispositionDetail_Rpt
RPTxxxxx.RPT.PROD_001_DATDUP_RPT
RPTxxxxx.RPT.PROD_002_DATPRS_RPT
RPTxxxxx.RPT.PROD_004_RSKFLT_RPT
RPTxxxxx.RPT.PROD_005_DSPSUM_RPT
RPTxxxxx.RPT.PROD_006_EDTDSP_RPT
RPTxxxxx.RPT.PROD_007_DSTDTL_RPT
PRODUCTION NAMING CONVENTION
FLAT FILE LAYOUT
P.xxxxx.EDPS_001_DataDuplicate_File
P.xxxxx.EDPS_002_DataProcessingStatus_File
P.xxxxx.EDPS_004_RiskFilter_File
P.xxxxx.EDPS_005_DispositionSummary_ File
P.xxxxx.EDPS_006_EditDisposition_ File
P.xxxxx.EDPS_007_DispositionDetail_ File
RPTxxxxx.RPT.PROD_001_DATDUP_File
RPTxxxxx.RPT.PROD_002_DATPRS_File
RPTxxxxx.RPT.PROD_004_RSKFLT_ File
RPTxxxxx.RPT.PROD_005_DSPSUM_ File
RPTxxxxx.RPT.PROD_006_EDTDSP_ File
RPTxxxxx.RPT.PROD_007_DSTDTL_ File
EDFES Notifications
The EDFES distributes special notifications to submitters when encounters have been processed by the
EDFES, but will not proceed to the EDPS for further processing. These notifications are distributed to MAOs
and other entities, in addition to standard EDFES Acknowledgement Reports (TA1, 999, and 277CA) in order
to avoid returned, unprocessed files from the EDS.
Table 10 below provides the file type, EDFES notification message, and EDFES notification message
description.
The file has an 80 character record length and contains the following record layout:
1. File Name Record
a. Positions 1 – 7 = Blank Spaces
b. Positions 8 – 18 = File Name:
c. Positions 19 – 62 = Name of the Saved File
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2.
3.
4.
5.
6.
d. Positions 63 – 80 = Blank Spaces
File Control Record
a. Positions 1 – 4 = Blank Spaces
b. Positions 5 – 18 = File Control:
c. Positions 19 – 27 = File Control Number
d. Positions 28 – 80 = Blank Spaces
File Count Record
a. Positions 1 – 18 = Number of Claims:
b. Positions 19 – 24 = File Claim Count
c. Positions 25 – 80 = Blank Spaces
File Separator Record
a. Positions 1 – 80 = Separator (----------)
File Message Record
a. Positions 1 – 80 = FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE
FOLLOWING REASON(S)
File Message Records
a. Positions 1 – 80 = File Message
The report format example is as follows:
FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
FILE CONTROL: XXXXXXXXX
NUMBER OF CLAIMS: 99,999
FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
TABLE 10 – EDFES NOTIFICATIONS
APPLIES TO
ENCOUNTER TYPE
NOTIFICATION MESSAGE
All files submitted
All
SUBMITTER NOT FRONT-END
CERTIFIED
Production files submitted
All
SUBMITTER NOT CERTIFIED FOR
PRODUCTION
Tier 2 file submitted
All
THE INTERCHANGE USAGE
INDICATOR MUST EQUAL ‘T’
All
PLAN (CONTRACT ID) HAS (X,XXX)
CLAIMS IN THIS FILE. ONLY 2,000
ARE ALLOWED
Tier 2 file submitted
Professional End-to-End
Testing – File 1
Professional End-to-End
Testing – Additional File(s)
Professional
FILE CANNOT CONTAIN MORE
THAN 38 ENCOUNTERS
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NOTIFICATION MESSAGE
DESCRIPTION
The submitter must be front-end
certified to send encounters for
validation or production
The submitter must be certified
to send encounters for
production
The Professional Tier II file is
being sent with a ‘P’ in the ISA15
field
The number of encounters for a
Contract ID cannot be greater
than 2,000
The number of encounters
cannot be greater than 38
23
TABLE 10 – EDFES NOTIFICATIONS (CONTINUED)
APPLIES TO
PACE End-to-End Testing –
File 1
PACE End-to-End Testing –
Additional File(s)
End-to-End Testing – File 1
End-to-End Testing –
Additional File(s)
End-to-End Testing – File 1
End-to-End Testing –
Additional File(s)
End-to-End Testing – File 1
End-to-End Testing –
Additional File(s)
ENCOUNTER TYPE
NOTIFICATION MESSAGE
PACE Professional
FILE CANNOT CONTAIN MORE
THAN 16 ENCOUNTERS
All
Professional,
PACE Professional
Professional,
PACE Professional
End-to-End Testing – File 1
All
End-to-End Testing –
Additional File(s)
All
All files submitted
All
PATIENT CONTROL NUMBER IS
MORE THAN 20 CHARACTERS
LONG THE TC# WAS TRUNCATED
FILE CANNOT CONTAIN BOTH
UNLINKED AND LINKED TEST
CASES
CANNOT SEND LINKED TEST CASES
UNTIL ALL UNLINKED TEST CASES
HAVE BEEN ACCEPTED
FILE CONTAINS (X) TEST CASE (X)
ENCOUNTER(S)
ADDITIONAL FILES CANNOT BE
VALIDATED UNTIL AN MAO-002
REPORT HAS BEEN RECEIVED
FILE ID (XXXXXXXXX) IS A
DUPLICATE OF A FILE ID SENT
WITHIN THE LAST 12 MONTHS
SUBMITTER NOT AUTHORIZED TO
SEND CLAIMS FOR PLAN
(CONTRACT ID)
DATE OF SERVICE CANNOT BE
BEFORE 2011
TRANSACTION SET (ST/SE)
(XXXXXXXXX) CANNOT EXCEED
5,000 CLAIMS
FILE CANNOT EXCEED 85,000
ENCOUNTERS
All files submitted
All
All files submitted
All
All files submitted
All
All files submitted
All
All files submitted
All
PLAN ID CANNOT BE THE SAME AS
THE SUBMITTER ID
All files submitted
All
AT LEAST ONE ENCOUNTER IS
MISSING A CONTRACT ID IN THE
2010BB-REF02 SEGMENT
All
NO TEST CASES FOUND IN THIS
FILE
Test
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NOTIFICATION MESSAGE
DESCRIPTION
The number of encounters
cannot be greater than 16
The Claim Control Number,
including the Test Case Number,
must not exceed 20 characters
The test cases from File 1 and File
2 cannot be in the same file
The test cases for File 2 cannot be
sent before all File 1 test cases
are accepted
The file must contain two (2) of
each test case
The MAO-002 report must be
received before additional files
can be submitted
The file ID must be unique for a
12 month period
A relationship between a
submitter ID and a contract ID
was not found
Files cannot be submitted with a
date of service before 2011
There can only be 5,000 claims in
each ST/SE Loop
The maximum number of
encounters allowed in a file
The submitter is 7 characters and
the plan ID is 5 characters they
are not the same
Every encounter must have a
contract ID
This file was processed with the
Interchange Usage Indicator = ‘T’
and the Submitter was not yet
Front End Certified
24
7.0
Front-End Edits
CMS provides a list of the edits used to process all encounters submitted to the EDFES. The Fee-for-Service
(FFS) Professional CEM Edits Spreadsheet identifies active and deactivated edits for MAOs and other
entities to reference for programming their internal systems and reconciling EDFES Acknowledgement
Reports.
The Professional CEM Edits Spreadsheet provides documentation regarding edit rules that explain how to
identify an EDFES edit and the associated logic. The Professional CEM Edits Spreadsheet also provides a
change log that lists the revision history for edit updates.
