(Medicare Claims Processing Manual)

A/B MACs are required to validate the incoming codes listed above against the most recent codes sets provided by the S SM. CMS will notify the shared system maintainers (via Recurring Update Notification) to load the most recent code sets into the CEM environment for download to the A/B MAC local data center (LDC) in conjunction with the quarterly release.   The CEM maintainer also updates the following code sets on a frequency basis other than quarterly in order to align with industry:    ZIP codes   Claim Adjustment Reason Codes (CARC)   Anesthesia Modifiers   Diagnosis Related Groups (DRG) codes   Healthcare Common Procedure  Coding System (HCPCS) codes   Health Insurance Premium Payment System (HIPPS) codes   International Classification of Diseases, (ICD) codes   National Drug Codes (NDC) (as published by the Federal Drug Administration(FDA))   National Provider Identifier (NPI)   Remittance Advice Remark Codes (RARC)   Taxonomy Codes   Procedure Code Modifier Codes   Admission Source Codes   Admission Type Codes   Patient Status Codes   Condition Codes   Occurrence Codes   Occurrence Span Codes   Value Codes   Revenue Codes   Uniform Bill Type codes   Provi der Control File (PCF) -  Part B only   A/B MACs are required to validate the incoming codes listed above against the most recent codes sets provided by the SSM. When the above listed reference code sets are updated, they are sent to the A/B MAC (LDC) as part of nightly code updates.  50.3.5 - Handling of Poorly Formed/Invalid Flat Files for a 277CA  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  When a poorly formed/corrupted invalid flat file for an ASC X12 277CA claim ackno wledgment outbound transaction is received, the contractor may manually correct the flat file acknowledgment data necessary to produce a valid ASC X12 277CA claim acknowledgment. The manually corrected information is then to be submitted to the translator.  This process shall be executed on an exception basis to ensure that an ASC X12 277CA claim acknowledgment can be produced for an accepted transaction.  50.4 - CEDI - Unique Specifications for DME  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implemen tation: 09 -17-13)  The Common Electronic Data Interchange (CEDI) contractor is the single front end solution for Durable Medical Equipment (DME) electronic transactions including ASC X12 837 claims, NCPDP claims, ASC X12 835 remittance advice (ERA), ASC X12 276 claims status requests, ASC X12 277 claim status responses, and electronic front end reports.   CEDI receives inbound claims (ASC X12 837 professional claim  and NCPDP claim), performs all front end editing on the claims, and returns the reports showi ng accepted and rejected claims to the Trading Partner's CEDI mailbox.   The following front end reports will be returned by CEDI:    ASC X12 837 professional claim and 276 claim status request transactions; NCPDP transactions    ASC X12 999 implementation acknowledgment for ASC X12 837 claim and ASC X12 276 claim status request transactions    ASC X12 TA1 interchange acknowledgment for ASC X12 837 claim and ASC X12 276 claim status request transactions (when requested)    ASC X12 277CA claim acknowledgment for ASC X12 837 professional  claim transactions    ASC X12 277 claim status response for ASC X12  transactions    NCPDP transmission response NCPDP transactions    DME MAC Front End Report with accepted claims received and CMN rejections based on ASC X12  claim submiss ions  Claims accepted by CEDI are assigned the Claim Control Number (CCN) to be used by the DME MACs in processing the claim.  CEDI translates the claims into the Medicare flat file format and delivers the claims to the appropriate DME MAC based on the beneficiary state code submitted on the claim.   CEDI receives inbound claim status requests (ASC X12 276 claim status request), performs all front end editing on the transactions, and returns the ASC X12 277 claim status response showing accepted and rejected  transactions.  ASC X12 276 claim status request transactions accepted by CEDI are translated to the Medicare flat file format and delivered to the DME MAC based on the contractor code submitted on the ASC X12 276 claim status request file.   CEDI receives the DME MAC front end report showing claims received by the DME MACs as well as any CMN rejections and returns this report to the Trading Partner's CEDI mailbox.   CEDI receives the ASC X12 835 remittance advice and ASC X12 277 claim acknowledgment flat fil e formatted transactions from the DME MACs, translates these to the ASC X12 format and delivers them to the Trading Partner's CEDI mailbox.   50.4.1 - CEDI Claim Numbering (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  CEDI wi ll assign the CCN to accepted ASC X12 and NCPDP claims utilizing the DME MACs defined range of CCNs.  The CCNs are reported back to the Trading Partner on the front end reports and response files.  On the 837 flat file, the CCN will be populated in the 2300 loop REF segment for that claim where REF01 = +CN.  For NCPDP, the CCN will be populated in the Transaction Header Segment in positions 117- 130.  If the number of accepted claims for a given DME MAC exceeds their defined threshold, CEDI will hold the claims in excess of the threshold to be delivered the next business day using the next business days range of CCNs.  Claims held will have the date of receipt when the CEDI received the claim.   50.4.2 - CEDI Receipt Control and Balancing (Rev. 2803, Issue d: 10 -28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  CEDI, upon receiving a submitted ASC X12 837 professional claim and/or NCPDP D.0 file from a Trading Partner, will run the file through their Commercial Off The Shelf (COTS) translator.  The COTS  translator creates an ASC X12 837 professional claim or NCPDP flat file, includes a CTRD record for each ISA/IEA and each Batch Header/Trailer present, forwards the flat file to the EDC, and stores the CTRD record to a database.   