Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-1 - General Provisions › Section 5160-1-20 - Electronic data interchange (EDI) trading partner enrollment and testing

Current through all regulations passed and filed through July 1, 2024
(A)
								For purposes of
			 this rule, the following definitions apply:
(1)
									"Covered entity"
			 has the same meaning as in
			 45
			 C.F.R. 160.103 (as in effect on October 1,
			 2021).
(2)
									"Electronic data interchange (EDI) transactions" are
			 transactions developed by standards development organizations recognized by the
			 federal centers for medicare and medicaid services (CMS) and adopted by the
			 Ohio department of medicaid (ODM). The different EDI transactions are as
			 follows:
(a)
										"American national standards institute (ANSI) X12 270
			 eligibility, coverage, or benefit inquiry" is a transaction used to inquire
			 about the eligibility, benefits or coverage under a subscriber's health care
			 policy.
(b)
										"ANSI X12 271 eligibility, coverage, or benefit
			 information response" is a transaction used to communicate information about,
			 or changes to, eligibility, benefits, or coverage.
(c)
										"ANSI X12 274
			 provider information" is a transaction used to exchange demographic and
			 educational or professional qualifications about health care providers between
			 providers, provider networks, or any other entity that maintains or verifies
			 health care provider information.
(d)
										"ANSI X12 275
			 patient information" is a transaction used to communicate individual patient
			 information requests and patient information (either solicited or unsolicited)
			 between separate care entities in a variety of settings.
(e)
										"ANSI X12 276
			 health care claim status request" is a transaction used to request the status
			 of a health care claim.
(f)
										"ANSI X12 277 health care claim status notification" is
			 a transaction used to respond to a request regarding the status of a health
			 care claim.
(g)
										"ANSI X12 278 health care services review information
			 request and response" is a transaction used to transmit health care service
			 information for the purpose of referral, certification, authorization,
			 notification, or reporting the outcome of a health care services
			 review.
(h)
										"ANSI X12 820 premium payment" is a transaction used to
			 make a payment or send a remittance advice.
(i)
										"ANSI X12 834
			 monthly member roster or enrollment and disenrollment in a health plan" is a
			 transaction used to establish communication between the sponsor of the
			 insurance product and the payer.
(j)
										"ANSI X12 835
			 health care claims payment and remittance advice" or "835 remittance advice" is
			 a transaction used to make a payment or send an explanation of benefits
			 remittance advice.
(k)
										"ANSI X12 837 health care claim" is a transaction used
			 to submit health care claim billing or encounter information, or both, from
			 providers (institutional, professional, or dental) of health care services to
			 payers, either directly or via clearinghouses.
(3)
									"Trading partner"
			 is a covered entity as defined in 42 C.F.R. 160.103 (as in effect October 1,
			 2021) that submits, receives, routes, or translates EDI transactions directly
			 related to the administration or provision of medical assistance provided under
			 a public assistance program.