MAOs and other entities are able to access the Professional CEM Edits Spreadsheet on the CMS website at
https://www.cms.gov/Medicare/Billing/MFFS5010D0/Technical-Documentation.html and on the CSSC
Operations website at:
http://www.csscoperations.com/internet/cssc3.nsf/docsCat/CSSC~CSSC%20Operations~Encounter%20Dat
a~Resources?open&expand=1&navmenu=Encounter^Data||,
7.1
Deactivated Front-End Edits
Several CEM edits currently active in the FFS Professional CEM edits spreadsheet will be deactivated in
order to ensure that syntactically correct encounters pass front-edit editing. Table 11 provides a list of the
deactivated EDFES CEM edits. The edit reference column provides the exact reference for the deactivated
edits. The edit description column provides the Claim Status Category Code (CSCC), the Claim Status Code
(CSC), and the Entity Identifier Code (EIC), when applicable. The notes column provides a description of the
edit reason. MAOs and other entities should reference the WPC website at www.wpc-edi.com for a
complete listing of all CSCCs and CSCs.
TABLE 11 – 837 PROFESSIONAL DEACTIVATED CEM EDITS
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X222.087.2010AA.NM109.030 CSCC A7: "Acknowledgement
Valid NPI Crosswalk must be available for this
/Rejected for Invalid Information…"
edit.
CSC 562: "Entity's National Provider
Identifier (NPI)"
EIC: 85 Billing Provider
X222.087.2010AA.NM109.050 CSCC A8: "Acknowledgement /
This Fee for Service edit validates the NPI and
X222.140.2010BB.REF02.075
Rejected for relational field in error"
submitter ID number to ensure the submitter
CSC 496 "Submitter not approved for
is authorized to submit on the provider’s
electronic claim submissions on behalf behalf. Encounter data cannot use this
of this entity."
validation as we validate the plan number
EIC: 85 Billing Provider
and submitter ID to ensure the submitter is
authorized to submit on the plans behalf.
X222.091.2010AA.N301.070
CSCC A7: "Acknowledgement
Remove edit check for 2010AA N3 P O Box
X222.091.2010AA.N302.060
/Rejected for Invalid Information…"
variations when ISA08 = 80882 (Professional
CSC 503: "Entity's Street Address"
payer code).
EIC: 85 Billing Provider
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TABLE 11 – 837 PROFESSIONAL DEACTIVATED CEM EDITS (CONTINUED)
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X222.094.2010AA.REF02.040
CSCC A7: "Acknowledgement
2010AA.REF02 must be nine digits with no
/Rejected for Invalid Information…"
punctuation.
CSC 128: "Entity's tax id"
EIC: 85 Billing Provider
X222.094.2010AA.REF02.050
CSCC A8: "Acknowledgement /
Valid NPI Crosswalk must be available for this
Rejected for relational field in error"
edit.
CSC 562: "Entity's National Provider
Identifier (NPI)"
CSC 128: "Entity's tax id"
EIC: 85 Billing Provider
X222.116.2000B.SBR03.004
CSCC A8: Acknowledgement/Rejected
X222.116.2000B.SBR03.006
for relational field in error
CSC 163: Entity's Policy Number
CSC 732: Information submitted
inconsistent with billing guidelines
EIC IL: Subscriber
X222.116.2000B.SBR04.005
CSCC A8: Acknowledgement/Rejected
X222.116.2000B.SBR04.007
for relational field in error
CSC 663: Entity's Group Name
CSC 732: Information submitted
inconsistent with billing guidelines
EIC IL: Subscriber
X222.157.2300.CLM02.020
IK403 = 6: "Invalid Character in Data
2300.CLM02 must be numeric.
Element"
X222.157.2300.CLM05-3.020
CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 535: "Claim Frequency Code"
X222.196.2300.REF.010
CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 732: "Information submitted
inconsistent with billing guidelines."
CSC 464: "Payer Assigned Claim
Control Number."
X222.262.2310B.NM109.030
CSCC A7: "Acknowledgement
/Rejected for Invalid Information…"
CSC 562: "Entity's National Provider
Identifier (NPI)"
EIC: 82 Rendering Provider
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Fee for Service does not allow a claim to
come in with a frequency type other than 1
(Original Claim). This Edit is turned off for
Encounter so that submitters can submit a
frequency type = 7 Replacement and
frequency type = 8 Deletion
Fee for service does not allow a REF segment
containing a claim control number to be used
when sending a corrected (Frequency type =
7) or deleted (Frequency type = 8) claim.
2300.REF with REF01 = "F8" must not be
present.
This edit needs to remain off in order for the
submitter to send the claim control number
they are trying to correct or delete.
Valid NPI Crosswalk must be available for this
edit.
26
TABLE 11 – 837 PROFESSIONAL DEACTIVATED CEM EDITS (CONTINUED)
EDIT REFERENCE
EDIT DESCRIPTION
EDIT NOTES
X222.351.2400.SV101-7.020
"CSCC A8: ""Acknowledgement /
When using a not otherwise classified or
Rejected for relational field in error""
generic HCPCS procedure code the CEM is
CSC 306 Detailed description of
editing for a more descriptive meaning of the
service"
procedure code. For example, the submitter
2400.SV101-7 must be present when
is using J3490. The description for this HCPCS
2400.SV101-2 is present on the table
is Not Otherwise Classified (NOC) Code. CMS
of procedure codes that require a
has made a decision not to price claims with
description.
these types of codes.
X222.430.2420A.NM109.030
CSCC A7: "Acknowledgement
2420A.NM109 must be a valid NPI on the
/Rejected for Invalid Information…"
Crosswalk when evaluated with
CSC 562: "Entity's National Provider
1000B.NM109.
Identifier (NPI)"
EIC 82 "Rendering Provider"
X222.480.2430.SVD02.020
IK403 = 6: Invalid Character in Data
Element
7.2
Temporarily Deactivated Front-End Edits
Table 12 provides a list of the temporarily deactivated EDFES Professional CEM balancing edits in order to
ensure that encounters that require balancing of monetary fields will pass front-end editing.
Note: The Professional edits listed in Table 12 are not all-inclusive and are subject to amendment.
TABLE 12 – 837 PROFESSIONAL TEMPORARILY DEACTIVATED CEM EDITS
EDIT REFERENCE
X222.157.2300.CLM02.070
EDIT DESCRIPTION
CSCC A7: "Acknowledgement/Rejected
for Invalid Information…"
CSC 178: "Submitted Charges"
EDIT NOTES
2300.CLM02 must equal the sum of all
2400.SV102 amounts.
X222.157.2300.CLM02.090
CSCC A7: "Acknowledgement /Rejected
for Invalid Information…"
CSC 400: "Claim is out of Balance"
CSC 672: "Payer's payment information
is out of balance"
CSCC A7: Acknowledgement/Rejected
for Invalid Information
CSC 41: Special handling required at
payer site
CSC 286: Other Payer's Explanation of
Benefits/payment information
CSC 732: Information submitted
inconsistent with billing guidelines
2300.CLM02 must equal the sum of all 2320 &
2430 CAS amounts and the 2320 AMT02
(AMT01=D).
X222.305.2320.AMT.040
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TABLE 12 – 837 PROFESSIONAL TEMPORARILY DEACTIVATED CEM EDITS (CONTINUED)
EDIT REFERENCE
X222.305.2320.AMT02.060
EDIT DESCRIPTION
CSCC A7: "Acknowledgement/Rejected
for Invalid Information…"
CSC 672: "Other Payer's payment
information is out of balance"
CSC 286: Other payer's Explanation of
Benefits/payment information
EDIT NOTES
2320 AMT02 must = the sum of all existing
2430.SVD02 payer paid amounts (when the
value in 2430.SVD01 is the same as the value
in 2330B.NM109) minus the sum of all claim
level adjustments (2320 CAS adjustment
amounts) for the same payer.
NOTE: Perform this edit only when 2430SVD
segments are present for this 2320-2330x
iteration's payer.
X222.351.2400.SV102.060
CSCC A7: "Acknowledgement/Rejected
for Invalid Information…"
CSC 400: "Claim is out of balance:
CSC 583:"Line Item Charge Amount"
CSC 643: "Service Line Paid Amount"
SV102 must = the sum of all payer amounts
paid found in 2430 SVD02 and the sum of all
line adjustments found in 2430 CAS
Adjustment Amounts.
8.0
Duplicate Logic
In order to ensure encounters submitted are not duplicates of encounters previously submitted, the EDS
will perform header and detail level duplicate checking. If the header and/or detail level duplicate checking
determines that the file is a duplicate, the file will reject, and an error report will be returned to the
submitter.