The EDC updates the Recei pt, Control and Balancing Detail Record (CTRD) creating a CTRD Response.  This file is sent back to CEDI who in turn triggers an alert when an out of balance condition has been reported, matches the response to the original CTRD record and stores the updat ed record to a database.  This process will check to be sure what was sent to the EDC is what the EDC received and to update the CTRD record.  If it balances, the file continues along through the DME MACs VMS cycle.  If it does not balance, the file will n ot continue.  The CTRD record contained in the database is updated with the counts (which identifies which pat of the file is out of balance).  CEDI will review the CTRD response file for the out of balance reason and resolve the issue. If necessary, a CTR R resubmission will be sent.   50.4.3 - CEDI Acknowledgments for ASC X12 Version 5010 and NCPDP D.0. Transactions (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)  Trading Partners transmit their ASC X12 5010 transactions and CED I performs the following functions.  1. CEDI front end performs Standard and Implementation Guide edits on the ASC X12 837 claims.  These edits include, but are not limited to, edits on the ASC X12 837 professional claim edit spreadsheet tagged for ASC X12 TA 1 interchange acknowledgment and  ASC X12 999R and 999E implementation acknowledgment responses.  Please refer to the CMS website for a copy of the ASC X12 837 professional claim edit spreadsheet.   2. CEDI uses the ASC X12 837 professional claim edit spreadshe et to determine whether an edit failure necessitates the rejection of the entire ASC X12 837 transaction set (ASC X12  999R implementation acknowledgment edit) or whether those files should be passed on for further business validation editing, resulting in  a claim level rejection via the ASC X12 277CA claim acknowledgment.  Errors that the translator identifies at the 999 level and passes on for further business validation and ASC X12 277CA claim acknowledgment issuance are referred to as ASC X12 999E imple mentation acknowledgment edits on the ASC X12 837 professional claim edit spreadsheet.  3. If the ASC X12 837 professional claim edit necessitates rejection of the entire ST -SE transaction set (ASC X12  999R implementation acknowledgment edit), CEDI returns t he ASC X12  999 implementation acknowledgment to the Trading Partner indicating the affected ST -SE was rejected. The transaction set is not passed for further processing.   4. If the ASC X12 837 professional claim edit sets an edit that does not necessitate rejection of the entire ST -SE transaction set (ASC X12 999E implementation acknowledgment edit), CEDI will:  a. Return the ASC X12 999 implementation acknowledgment to the Trading Partner indicating the affected ST -SE transaction was accepted with errors.   b. Continue with performing the ASC X12 837 professional claim edit at the Business Validation level.  c. Read the beneficiary state code submitted on the accepted claims for use in performing appropriate Business Validation editing (ASC X12 277CA claim acknowle dgment) at the DME MAC level.   d. If an ASC X12 999E implementation acknowledgment error is listed with a coordinating ASC X12 277CA claim acknowledgment, any claims falling subordinate to the level at which the ASC X12 999E implementation acknowledgment erro r occurred will be rejected.   5. If CEDI does not set any  ASC X12 999E implementation acknowledgment edits, CEDI will:  a. Return ASC X12 999 implementation acknowledgment to the Trading Partner indicating the affected ST -SE transaction was accepted.   b. Continue performing the ASC X12 837 professional claim edit at the Business Validation level.   6. After all ASC X12 837 professional claim edits have been performed, and claims have successfully passed any  ASC X12 999R implementation acknowledgment, ASC X12 999E impl ementation acknowledgment, or ASC X12 277CA claim acknowledgment level editing, CEDI will:  a. Assign the CCN to the accepted ASC X12 837 claims.  b. Insert a receipt date segment (+RC DTP segment) into the ASC X12 837 flat file.  c. Create a control record (CTR segment) containing the appropriate counts.  The CTR is placed in front of each ISA segment on the ASC X12 837 flat file.  7. CEDI will create the ASC X12 277CA claim acknowledgment transactions to be returned to the Trading Partner, containing all ASC X12 277CA claim acknowledgment errors that may have occurred at the ASC X12 999E implementation acknowledgment  or Business Validation level.  8. CEDI will deliver the ASC X12 837 flat files to the EDC for the appropriate DME MAC.   Trading Partners transmit their NC PDP D.0 transactions to and CEDI performs the following functions.  1. CEDI front end performs Standard and Implementation Guide edits on the NCPDP claims.  These edits include, but are not limited to, edits on the NCPDP edit spreadsheet tagged for NCPDP t ransmission response.   2. CEDI uses the NCPDP edit spreadsheet to determine whether an edit failure necessitates the rejection of the entire NCPDP batch or an individual claim.   3. CEDI will read the beneficiary state code submitted on the accepted claims for use in performing appropriate Business Validation editing at the DME MAC level.   4. After all NCPDP edits have been performed, CEDI will assign the CCN to the accepted NCPDP claims.   5. CEDI will return the NCPDP transmission response showing accepted and rejected batches and individual claims as well as the CCN for all accepted claims.   6. Create the NCPDP flat file for each DME MAC with claims for their Jurisdiction.   7. CEDI will deliver the NCPDP flat files to the EDC for the appropriate DME MAC.   50.5 - EDI Testing Accuracy  (Rev. 2803, Issued: 10- 28-13, Effective: 09- 17-13, Implementation: 09- 17-13)