Encounter Data System - CSSC Operations

More documents

Recommendations

Info

1.3 Major Updates1.3.1 Duplicate LogicAs testing has progressed, it has been determined that revenue code(s) are necessary to performduplicate checking rather than procedure code(s). Further information is provided in Section 8.2.1.3.2 EDIPPS EditsMAOs and other entities can now find the complete list of Institutional Processing and Pricing Edits inSection 10.0.Edit 03102 – Provider Type or Specialty Not Allowed to Bill For Procedure is temporarily “informational”.1.3.3 True COBTwo (2) edits are not functioning correctly for true COB encounter submissions. As a result, EDS hastemporarily deactivated the following edits:Edit ReferenceX223.143.2300.CLM02.080X223.424.2400.SV203.060Edit DescriptionCSCC A7: "Acknowledgement /Rejected for Invalid Information…"CSC 400: "Claim is out of Balance"CSC 672 "Payer's payment information is out of balanceCSCC A7: "Acknowledgement /Rejected for Invalid Information…"CSC 400: "Claim is out of balance:CSC 583:"Line Item Charge Amount"The Fee-For-Service (FFS) CEM Maintainers are reviewing these edits to determine if they can bepermanently corrected.1.3.4 EDFES NotificationsThe Encounter Data Front-End System (EDFES) provides notifications to inform MAOs and other entitiesof the reason the submitted file was not sent to the Encounter Data Processing System (EDPS). Theseare in addition to the EDFES acknowledgement reports, including the TA1, 999, and 277CA and to theEDPS Reports. All EDFES notifications will begin with the following notification: “FILE WAS NOT SENT TOTHE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S)”. Section 6.6, Table 9 provides thecomplete list of testing and production EDFES notification messages.1.3.5 Revised Business Case 9.10 – Bundled Institutional EncounterBusiness Case 9.10 (Bundled Institutional Encounter) was revised to reflect the original code populatedin SV1 and the bundled procedure code in SVD. In addition, the monetary amounts were changed toallow the encounter to balance appropriately.837 Institutional Companion Guide Version 8.0/June 20126
1.4 ReferencesMAOs and other entities must use the ASC X12N IG adopted under the HIPAA AdministrativeSimplification Electronic Transaction rule along with CMS’ Encounter Data Participant Guides, and CMS’EDS Companion Guidelines for development of EDS transactions. These documents are accessible at thefollowing:www.csscoperations.com.Additionally, the EDS submitter guidelines and application, testing documents, 5010 companion guides,and Encounter Data Participant Guides can be found at that location.MAOs and other entities must use the most current national standard code lists applicable to the 5010transaction. The code lists may be accessed at the Washington Publishing Company (WPC) website:http://www.wpc-edi.comThe applicable code lists are as follows:Claim Adjustment Reason CodeClaim Status Category CodesClaim Status CodesCMS provides X12 5010 file format technical edit spreadsheets for the 837-I and 837-P. The editsincluded in the spreadsheet are intended to clarify the WPC instructions or add Medicare specificrequirements. In order to determine the implementation date of the edits contained in thespreadsheet, MAOs and other entities will first need to refer to the spreadsheet version. The version isa 10 character identifier 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 montho 1 – January releaseo 2 – April releaseo 3 – July releaseo 4 – October releasePositions 8-10 indicate the spreadsheet version iteration number (e.g. V01-first iteration, V02-second iteration)The effective date of the spreadsheet is the first calendar day of the release quarter month. Theimplementation date is the first business Monday of the release quarter month. Federal holidays whichcould potentially fall on the first business Monday must be accounted for when determining theimplementation date. For example, the edits contained in a spreadsheet version of EB20113V01 areeffective July 1, 2011 and will be implemented on July 5, 2011.7837 Institutional Companion Guide Version 8.0/June 2012
Page 1 and 2: ___________________________________
Page 3 and 4: Table of Contents1.0 Introduction1.
Page 5: 1.0 Introduction1.1 ScopeThe CMS En
Page 9 and 10: other entities should refrain from
Page 11 and 12: ISATABLE 1 - ISA-IEA INTERCHANGE EL
Page 13 and 14: TABLE 3 - ST-SE TRANSACTION SET HEA
Page 15 and 16: TABLE 4 - 837 INSTITUTIONAL HEALTH
Page 21 and 22: The 277CA is used to acknowledge th
Page 23 and 24: TABLE 6 - TESTING FILE NAME COMPONE
Page 25 and 26: The report format example is as fol
Page 27 and 28: TABLE 10 - 837 INSTITUTIONAL PERMAN
Page 29 and 30: 9.0 837 Institutional Business Case
Page 31 and 32: SBR*P*18*XYZ1234567******16~AMT*D*2
Page 33 and 34: HI*BG:01~NM1*71*1*JONES*AMANDA*AL**
Page 35 and 36: HI*BR:3121:D8:20120330~HI*BH:41:D8:
Page 37 and 38: HI*BE:30:::20~HI*BG:01~NM1*71*1*JON
Page 39 and 40: HI*BE:30:::20~HI*BG:01~NM1*71*1*JOH
Page 41 and 42: N3*705 E HUGH ST~N4*NORFOLK*VA*2350
Page 43 and 44: SV2*0300*HC:D0999*50.00*UN*1~DTP*47
Page 45 and 46: N4*NORFOLK*VA*235049999~REF*T4*Y~LX
Page 47 and 48: N4*NORFOLK*VA*235099999~NM1*PR*2*HA
Page 49 and 50: SBR*P*18*XYZ1234567******16~AMT*D*9
Page 51 and 52: TABLE 11 - ENCOUNTER DATA INSTITUTI
Page 53 and 54: TABLE 11 - ENCOUNTER DATA INSTITUTI

Encounter Data System - CSSC Operations

Create successful ePaper yourself

Delete template?

Save as template?