8.1
Header Level
When a file (ISA/IEA) is received, the system assigns a hash total to the file based on the entire ISA/IEA
interchange. The EDS uses hash totals to ensure the accuracy of processed data. The hash total is a total of
several fields or data in a file, including fields not normally used in calculations, such as the account
number. At various stages in processing, the hash total is recalculated and compared with the original. If a
file comes in later in a different submission, or a different submission of the same file, and gets the same
hash total, it will reject as a duplicate.
In addition to the hash total, the system also references the values collectively populated in ISA13, GS06,
ST02, and BHT03. If two (2) files are submitted with the same values populated as a previously submitted
and accepted file, the file will be considered a duplicate and the error message CSCC - A8 =
Acknowledgement / Rejected for relational field in error, CSC -746 = Duplicate Submission will be provided
on the 277CA.
8.2
Detail Level
Once an encounter passes through the Institutional or Professional processing and pricing systems, it is
stored in an internal repository, the Encounter Operational Data Store (EODS). If a new encounter is
submitted that matches specific values on another stored encounter, the encounter will reject as a
duplicate encounter. The encounter will be returned to the submitter with an error message identifying it
837 Professional Companion Guide Version 29.0/May 2014
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as a duplicate encounter. Currently, the following values are the minimum set of items used for matching
an encounter in the EODS:
•
•
•
•
•
•
•
Beneficiary Demographic
o Health Insurance Claim Number (HICN)
o Name
Date of Service
Place of Service (2 digits)
Type of Service – not submitted on the 837-P but is derived from data captured
Procedure Code(s) and 4 modifiers
Rendering Provider NPI
Paid Amount*
* Paid Amount is the amount paid by the MAO or other entity and should be populated in Loop ID-2320,
AMT02.
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9.0
837 Professional Business Cases
In accordance with 45 CFR 160.103 of the HIPAA, Protected Health Information (PHI) has been removed
from all business cases. As a result, the business cases have been populated with fictitious information
about the Subscriber, MAO, and provider(s). The business cases reflect 2012 dates of service.
Although the business cases are provided as examples of possible encounter submissions, MAOs and other
entities must populate valid data in order to successfully pass translator and CEM level editing.
MAOs and other entities should direct questions regarding the contents of the EDS Test Case Specifications
[email protected].
Note: The business cases identified in the CMS EDS 837-P Companion Guide indicate paid amounts and DTP
segments at the line level.
The Adjudication or Payment Date (DTP 573 segment) must follow the paid amount. For example, if the
paid amount is populated at the claim level, the DTP 573 segment must be populated at the claim level. If
the paid amount is populated at the line level, the DTP 573 segment must be populated at the line level.
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9.1
Standard Professional Encounter
Business Scenario 1: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smith
because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smith diagnosed Mary
with abdominal pain in her right upper quadrant (78901).
File String 1:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*200000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*69*X*005010X222A1~
ST*837*0534*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*100.50*UN*1***1~
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DTP*472*D8*20120401~
SVD*H9999*100.50*HC:99212**1~
DTP*573*D8*20120403~
SE*38*0534~
GE*1*69~
IEA*1*200000031~
837 Professional Companion Guide Version 29.0/May 2014
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9.2
Capitated Professional Encounter
Business Scenario 2: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smart
because she was experiencing abdominal pain. Happy Health Plan is the MAO and has a capitated
arrangement with Mercy Hospital. Dr. Smart diagnosed Mary with abdominal pain in the upper quadrant.
File String 2:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000032*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*82*X*005010X222A1~
ST*837*0037*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344345879~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*0.00***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
LX*1~
SV1*HC:99212*0.00*UN*1***1~
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DTP*472*D8*20120401~
CN1*05~
SVD*H9999*100.50*HC:99212**1~
CAS*CO*24*-100.50~
DTP*573*D8*20120403~
SE*40*0037~
GE*1*82~
IEA*1*000000032~
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9.3
Chart Review Professional Encounter – No Linked ICN
Business Scenario 3: Mary Dough is the patient and the subscriber. Happy Health Plan is the MAO and Dr.
Elizabeth A. Smart is the professional service provider. Happy Health Plan performs a chart review at Dr.
Smith’s office and determines that Mary Dough was diagnosed with necrosis of artery. Dr. Smith never
submitted a claim to Happy Health Plan. The medical record does not contain enough information to
submit a full claim, yet there is enough information to support the diagnosis and link the chart review
encounter back to the medical record. Happy Health Plan submits a chart review encounter with no linked
ICN to add necrosis of artery diagnosis.
File String 3:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120530*114
7*^*00501*000000056*1*P*:~
GS*HC*ENH9999*80882*20120530*1147*89*X*005010X222A1~
ST*837*0043*005010X222A1~
BHT*0019*00*3920394930206*20120530*1147*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*456789032~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*0.00***11:B:1*Y*A*Y*Y~
PWK*09*AA~
HI*BK:4475~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
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N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
LX*1~
SV1*HC:99212*0.00*UN*1***1~
SVD*H9999*65.00*HC:99212**1~
DTP*472*D8*20120401~
SE*38*0043~
GE*1*89~
IEA*1*000000056~
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9.4
Chart Review Professional Encounter – Linked ICN
Business Scenario 4: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smart
because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smart diagnosed Mary
with abdominal pain. Happy Health Plan submits the encounter to CMS and receives an ICN
1298768987657. Happy Health Plan performs a chart review related to ICN 1298768987657 and
determines that the incorrect NPI was populated for the Billing Provider.
File String 4:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120530*114
7*^*00501*000000056*1*P*:~
GS*HC*ENH9999*80882*20120530*1147*89*X*005010X222A1~
ST*837*0043*005010X222A1~
BHT*0019*00*3920394930206*20120530*1147*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999899~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*456789032~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*0.00***11:B:1*Y*A*Y*Y~
PWK*09*AA~
REF*F8*1298768987657~
HI*BK:4475~
SBR*P*18*XYZ1234567******16~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
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N4*NORFOLK*VA*235049999~
NM1*82*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
LX*1~
SV1*HC:99212*0.00*UN*1***1~
SVD*H9999*120.00*HC:99212**1~
DTP*472*D8*20120401~
SE*40*0043~
GE*1*89~
IEA*1*000000056~
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9.5
Complete Replacement Professional Encounter
Business Scenario 5: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smart
because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smart diagnosed Mary
with abdominal pain in the lower right quadrant (78903). Happy Health Plan submits the encounter to CMS
and receives an ICN 1212278567098. Happy Health Plan determines that the diagnosis submitted was
incorrect and was actually for the upper right quadrant (78901). Happy Health Plan submits a correct and
replace adjustment encounter to replace encounter 1212278567098 with the newly submitted encounter.
File String 5:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120530*114
2*^*00501*000000045*1*P*:~
GS*HC*ENH9999*80882*20120530*1142*299*X*005010X222A1~
ST*837*0421*005010X222A1~
BHT*0019*00*3920394930206*20120430*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*765876890~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:7*Y*A*Y*Y~
REF*F8*1212278567098~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
CAS*CO*39*50.00~
AMT*D*50.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
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N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*100.50*UN*1***1~
DTP*472*D8*20120401~
SVD*H9999*50.50*HC:99212**1~
DTP*573*D8*20120403~
SE*41*0421~
GE*1*299~
IEA*1*000000045~
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9.6
Deletion Professional Encounter
Business Scenario 6: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A.
Smart because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smart
diagnosed Mary with abdominal pain. Happy Health Plan submits the encounter to CMS and
receives ICN 1212487000032. Happy Health Plan then determines that they mistakenly sent the
encounter without it being adjudicated in their internal system, so they want to delete the
encounter. Happy Health Plan submits an adjustment encounter to delete the previously
submitted encounter 1212487000032.
File String 6:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000298*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*82*X*005010X222A1~
ST*837*0290*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*1299999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*765879876~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:8*Y*A*Y*Y~
REF*F8*1212487000032~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
CAS*CO*223*100.50~
AMT*D*0.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
837 Professional Companion Guide Version 29.0/May 2014
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N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*100.50*UN*1***1~
DTP*472*D8*20120401~
SVD*H9999*0.00*HC:99212**1~
DTP*573*D8*20120403~
SE*41*0290~
GE*1*82~
IEA*1*000000298~
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9.7
Atypical Provider Professional Encounter
Business Scenario 7: Mary Dough is the patient and the subscriber, and receives services from an atypical
provider. Happy Health Plan was the MAO.
