clm104c31.pdf

2. If a contractor elects to continue to display claim status -specific data elements in their DDE screens, those data elements must at a minimum contain/report data that conforms to:    All required and applicable  conditional data elements for those segments in the ASC X12 277 claim status response; and    Data content as specified for those data elements in the ASC X12 277 claim status response, as applicable, including compliance with the data attributes for those data elements as defined in the ASC X12 277 implementation guide.   Preliminary feedback from contractors suggests that existing DDE screens used for Medicare may already conform to the ASC X12 277 claim status response implementation guide requirements, b ut data element mapping is required to verify.  For example, since industry input was used to develop the ASC X12 277 claim status response implementation guide as well as, presumably the data elements for claim status currently furnished via DDE, it is unlikely that DDE screen field sizes would be larger than the ASC X12 277 claim status response maximum length or shorter than the ASC X12 277 claim status response minimum length.  It is also unlikely that a DDE screen would contain a data element considere d important for claim status that is not included in the ASC X12 277 claim status response, or vice versa.   If a shared system maintainer determines that DDE screen changes are required, the maintainer in conjunction with its users must determine if it wou ld be cost effective to modify the DDE screens to conform to the ASC X12 277 claim status response implementation guide.  If not cost effective, the maintainer must eliminate the claim status -only data elements from the DDE screens and require the contract ors to use the batch ASC X12 276/277 claim status request and response, an ARU, and/or other non-EDI means to obtain claim status information.   If retention is cost effective, the maintainer must modify these screens as necessary to ensure that providers a re able to access all applicable data content available in the ASC X12 277 claim status response.  The DDE screens must be able to furnish providers information that conforms to the data that would have been issued to the provider in an ASC X12 277 claim s tatus response.  See above for the discussion of conformity.   20.1.3 - Interactive/Online (Non -DDE)  (Rev. 2937, Issued; 04- 25-14, Effective: 04- 14-14, Implementation: 04- 14-14)  Contractors are not required to accept an ASC X12 276 claim status inquiry or respond with an ASC X12 277 claim status response in an interactive, online mode if they do not already do so. If contractors do support the ASC X12 276/277 claim status request and response in an interactive online mode, it must be offered in addition to batch ASC X12 276/277 claim status request and response.   20.2 - Summary of the ASC X12 276/277 Claim Status Request and Response Process for A/B Medicare Administrative Contractors, DME MACs, CEDI  (Rev. 2937, Issued; 04- 25-14, Effective: 04- 14-14, Implementation: 04 -14-14)  A. The contractors translator must perform editing on the submitted ASC X12 276 claim status request transaction at the ASC X12 standard and implementation levels, and generate an ASC X12 TA1 interchange acknowledgment in batch  if  an interchange control error was detected.  The contractor shall generate an appropriate ASC X12 999 implementation acknowledgment in batch if a syntax error is detected.  In the absence of any interchange control or syntax error, an ASC X12 999 implement ation acknowledgement is issued in the batch mode only, to confirm receipt of an ASC X12 276 received via batch.  See 20.4 for additional translation requirements.  Translation does not apply to DDE screens.   An ASC X12 TA1 interchange acknowledgment and an ASC X12 999 implementation acknowledgment (issued for an ASC X12 276 claim status request submitted in a batch) must be issued within 1 business day of receipt of the ASC X12 276 claim status request.   An ASC X12  TA1 interchange acknowledgment and ASC X12 999 implementation acknowledgment of an ASC X12 276 claim status request submitted in an interactive/online mode must be issued as quickly as the ASC X12 277 claim status response would have been issued had the ASC X12 276 claim status request been val id.  Under the current HIPAA adopted ASC X12 version, inclusive of any adopted Errata moving forward, the contractors translator shall edit the incoming ASC X12 276 claim status request  transaction as documented by the CMS 276/277 Edits spreadsheet (as u pdated per quarterly release) from the CMS Website: http://www.cms.gov/ElectronicBillingEDITrans/10_ClaimStatus.asp#TopOfPage   B. The shared system shall continue t o process claim status transactions in current ASC X12 version to include edits to verify that the submitted ASC X12 276 data complies with IG and Medicare requirements.  If edits are failed, the shared system must generate an edit report following the mod el established for TR3 and Medicare program edit reporting for the HIPAA compliant version of the ASC X12 837 claim implementation.  The edit report must include any reason(s) for the rejection in a concise but explicit manner that can be understood by provider staff as well as contractor staff.  Contractors will forward the edit messages to submitters for correction of the edit condition.  The shared system must generate these edit reports within 1 business day.   The TR3 edits must be performed as defined in the TR3 segment and data element notes, data element attributes, conditions of use, and overall guiding principles for use of the standards as contained in the introduction section and addenda to the IG.  The Medicare program edits must be performed as required by current Medicare program instructions.  C. The A/B MAC or, for DME, the CEDI contractor, shall process inbound claim status transactions in the current ASC X12 version(s) (inclusive of any ASC X12 Errata) and beyond to include the edits defined in the CMS 276/277 Edits spreadsheet as translator applicable in order to pass to the Part A or Part B Common Edits and Enhancement Module (CEM) software a CMS defined flat file format (inclusive of Control Record(s) hereafter referred to as CTRD).   