File String 7:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*79*X*005010X222A1~
ST*837*0034*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*2*MERCY SERVICES*XX*1999999984~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*199999998~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*PAYER01~
CLM*2997677856479709654A*100.50***11:B:1*Y*A*Y*Y~
HI*BK:78901~
NTE*ADD* NO NPI ON PROVIDER CLAIM NO EIN ON PROVIDER CLAIM~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
LX*1~
SV1*HC:99212*150.00*UN*1*1***1~
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DTP*472*D8*20120401~
SVD*H9999*150.00*HC:99212**1~
DTP*573*D8*20120403~
SE*39*0034~
GE*1*79~
IEA*1*000000031~
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9.8
Paper Generated Professional Encounter
Business Scenario 8: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smith
because she was experiencing abdominal pain. Happy Health Plan is the MAO. Dr. Smith diagnosed Mary
with abdominal pain in her right upper quadrant (78901).
File String 8:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*200000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*69*X*005010X222A1~
ST*837*0534*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.50***11:B:1*Y*A*Y*Y~
PWK*OZ*AA~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*100.50~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
LX*1~
SV1*HC:99212*100.50*UN*1***1~
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DTP*472*D8*20120401~
SVD*H9999*100.50*HC:99212**1~
DTP*573*D8*20120403~
SE*39*0534~
GE*1*69~
IEA*1*200000031~
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9.9
True Coordination of Benefits Professional Encounter
Business Scenario 9: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smith
because she was experiencing abdominal pain. Happy Health Plan is the MAO. Other Health Plan also
provided payment for Mary Dough. Dr. Smith diagnosed Mary with abdominal pain in her right upper
quadrant (78901).
File String 9:
ISA*00* *00* *ZZ*ENH9999 *ZZ*80882 *120430*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*79*X*005010X222A1~
ST*837*0034*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*TE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*712.00***11:B:1*Y*A*Y*Y~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*700.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH ST~
N4*NORFOLK*VA*235049999~
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SBR*T*18*XYZ1234388******16~
CAS*CO*223*700.00~
AMT*D*12.00~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*OTHER HEALTH PLAN*****XV*PAYER01~
N3*400 W 21 ST~
N4*NORFOLK*VA*235059999~
REF*T4*Y~
LX*1~
SV1*HC:99212*712.00*UN*1***1~
DTP*472*D8*20120401~
SVD*H9999*700.00*HC:99212**1~
CAS*CO*45*12.00~
DTP*573*D8*20120403~
SE*50*0034~
GE*1*79~
IEA*1*000000031~
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9.10
Bundled Professional Encounter
Business Scenario 10: Mary Dough is the patient and the subscriber, and went to Dr. Elizabeth A. Smith
because she was experiencing abdominal pain. She was given a blood test, which was bundled into an
electrolyte panel. Happy Health Plan is the MAO. Dr. Smith diagnosed Mary with abdominal pain in her
right upper quadrant (78901).
File String 10:
ISA*00*
*00*
*ZZ*ENH9999
*ZZ*80882
*120430*114
4*^*00501*000000031*1*P*:~
GS*HC*ENH9999*80882*20120430*1144*79*X*005010X222A1~
ST*837*0034*005010X222A1~
BHT*0019*00*3920394930206*20120428*1615*CH~
NM1*41*2*HAPPY HEALTH PLAN*****46*ENH9999~
PER*IC*JANE DOE*PE*5555552222~
NM1*40*2*EDSCMS*****46*80882~
HL*1**20*1~
NM1*85*1*SMITH*ELIZABETH*A**MD*XX*12999999999~
N3*123 CENTRAL DRIVE~
N4*NORFOLK*VA*235139999~
REF*EI*344232321~
PER*IC*BETTY SMITH*TE*9195551111~
HL*2*1*22*0~
SBR*S*18*XYZ1234567**47****MB~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 SPAPE DRIVE~
N4*NORFOLK*VA*235099999~
DMG*D8*19390807*F~
NM1*PR*2*EDSCMS*****PI*80882~
N3*7500 SECURITY BLVD~
N4*BALTIMORE*MD*212441850~
REF*2U*H9999~
CLM*2997677856479709654A*100.00***11:B:1*Y*A*Y*N~
HI*BK:78901~
SBR*P*18*XYZ1234567******16~
AMT*D*9.48~
OI***Y***Y~
NM1*IL*1*DOUGH*MARY****MI*672148306~
N3*1234 STATE DRIVE~
N4*NORFOLK*VA*235099999~
NM1*PR*2*HAPPY HEALTH PLAN*****XV*H9999~
N3*705 E HUGH SP~
N4*NORFOLK*VA*235049999~
REF*T4*Y~
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LX*1~
SV1*HC:82374*50.00*UN*1***1~
DTP*472*D8*20120401~
SVD*H9999*9.48*HC:80051**1~
CAS*CO*45*40.52~
DTP*573*D8*20120403~
LX*2~
SV1*HC:82435*50.00*UN*1*11~
DTP*472*D8*20120401~
SVD*H9999*0.00*HC:80051**1*1~
CAS*OA*97*50.00~
DTP*573*D8*20120403~
SE*46*0034~
GE*1*79~
IEA*1*000000031~
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10.0
Encounter Data Professional Processing and Pricing System Edits
After a Professional encounter passes translator and CEM level editing and receives an ICN on a 277CA, the
EDFES then transfers the encounter to the Encounter Data Professional Processing and Pricing System
(EDPPPS), where editing, processing, pricing, and storage occur. In order to assist MAOs and other entities
with submission of encounter data through the EDPPPS, CMS has provided the current list of the EDPPPS
edits in Table 13.
Note: The edit descriptions listed in Table 13 have been revised to identify a maximum of 41 characters in
order to display a more comprehensive explanation of edits on the MAO-002 Reports.
The EDPPPS edits are organized in nine (9) different categories, as provided in Table 13, Column 2. The
EDPPPS edit categories include the following:
•
•
•
•
•
•
•
•
•
Validation
Provider
Beneficiary
Reference
Limit
Conflict
Pricing
Duplicate
NCCI
Table 13, Column 3 identifies two (2) edit dispositions: Informational and Reject. Informational edits will
cause the encounter to be flagged; however, the Informational edit will not cause processing and/or pricing
to cease. Reject edits will cause an encounter to stop processing and/or pricing, and the MAO or other
entity must resubmit the encounter through the EDFES. The encounter must then pass translator and CEM
level editing prior to transferring the data to the EDPPPS for reprocessing. The EDPPPS edit description, as
found in Table 13, Column 4, is included on the EDPS transaction reports to provide further information for
the MAO or other entity to identify the specific reason for the edit generated.
If there is no reject edit at the header level and at least one of the lines is accepted, then the encounter is
accepted. If there is no reject edit at the header level, but all lines reject, then the encounter will reject. If
there is a reject edit at the header level, the encounter will reject.
Table 13 reflects only the currently programmed EDPPPS edits. MAOs and other entities should note that,
as testing progresses, it may be determined that the current edits require modifications, additional edits
may be necessary, or edits may be deactivated. MAOs and other entities must always reference the most
recent version of the CMS EDS 837-P Companion Guide to determine the current edits in the EDPPPS.
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TABLE 13 – ENCOUNTER DATA PROFESSIONAL PROCESSING AND PRICING SYSTEM (EDPPPS) EDITS
EDPPPS
EDIT
EDPPPS EDIT
CATEGORY
EDPPPS EDIT
DISPOSITION
00010
00011
00012
00025
00065
00175
00265
00660
00699
00745
00750
00755
00760
00761
00762
00764
00765
01405
01415
02106
02110
02112
02120
02125
02240
02255
02256
03015
03017
03101
03340
16002
20515
25000
25001
98315
98320
98325
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Validation
Pricing
Validation
Validation
Validation
Validation
Validation
Validation
Provider
Provider
Beneficiary
Beneficiary
Beneficiary
Beneficiary
Beneficiary
Beneficiary
Beneficiary
Beneficiary
Reference
Reference
Reference
Reference
Pricing
Conflict
NCCI
NCCI
Duplicate
Duplicate
Duplicate
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Informational
Informational
Reject
Reject
Reject
Reject
Reject
Reject
Reject
Informational
Informational
Informational
Reject
Informational
Informational
Informational
Informational
Reject
Reject
Reject
EDPPPS EDIT DESCRIPTION
From DOS Greater Than TCN Date
Missing DOS in Header/Line
DOS Prior to 2012
Through DOS After Receipt Date
Missing Pick-up Zip Code
Verteporfin
Correct/Replace or Void ICN Not in EODS
Codes Billed Together in Error
Void Must Match Original
Anesthesia Service Requires Modifier
Service(s) Not Covered Prior To 4/1/2013
Void Encounter Already Void/Adjusted
Adjusted Encounter Already Void/Adjusted
Billing Provider Different from Original
Unable to Void Rejected Encounter
Original Must Be a Chart Review to Void
Original Must Be a Chart Review to Adjust
Sanctioned Provider
Rendering Provider Not Eligible for DOS
Invalid Beneficiary Last Name
Beneficiary HICN Not on File
DOS After Beneficiary DOD
Beneficiary Gender Mismatch
Beneficiary DOB Mismatch
Beneficiary Not Enrolled in MAO for DOS
Beneficiary Not Part A Eligible for DOS
Beneficiary Not Part C Eligible for DOS
DOS Spans CPT/HCPCS Effective/End Date
Dx Not Covered for PET Scan Procedure
Invalid Gender for CPT/HCPCS
Dx Not Listed on the Reference Table
Service Line Amount Adjusted for MTP
Dx Code V053 Must Be Aligned With HCPCS
CCI Error
Medically Unlikely Error
Linked Chart Review Duplicate
Chart Review Duplicate
Service Line(s) Duplicated
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10.1
EDPPPS Edits Enhancements Implementation Dates
As the EDS matures, the EDPS may require enhancements to the EDPPPS editing logic. As these
enhancements occur, CMS will provide the updated information (i.e., disposition changes and activation or
deactivation of an edit). Table 14 provides MAOs and other entities with the implementation dates for
enhancements made to the EDPPPS since the last release of the CMS EDS 837-P Companion Guide.
Note: Table 14 will not be provided when there are no enhancements implemented for the current release
of the CMS EDS Companion Guides.
10.2 EDPS Edits Prevention and Resolution Strategies
In order to assist MAOs and other entities with the prevention of potential errors in their encounter data
submission and with resolution of edits received on the generated MAO-002 reports, CMS has provided
comprehensive strategies and scenarios. CMS has identified the strategies and scenarios in three (3)
phases.
10.2.1 EDPS Edits Prevention and Resolution Strategies – Phase I: Frequently Generated EDPPPS Edits
Table 15 outlines Phase 1 of the prevention and resolution strategies for Professional edits most frequently
generated on the MAO-002 reports.
TABLE 15 – EDPPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE I
Edit #
Edit Description
00065
FREQUENTLY GENERATED EDPPPS EDITS
Missing Pick up Point ZIP Code
Edit
Disposition
Reject
Comprehensive Resolution/Prevention
Submitter must provide a valid nine (9)-digit ZIP code for
ambulance pick-up location in Loop 2310E.
Scenario: Atlas Health Plan received a claim from MOMnPOP Ambulance for a 30-mile transport. Atlas Health Plan
submitted the encounter to the EDS with the pick-up locations street address, city, and state populated. However, the
pick-up ZIP code was not included. Atlas Health Plan will receive edit 00065 because the pick-up ZIP code is required for all
ambulance encounters.
00745
Anesthesia Service Requires
Reject
Anesthesia CPT/HCPCS must include appropriate modifiers
Modifier
(AA, AD, QK, QX, QY, or QZ). Service lines submitted
without one of these modifiers in SV101-3 (the first
modifier field) would receive this error.
Scenario: Dr. Nitze, an instructional anesthesiologist, assisted a resident anesthetist during a thyroidectomy. Dr. Nitze
submitted an encounter to World Peace Health Plan with an anesthesia code of 00320, but did not include the modifier of
AA. Dr. Nitze will receive an error message of 00745 because the required modifier was not included on the service line.
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TABLE 15 – EDPPPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE I (CONTINUED)
Edit #
Edit Description
00760
FREQUENTLY GENERATED EDPPPS EDITS
Adjusted Encounter Already
Void/Adjusted
Edit
Disposition
Reject
Comprehensive Resolution/Prevention
Submitter has previously adjusted or voided an encounter
and is attempting to adjust the same encounter.
Submitter should review returned MAO-002 reports to
confirm processing of the adjusted encounter prior to
resubmission of the adjustment.
Scenario: On August 20, 2012, Pragmatic Health submitted a correct/replace encounter to correct a CPT code. Pragmatic
Health had not received their MAO-002 report by August 23, 2012 and decided to resubmit the correct/replace encounter.
The MAO-002 report was returned on August 24, 2012 with the correct/replace encounter identified as accepted.
Pragmatic Health received edit 00760 on a subsequent MAO-002 report because the EDPS had already processed the
resubmitted correct/replace encounter.
00762
Unable to Void Reject Encounter
Reject
Submitter is attempting to void a previously rejected
encounter. Submitter should review returned MAO-002
reports to confirm the rejected encounter.
Scenario: On July 20, 2012, Hero Health Plan submitted an encounter with an invalid HICN. On July 26, 2012, Hero Health
Plan attempted to void the encounter due to the invalid HICN without referencing the MAO-002 report, dated July 25,
2012, that indicated that the encounter was rejected. On August 1, 2012, Hero Health Plan received an MAO-002 report
with edit 00762 for the voided encounter because the original encounter had already been processed and rejected.
03340
Dx Not Listed on the Reference
Reject
The diagnosis provided is not a valid/current ICD-9 code.
Table
Submitter should verify that the diagnosis code is
accurate, the diagnosis code is Medicare acceptable, and
ICD-10 codes are not submitted prior to October 2014.
Scenario: Elysium Health Plan submitted an encounter for lab services, which included Blood Glucose Testing. The
diagnosis code provided was 275.0 – Disorders of iron metabolism. Elysium Health Plan received an MAO-002 report with
edit 03340 for this service because diagnosis code 275.0 was deleted from the ICD-9 CM and is not populated on the
current reference table. Elysium Health Plan must obtain the correct and current diagnosis code and submit a
correct/replace encounter for this service line.
10.2.2 EDPS Edits Prevention and Resolution Strategies – Phase II: Common EDPS Edits
Table 16 outlines Phase II for edits mutually generated in all subsystems of the EDPS (Professional,
Institutional, and DME).
TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II
COMMON EDPS EDITS
Edit
Comprehensive Resolution/Prevention
Edit #
Edit Description
Disposition
00010
From DOS Greater Than TCN
Reject
Encounter must have a DOS prior to submission date.
Date
Scenario: Perfect Health of America submitted an encounter to the EDS on May 10, 2012 for a knee replacement
performed at Wonderful Hills Mediplex for DOS May 12, 2012. The encounter was rejected because the “from” DOS was
after the date of encounter submission.
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TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED)
COMMON EDPS EDITS
Edit
Comprehensive Resolution/Prevention
Edit #
Edit Description
Disposition
00011
Missing DOS in Header/Line
Reject
Encounter header and/or line levels must include “from”
and “through” DOS (procedure or service start date).
Scenario: Chloe Pooh was admitted to Regional Port Hospital on October 21, 2012 for a turbinectomy and was released on
October 22, 2012. Regional Port Hospital submitted a claim to Robbins Health for the surgical procedure. Robbins Health
submitted the encounter to the EDS, but did not include the “through” DOS of October 22, 2012.
00012
DOS Prior to 2012
Reject
Encounter must contain 2012 “through” DOS for each
service line.
Scenario: Ion Health submitted an encounter with DOS from December 2, 2011 through December 28, 2011, for an
inpatient admission at Better Health Hospital. The encounter was rejected because the EDS will only process encounters
that include a 2012 “through” DOS or later.
00699
Void Must Match Original
Reject
Voided encounter must have the same number of lines as
the original encounter.