For Part  A and Part B, the CEM software shall perform all edits not marked as Translator on the CMS 276/277 Edits spreadsheet for inbound claim status transactions in order to pass the fully edited inbound claim status transaction on to the appropriate Part A or P art B shared system for appropriate claim status request processing in the shared system.   For DME, the CEDI contractor shall also process inbound claim status transactions in the current ASC X12 version(s) (inclusive of any ASC X12 Errata) and beyond to a lso include edits defined in the CMS 276/277 Edits spreadsheet other than translator applicable in order to pass the fully edited inbound claim status transaction on to the DME shared system for appropriate claim status request processing in the shared sys tem.  D. For claim status request and response transactions formatted in the current ASC X12 version(s)  and beyond the shared system:    Updates the Control Record database with the CTRD record for the activities being processed (e.g. interchange  ISA segment  to IEA) and appropriate content of the Control Record.  Stores any ASC X12 276 claim status request data elements required for preparation of a compliant ASC X12 277 claim status response that are either not retained in the Medicare core system, or exceed  the size limits for that type of data in the Medicare core system in a temporary file.   Completes the application request/inquiry according to the components that outbound claim status response requires, as well as, generates and populates the outbound Control Record for the outbound claim status response.  These processes shall comply with the TR3 for the ASC X12 transaction and the CMS defined Control Record definition (inclusive of any quarterly release updates).  The shared system shall also perform data scrubbing of outbound data prior to the data exiting the Enterprise Data Center (EDC) and being transferred to the Local Data Center (LDC) as deemed appropriate by CMS and the MACs.  The initial instructions for the outbound data scrubbing were containe d in Transmittal 702, Change Request 6946.  This edit process shall be implemented beginning with the October 2010 release for DME and in the January 2011 release for Part A and Part B shared systems.  The processes shall be modified through subsequent releases, as directed via future Change Requests, add to the editing process of the reference file mechanism designed for each shared system to perform the data scrubbing conversion process.   20.3 - Flat Files (Rev. 2937, Issued; 04- 25-14, Effective: 04- 14-14, Implementation: 04 -14-14)  For the current ASC X12 276/277 claim status request and response and beyond inclusive of any adopted Errata by ASC X12, the CMS developed flat files that maintainers and contractors may use.  These files are available on the f ollowing CMS Web page: http://www.cms.gov/ElectronicBillingEDITrans/10_ClaimStatus.asp#TopOfPage   20.4 - Translation Requirements  (Rev. 2937, Issued; 04- 25-14, E ffective: 04 -14-14, Implementation: 04- 14-14)  For the current ASC X12 276/277 claim status request and response transactions and beyond inclusive of any adopted Errata by ASC X12, contractors and shared system maintainers shall exchange ASC X12 claim status request and response transactions using the Extended Character Set. except when a CMS and the contractors have deemed to be data scrubbed under the initial instructions for the outbound data scrubbing as contained in Transmittal 702, Change Request 6946 and the modifications  through subsequent releases, as directed via future Change Request.  Detailed information about the Extended Character Set can be obtained in Appendix B of any ASC X12 TR3.  20.5 - Transmission Mode  (Rev. 2937, Issued; 04- 25-14, Effective: 04 -14-14, Implementation: 04- 14-14)  The HIPAA compliant version of the ASC X12 276/277 claim status request and response transaction is a variable- length record designed for wire transmission.  The CMS requires that the contractor accept the i nbound and transmit the outbound over a wire connection.  20.6 - Restriction and Controlling Access to Claims Status Information  (Rev. 1, 10- 01-03)  Provide claims status information to providers, suppliers and their agents when an EDI Enrollment Form is o n file for that entity, and to network service vendors if there is an EDI Enrollment Form and EDI Network Service Agreement on file.  (See Medicare Claims Processing Manual, Chapter 24, EDI Support Requirements for instructions on the enrollment form and t he EDI Network Service Agreement.)   20.7  Health Care Claim Status Category Codes and Health Care Claim Status Codes for Use with the Health Care Claim Status Request and Response ASC X12 276/277 Claim Status Request and Response  (Rev. 10236, Issued: 07- 31-2020, Effective: 08- 31-2020, Implementation: 08- 31-2020)   Under HIPAA, all payers must use health care claim status category codes and health care claim status codes approved by the Health Care Code Maintenance Committee as applicable.  At each ASC X 12 trimester meeting (generally held the months of February, June and October), the Committee may update the claim status category codes and the claim status codes.  When instructed, Medicare contractors must update their claims systems to assure that the current version of these codes is used in their claim status responses.  The codes sets are available at the official Washington Publishing Company website .  Included in the code lists are specific details, including the date when a code was added, changed  or deleted.   CMS will issue recurring, one -time change requests regarding the need for and deadline for future updates to these codes.  Contractor and shared system changes will be made as necessary as part of a routine release to reflect applicable chang es such as retirement of previously used codes or newly created codes that may impact Medicare.  Shortly after the release of each code update, a provider education article will be available at http://www.cms.hhs.gov/medlearn/matters  for contractors to use to conduct provider outreach.   Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R10236CP