Scenario: Lamb Professional Care submitted an encounter for an inpatient hospital stay with five (5) service lines. Lamb
Professional Care submitted a void encounter for the hospital stay. However, the void encounter contained only 4 lines
from the original encounter. Lamb Professional Care received an MAO-002 report with edit 00699 because one of the lines
from the original encounter was not included on the void encounter.
00761
Billing Provider Different from
Reject
Billing provider’s NPI must be identical in both the original
Original
and void encounters.
Scenario: Mastermind General Hospital submitted an encounter for a procedure performed by Dr. Jackson Martinez on
October 17, 2012. Spartacus Regional Health submitted the encounter to the EDS and received an MAO-002 report with an
accepted ICN of 342431098. On October 27, 2012, Spartacus Regional Health submitted a void encounter for ICN
342431098 using an NPI for Dr. Mary Jane. The encounter was rejected because the billing provider NPI on the void
encounter did not match the billing provider on the original encounter.
01415
Rendering Provider Not Eligible
Informational Verify that NPI is accurate and that the provider was
for DOS
eligible for DOS submitted.
Scenario: ABC Care Plan submitted an encounter for a procedure performed by Dr. Destiny at Avid Health Hospital on
February 14, 2012. The EDPS provider reference files indicate that Dr. Destiny’s NPI was effective on February 16, 2012.
02106
Invalid Beneficiary Last Name
Informational Verify that last name populated on the encounter matches
the last name listed in MARx database.
Scenario: Blue Skies Rural Health submitted an encounter for patient Ina Batiste-Rhogin. The MARx database listed the
patient as Ina Rhogin. The EDPS processed and accepted the encounter with an informational flag indicating that the name
provided on the encounter was not identical to the name listed in the eligibility database.
02110
Beneficiary HICN Not on File
Reject
Verify that HICN populated on the encounter is valid in
MARx database.
Scenario: Bright Medical Center submitted a claim to Sunshine Complete Health for an office visit for Mr. Everett Banks for
DOS May 26, 2012. Sunshine Complete Health submitted an encounter to the EDS. The encounter was rejected for edit
02110, because the HICN populated on the encounter was not on file in the MARx database.
02112
DOS After Beneficiary DOD
Reject
Verify that DOS submitted is accurate and does not exceed
the beneficiary DOD.
Scenario: Mountain Hill Health submitted an encounter for an inpatient admission for Ray Rayson for DOS July 15, 2012.
The EDPS was unable to process the encounter because the MARx database indicated that Mr. Rayson expired on July 13,
2012.
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TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED)
COMMON EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
02120
Beneficiary Gender Mismatch
Reject
Verify that gender populated on the encounter is accurate
and matches gender listed in MARx database.
Scenario: Jenna Jorgineski went to Lollipop Lab for a sleep study on September 4, 2012. Lollipop Lab submitted a claim for
the sleep study to Capital City Community Care with Ms. Jorgineski’s gender identified as “male”. Capital City Community
Care submitted the encounter. The EDS processed and accepted the encounter. The MAO-002 report was returned with a
reject edit 02120, because Ms. Jorgineski’s gender was listed as “female” in the MARx database.
02125
Beneficiary DOB Mismatch
Reject
Verify that DOB populated on the encounter is accurate
and matches DOB listed in MARx database.
Scenario: Swan Health submitted an encounter to the EDS for Joe Blough on March 3, 2012. The encounter listed Mr.
Blough’s DOB as December 13, 1940. The eligibility database (MARx) listed Mr. Blough’s DOB as December 13, 1937. The
EDS returned the MAO-002 report to Swan Health with edit 02125 due to the conflicting dates of birth.
02240
Beneficiary Not Enrolled in MAO
Reject
Verify that beneficiary was enrolled in your MAO during
for DOS
DOS on the encounter.
Scenario: Gabrielle Boyd was admitted to Faith Hospital for an appendectomy on June 11, 2012 and was discharged on
June 14, 2012. Faith Hospital submitted the claim for the hospital admission to Adams Healthcare. Adams Healthcare
adjudicated the claim and submitted an encounter to the EDS on July 12, 2012. Ms. Boyd’s effective date with Adams
Healthcare was July 1, 2011. The EDS returned an MAO-002 report to Adams Health with edit 02240 because Ms. Boyd
was not enrolled with the health plan for the DOS submitted by Faith Hospital.
02255
Beneficiary Not Part A Eligible for
Reject
Verify that beneficiary was enrolled in Part A for DOS listed
DOS
on the encounter.
Scenario: Mr. Carl Evergreen was transferred from a VA hospital and admitted to Rainforest Regional on April 28, 2012.
Mr. Evergreen was effective for Medicare Part A on May 1, 2012. Strides in Care Health Plan submitted the encounter for
the admission to Rainforest Regional and received an MAO-002 report with edit 02255 because Mr. Evergreen was
enrolled in Medicare Part A after the date of hospital admission.
02256
Beneficiary Not Part C Eligible for
Reject
Verify that beneficiary was enrolled in Part C for DOS listed
DOS
on the encounter.
Scenario: On July 4, 2012, Gail Williams has severe chest pains and goes to the emergency room for a chest x-ray at
Underwood Memorial Hospital. At the time of the emergency room visit, Ms. Williams only has Part A Medicare
coverage. Underwood Memorial submits the claim to AmeriHealth and the claim is adjudicated under Part A
Medicare. AmeriHealth submits an encounter to the EDS, which is rejected with edit 02256, because Ms. Williams is not
covered under Part C Medicare for the DOS.
03015
DOS Spans CPT/HCPCS
Informational The procedure code is not valid/effective for the DOS
Effective/End Date
populated on the encounter
Scenario: Oren Davis went to Independent Lab for a urinalysis on February 24, 2012. Independent Lab submitted a claim
to World Healthcare with procedure code 81000. As of August 1, 2011, procedure code 81000 is no longer a valid
procedure code. World Health submits an adjudicated encounter to the EDS. World Health receives an MAO-002 report
with a “reject” status for edit 03015 because the procedure code was not valid on the DOS.
03101
Invalid Gender for CPT/HCPCS
Informational Verify that the gender populated on the encounter is
accurate. Ensure that the beneficiary’s gender is
appropriate for the CPT/HCPCS code provided
Scenario: True Blue General Hospital submitted a claim to Valley View Health for Ms. Clara Bell with CPT code 54530.
Valley View submitted an adjudicated encounter to the EDS. Valley View received an MAO-002 report with edit 03101
because the procedure identified for Ms. Bell was an orchiectomy, which is routinely performed for a male.
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TABLE 16 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE II (CONTINUED)
COMMON EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
25000
CCI Error
Informational Ensure that CCI code pairs are appropriately used. Ensure
that CCI single codes meet the MUE allowable units of
service (UOS).
Scenario: Hippos Health Plan submitted an encounter to the EDS with a DOS of May 5, 2012 and HCPCS code 15780 and
two (2) units of service. The returned MAO-002 report indicated an informational edit of 25000 because HCPCS code
15780 – dermabrasion, is only valid for one (1) unit of service per day.
98325
Service Line(s) Duplicated
Reject
Verify that encounter was not previously submitted. If not
a duplicate encounter, ensure that elements validated by
duplicate logic are not the same (refer to the 2012 ED
Participant Guide for duplicate logic validation elements)
Scenario: Sanford Health Systems submitted an encounter for two (2) service lines for 15-minute therapy services. The
encounter lines submitted were the same for the timed procedure code, totaling 35 minutes and should have been
submitted with 2 units of service under the total time rather than as separate duplicate lines.
10.2.3 EDPPPS Edits Prevention and Resolution Strategies – Phase III: General EDPPPS Edits
Table 17 outlines Phase III for the remaining EDPPPS edits generated on the MAO-002 Encounter Data
Processing Status Reports.
Edit #
00025
TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III
GENERAL EDPS EDITS
Edit
Edit Description
Comprehensive Resolution/Prevention
Disposition
Through DOS After Receipt Date
Reject
Encounter submitted prior to the latest “through” DOS for
the service line or encounter
Scenario: On October 27, 2012, Northwest Community Health submitted an encounter to the EDS for DOS from
10/12/2012 through 10/31/2012. The encounter was rejected because the “through” DOS was after the date that the
encounter was submitted.
03017
Dx Not Covered for PET Scan
Informational Encounter submitted with a diagnosis that is not
Procedure
appropriate for the PET Scan procedure identified.
Scenario: Pathway to Life submitted an encounter for Mr. Jones, who visited Dr. Michaels for a bone scan. The encounter
contained a diagnosis for celiac disease (579.0), which is not an appropriate diagnosis for the service provided.
00265
Correct/Replace or Void ICN Not
Reject
Adjustment encounter submitted with an invalid or
in EODS
rejected ICN. EDS does not store rejected ICNs.
Scenario: Wednesday Health Services sent an original encounter to the EDS and received accepted ICN 123456789. Dr.
John May corrected the associated claim and resubmitted to Wednesday Health Services. Wednesday Health Services
submitted the adjustment encounter to the EDS using ICN 234567890. The encounter was rejected because the ICN was
invalid for the adjustment encounter submission.
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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
00764
Original Must Be a Chart Review
Reject
If the void encounter (frequency code ‘8’) is populated
to Void
with PWK01=’09 and PWK02=’AA’, the original encounter
submission must be a chart review encounter populated
with PWK01=’09’ and PWK02=’AA’
Scenario: On January 12, 2013, Paisley Community Health submitted an original encounter for Mr. Jolly Jones to the EDS
and received the accepted ICN of 3029683010582. On February 2, 2013, Paisley Community Health submitted a chart
review encounter to the EDPS to delete a diagnosis code from the original encounter and received the accepted ICN of
5039530285074. In April 2013, Paisley Community Health performed another chart review of Mr. Jones’ medical records
and discovered that the service was never provided. Paisley Community Health submitted a void encounter to the EDS
using the reference ICN of 3029683010582 (the original encounter ICN) and populated PWK01=’09’ and PWK02=’AA’. The
EDS rejected the encounter because the ICN referenced was for the original encounter, not the initial chart review.
01405
Sanctioned Provider
Reject
Submitter must ensure that the billing provider was not
suspended or terminated from providing services to
Medicare beneficiaries during the time(s) of service
indicated on the encounter.
Scenario: Golden Gateway Health Plan submitted an encounter on behalf of Dr. Canen Harp for DOS February 12, 2013.
The EDPS provider files indicated that Dr. Harp was suspended effective February 1, 2013 and not authorized to provide
healthcare services. The EDPS rejected the encounter for edit 01405.
00765
Original Must Be a Chart Review
Reject
Submitter must ensure that, if the correct/replace
to Adjust
encounter (frequency code ‘7’) is populated with
PWK01=’09 and PWK02=’AA’, the original encounter
submission was a chart review encounter populated with
PWK01=’09’ and PWK02=’AA’. The submitter must also
ensure that the ICN references the initial chart review
encounter, not the original full encounter.
Scenario: Flashback Health performed a chart review for Prosperous Living Medical Center. Flashback Health discovered
two (2) additional diagnosis codes for an encounter previously submitted for Ms. Leanne Liberty. Flashback Health
submitted an initial chart review encounter using the frequency code of ‘7’. The EDS rejected the chart review encounter
submission because initial chart review encounters should contain a frequency code ‘1’.
00750
Service(s) Not Covered Prior To
Reject
Encounters submitted for Ventricular Assist Devices
4/1/2013
(VADs) supplies and accessories with procedure code
Q0507, Q0508, or Q0509 must contain dates of service
(DOS) on or after 04/01/2013
Scenario: Dr. Zhivago’s office submitted a claim to Healthy Heart Health Plan for a battery and battery charger provided to
Mr. Joe Schmeaux following the attachment of his VAD on February 3, 2013. Healthy Heart submitted an encounter to the
EDS using Q0507. The EDS rejected the encounter with error code 00750 because Q0507 was not an effective code for
DOS prior to 4/1/2013.
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TABLE 17 – EDPS EDITS PREVENTION AND RESOLUTION STRATEGIES – PHASE III (CONTINUED)
GENERAL EDPS EDITS
Edit
Edit #
Edit Description
Comprehensive Resolution/Prevention
Disposition
00175
Verteporfin
Reject
Encounters submitted for Ocular Photodynamic
Tomography with Verteporfin must contain the
same dates of service for the combination of these
services, with the appropriate ICD-9 and ICD-10
diagnosis codes. Submitter must also ensure that
the procedures are valid for the dates of service.
Scenario: Dr. Cuff conducted an OPT with Verteporfin (J3396 and 67225) for Mr. Jay Bird as treatment for Mr. Bird’s
diagnosis of atrophic macular degeneration (362.51). The encounter was submitted to the EDS by Strideways Health and
rejected because the diagnosis of 362.51 should not be identified for the service submitted on the encounter.
00755
Void Encounter Already
Reject
Submitter has previously voided or adjusted an
Void/Adjusted
encounter and is attempting to void the same
encounter. Submitter should review returned MAO002 reports to confirm processing of the voided
encounter prior to resubmission of the void.
Scenario: Happy Trails Health Plan submitted a void/delete encounter on October 10, 2012. Happy Trails Health Plan
voided the same encounter, in error, on October 15, 2012, prior to receiving the MAO-002 report for the initial void/delete
encounter, which was returned on October 16, 2012. The MAO-002 report for the subsequent voided encounter was
returned with edit 00755 due to the submission of the second void/delete encounter.
98315 Linked Chart Review Duplicate
Reject
Linked Chart Review encounters cannot be submitted where
the Health Insurance Claim Number (HICN), Associated
Internal Control Number (ICN) and header Date of Service
(DOS), diagnosis code(s) contain the exact same values as
another Chart Review encounter already present within the
EODS.
Scenario: Sequoia Health Plan conducted an audit of Timber Lake Family Physicians and discovered an encounter
previously submitted to the EDS contained an unnecessary diagnosis code. On 04/01/14, Sequoia Health Plan submitted a
linked chart review encounter to the EDS containing the associated ICN of the original counter to identify the unnecessary
diagnosis code. On 05/01/14 Sequoia Health Plan inadvertently submitted the exact same linked chart review encounter
to the EDS. The EDS rejected the second submission of the linked chart review encounter because no changes were
detected between the two linked chart review encounters.
98320 Chart Review Duplicate
Reject
Unlinked Chart Review encounters cannot be submitted
where the Health Insurance Claim Number (HICN), header
date of service (DOS) and diagnosis code(s) contain the exact
same values as another Chart Review encounter already
present within the EODS.
Scenario: Ohio Health Plan conducted an audit of Cincinnati Fair Physicians Group and discovered an encounter not
previously submitted to the EDS required an additional diagnosis code. On 03/15/14, Ohio Health Plan submitted an
unlinked chart review encounter to the EDS to include the additional diagnosis code. On 06/01/14, Ohio Health Plan
submitted the same unlinked chart review encounter to the EDS due to a clerical error. The EDS rejected the second
submission of the unlinked chart review encounter because the EDS detected no changes between the two unlinked chart
review encounters.
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11.0
Submission of Default Data in a Limited Set of Circumstances
MAOs and other entities may submit default data in a limited set of circumstances, as identified and
explained in Table 18. MAOs and other entities cannot submit default data for any circumstances, other
than those listed in the table below. CMS will use this interim approach for the submission of encounter
data. In each circumstance where default information is submitted, MAOs and other entities are required
to indicate in Loop 2300, NTE01=’ADD’, NTE02 = the reason for the use of default information. If there are
questions regarding appropriate submission of default encounter data, MAOs and other entities should
contact CMS for clarification. CMS will provide additional guidance concerning default data, as necessary.
11.1
Default Data Reason Codes (DDRC)
Loop 2300, NTE02 allows for a maximum of 80 characters and one (1) iteration, which limits the submission
of default data to one (1) message per encounter.
In order to allow the population of multiple default data messages in the NTE02 field, CMS will use a three
(3)-digit default data reason code (DDRC), which will map to the full default data message in the EDS.
MAOs and other entities may submit multiple DDRCs with the appropriate three (3)-digit DDRC. Multiple
DDRCs will be populated in a stringed sequence with no spaces or separators between each DDRC (i.e.,
036040048). Table 18 provides the CMS approved situations for use of default data, the default data
message, and the default data reason code.
TABLE 18 – DEFAULT DATA
*DEFAULT DATA
DEFAULT DATA MESSAGE
DEFAULT DATA REASON
CODE (NTE02)
Rejected Line Extraction
REJECTED LINES CLAIM CHANGE DUE TO REJECTED
LINE EXTRACTION
036
Medicaid Service Line Extraction
MEDICAID CLAIM CHANGE DUE TO MEDICAID
SERVICE LINE EXTRACTION
040
EDS Acceptable Anesthesia Modifier
MODIFIER CLAIM CHANGE DUE TO EDS
ACCEPTABLE ANESTHESIA MODIFIER
044
Default NPI for atypical, paper, and 4010
claims
NO NPI ON PROVIDER CLAIM
048
Default EIN for atypical providers
NO EIN ON PROVIDER CLAIM
052
Chart Review Default Procedure Codes
DEFAULT PROCEDURE CODES INCLUDED IN CHART
REVIEW
056
True COB Default Adjudication Date
DEFAULT TRUE COB PAYMENT ADJUDICATION
DATE
060
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12.0
Tier II Testing
CMS developed the Tier II testing environment to ensure that MAOs and other entities have the
opportunity to test a more inclusive sampling of their data. MAOs and other entities that have obtained
end-to-end certification may submit Tier II testing data.
CMS encourages MAOs and other entities to utilize the Tier II testing environment when they have
questions or issues regarding edits received on EDFES Acknowledgement Reports or MAO-002 Encounter
Data Processing Status reports; and when they have new submission scenarios that they wish to test prior
to submitting to production.
MAOs and other entities may submit chart review, correct/replace, or void/delete encounters to the Tier II
testing environment only when the encounters are linked to previously submitted and accepted encounters
in the Tier II testing environment.
Encounter files submitted to the Tier II testing environment must comply with the TR3, CMS Edits
Spreadsheet, and the CMS EDS Companion Guides, as well as the following requirements:
•
•
•
•
•
•
Files must be identified using the Authorization Information Qualifier data element “Additional
Data Identification” in the ISA segment (ISA01= 03).
Files must be identified using the Authorization Information data element to identify the “Tier II
indicator” in the ISA segment (ISA02= 8888888888).
Files must be identified as “Test” in the ISA segment (ISA15=T).
Submitters may send multiple Contract IDs per file
Submitters may send multiple files for a Contract ID, as long as each file does not exceed 2,000
encounters per Contract ID
If any Contract ID on a given file exceeds 2,000 encounters during the processing of the file, the
entire file will be returned
As with production encounter data, MAOs and other entities will receive the TA1, 999, and 277CA
Acknowledgement Reports and the MAO-002 Reports.
While not required, MAOs and other entities are strongly encouraged to correct errors identified on the
reports and resubmit data.
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13.0
EDS Acronyms
Table 19 outlines a list of acronyms currently used in the EDS documentation, materials, and reports
distributed to MAOs and other entities. This list is not all-inclusive; and should be considered a living
document. CMS will add acronyms as required.
TABLE 19– EDS ACRONYMS
ACRONYM
DEFINITION
A
ASC
C
Ambulatory Surgery Center
CAH
CARC
CAS
CC
CCI
CCN
CEM
CMG
CMS
CORF
CPO
CPT
Critical Access Hospital
Claim Adjustment Reason Code
Claim Adjustment Segments
Condition Code
Correct Coding Initiative
Claim Control Number
Common Edits and Enhancement Module
Case Mix Group
Centers for Medicare & Medicaid Services
Comprehensive Outpatient Rehabilitation Facility
Care Plan Oversight
Current Procedural Terminology
CRNA
CSC
CSCC
CSSC
D
DDRC
DME
DMEPOS
DMERC
DOB
DOD
DOS
E
E & M or E/M
EDDPPS
Certified Registered Nurse Anesthetist
Claim Status Code
Claim Status Category Code
Customer Service and Support Center
EDFES
EDI
Encounter Data Front-End System
Electronic Data Interchange
Default Data Reason Code
Durable Medical Equipment
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
Durable Medical Equipment Carrier
Date of Birth
Date of Death
Date(s) of Service
Evaluation and Management
Encounter Data DME Processing and Pricing Sub-System
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TABLE 19– EDS ACRONYMS (CONTINUED)
ACRONYM
DEFINITION
E
EDIPPS
EDPPPS
Encounter Data Institutional Processing and Pricing Sub-System
Encounter Data Professional Processing and Pricing Sub-System
EDPS
EDS
EIC
EODS
Encounter Data Processing System
Encounter Data System
Entity Identifier Code
Encounter Operational Data Store
ESRD
F
FFS
FQHC
FTP
FY
H
HCPCS
HHA
HICN
HIPAA
HIPPS
End Stage Renal Disease
I
ICD-9CM/ICD-10CM
ICN
IPPS
IRF
M
MAC
MAO
Fee-for-Service
Federally Qualified Health Center
File Transfer Protocol
Fiscal Year
Healthcare Common Procedure Coding System
Home Health Agency
Health Information Claim Number
Health Insurance Portability and Accountability Act
Health Insurance Prospective Payment System
International Classification of Diseases, Clinical Modification (versions 9 and 10
Interchange Control Number
Inpatient Prospective Payment System
Inpatient Rehabilitation Facility
Medicare Administrative Contractor
Medicare Advantage Organization
MTP
MUE
N
NDC
Multiple Technical Procedure
Medically Unlikely Edits
NPI
NCCI
NOC
NPPES
National Provider Identifier
National Correct Coding Initiative
Not Otherwise Classified
National Plan and Provider Enumeration System
National Drug Codes
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TABLE 19– EDS ACRONYMS (CONTINUED)
ACRONYM
O
OCE
OIG
OPPS
P
PACE
DEFINITION
Outpatient Code Editor
Officer of Inspector General
Outpatient Prospective Payment System
Program for All-Inclusive Care for the Elderly
PHI
PIP
Protected Health Information
Periodic Interim Payment
POA
POS
PPS
R
RAP
RHC
RNHCI
RPCH
S
SME
SNF
SSA
T
TARSC
Present on Admission
Place of Service
Prospective Payment System
TCN
TOB
TOS
TPS
V
VC
Z
ZIP Code
Transaction Control Number
Type of Bill
Type of Service
Third Party Submitter
Request for Anticipated Payment
Rural Health Clinic
Religious Nonmedical Healthcare Institution
Regional Primary Care Hospital
Subject Matter Expert
Skilled Nursing Facility
Social Security Administration
Technical Assistance Registration Service Center
Value Code
Zone Improvement Plan Code
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REVISION HISTORY
DESCRIPTION OF REVISION
VERSION
DATE
2.1
9/9/2011
3.0
11/16/2011
Release 1
4.0
12/9/2011
Release 2
5.0
1/9/2012
Release 3
6.0
3/8/2012
Release 4
7.0
5/8/2012
Release 5
8.0
6/22/2012
Release 6
9.0
8/31/2012
Release 7
10.0
9/26/2012
Release 8
11.0
11/2/2012
Release 9
12.0
11/26/2012
Release 10
13.0
12/21/2012
Release 11
14.0
01/25/2013
Release 12
15.0
2/26/2013
Release 13
16.0
03/20/2013
Release 14
17.0
04/15/2013
Release 15
18.0
05/20/2013
Release 16
19.0
06/24/2013
Release 17
20.0
07/25/2013
Release 18
21.0
09/26/2013
Release 19
22.0
10/25/2013
Release 20
23.0
11/26/2013
Release 21
24.0
12/27/2013
Release 22
25.0
01/20/2014
Release 23
26.0
02/21/2014
Release 24
27.0
03/18/2014
Release 25
Baseline Version
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REVISION HISTORY (CONTINUED)
DESCRIPTION OF REVISION
VERSION
DATE
28.0
04/28/2014
Release 26
29.0
05/30/2014
Section 13.0, Table 19 – Updated EDS Acronyms table
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| File Type | application/pdf |
| Author | andreab |
| File Modified | 2014-09-22 |
| File Created | 2014-06-02 |