D00010_837D_LTC_Companion_Guide.pdf

TEXAS MEDICAID

HIPAA TRANSACTION STANDARD

COMPANION GUIDE

Refers to the Implementation Guide Long Term Care

837 Health Care Claim: Dental

Based on ASC X12 version 005010 CORE v5010 Companion Guide

837D Health Care Claim: Dental

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August 2023

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Table of Contents

1 INTRODUCTION

1.1 Scope

1.2 Overview

1.3 References

1.4 Additional Information

1.4.1 Security and Privacy Statement

2 GETTING STARTED

2.1 Working with Texas Medicaid

2.2 Trading Partner Registration

3 TESTING WITH TEXAS MEDICAID

4 CONNECTIVITY WITH THE TEXAS MEDICAID COMMUNICATIONS

4.1 Transmission Administrative Procedures

4.2 Communication protocol specifications

4.3 Passwords

5 CONTACT INFORMATION

5.1 Customer Service

5.1.1 Texas Medicaid EDI Help Desk

5.1.2 Applicable websites/e-mail

6 CONTROL SEGMENTS/ENVELOPES

6.1 ISA-IEA

6.2 GS-GE

7 TEXAS MEDICAID SPECIFIC BUSINESS RULES AND LIMITATIONS

8 ACKNOWLEDGEMENTS AND/OR REPORTS

9 TRADING PARTNER AGREEMENTS

9.1 Trading Partner

10 TRANSACTION SPECIFIC INFORMATION

11 APPENDICES

11.1 Transmission Examples

11.2 Change Summary

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Disclosure Statement

Copyright © 2016 by Texas Medicaid. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided “as is” without any expressed or implied warranty. Note that the copyright on the underlying Accredited Standards Committee (ASC) X12 Standards is held by the Data Interchange Standards Association (DISA) on behalf of ASC X12.

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Preface

This Companion Guide to the v5010 ASC X12N Implementation Guide and associated errata adopted under Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies the data content when exchanging electronically with Texas Medicaid. Transmissions based on this Companion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12N syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

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1 INTRODUCTION

1.1 Scope

Under the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the Secretary of the Department of Health and Human Services (HHS) is directed to adopt standards to support the electronic exchange of administrative and financial health care transactions. The purpose of the Administrative Simplification portion of HIPAA is to enable health information to be exchanged electronically and to adopt standards for those transactions.

Texas Medicaid defines a Trading Partner as any entity trading data with Texas Medicaid EDI.

Trading partners include vendors, clearinghouses, Providers and billing agents.

The 5010 Technical Report Type 3 (TR3) dated May 2006 was used to create this Companion Guide for the 837 file format. All instructions in this document are written using information known at the time of publication and are subject to change.

1.2 Overview

This guide is intended as a resource to assist submitters in successfully conducting EDI 837 Health Care Claims: Dental transactions with Texas Medicaid. This document does not provide detailed data specifications, which are published separately by the industry committees responsible for their creation and maintenance.

The purpose of this document is to assist the provider with Texas Medicaid-particular data sets for information specified in the National Electronic Data Interchange Transaction Set Implementation Guide for the file type. The federal government has set standards to simplify Electronic Data Interchange (EDI). To comply with the standard, Texas Medicaid has updated the data sets for EDI files to be in accordance with HIPAA and is utilizing the ASC X12 nomenclatures.

The instructions in this companion guide are not intended to be stand-alone requirements documents and must be used in conjunction with the associated ANSI ASC X12N National Implementation Guide. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guide and is in conformance with ASC X12’s Fair Use and Copyright statements.

1.3 References

The ANSI ASC X12N Implementation Guides are available for purchase at the Washington Publishing Company web site at:

https://x12.org/products/technical-reports

The Texas Medicaid EDI Connectivity Guide which contains instructions regarding connectivity options including CORE compliant Safe Harbor information, can be found on the EDI page of the Texas Medicaid website at:

https://www.tmhp.com/topics/edi

The Companion Guides, published by Texas Medicaid can be found on:

https://www.tmhp.com/topics/edi https://x12.org/products/technical-reports https://www.tmhp.com/topics/edi

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1.4 Additional Information

1.4.1 Security and Privacy Statement

Covered entities were required to implement HIPAA Privacy Regulations no later than April 14, 2003. A covered entity is defined as a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. Providers that conduct certain electronic transmissions are responsible for ensuring these privacy regulations are implemented in their business practices. Health and Human Services Commission (HHSC) is a HIPAA Covered Entity. Accordingly, Texas Medicaid is operating as a HIPAA Business Associate of HHSC as defined by the federally mandated rules of HIPAA. A Business Associate is defined as a person or organization that performs a function or activity on behalf of a covered entity but is not part of the covered entity's workforce.

The privacy regulation has three major purposes:

1. To protect and enhance the rights of consumers by providing them access to their health information and controlling the appropriate use of that information;

2. To improve the quality of health care in the United States by restoring trust in the health care system among consumers, health care professionals and the many organizations and individuals committed to the delivery of health care; and

3. To improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy and protection.

2 GETTING STARTED

2.1 Working with Texas Medicaid

This section describes how to interact with Texas Medicaid’s Electronic Data Interchange (EDI) systems.

EDI Help Desk is available to assist trading partners in exchanging data with Texas Medicaid.

Below are details on how to register and contact the department for assistance.

2.2 Trading Partner Registration

HHSC requires any entity exchanging electronic data with Texas Medicaid to be enrolled in the Texas Medicaid Program and approved for the submission of X12 transaction sets.

Texas Medicaid Enrollment Forms and instructions are available at:

https://www.tmhp.com/topics/provider-enrollment

Successful enrollment in Texas Medicaid is required before proceeding with EDI.

To get started with EDI transactions, the necessary forms and instructions are available at:

https://www.tmhp.com/resources/forms?field_topics_target_id=96 https://www.tmhp.com/topics/provider-enrollment https://www.tmhp.com/resources/forms?field_topics_target_id=96

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3 TESTING WITH TEXAS MEDICAID

Texas Medicaid provides a self-testing tool through Edifecs. Testing and Certification instructions, along with setup information can be found in Section 9.1 of the Texas Medicaid EDI Connectivity Guide found at:

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

4 CONNECTIVITY WITH THE TEXAS MEDICAID

COMMUNICATIONS

4.1 Transmission Administrative Procedures

The Texas Medicaid EDI Connectivity Guide that contains specific instructions regarding connectivity options, can be found on the EDI page of the Texas Medicaid website at:

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

4.2 Communication protocol specifications

The Texas Medicaid EDI Connectivity Guide that contains specific instructions regarding connectivity options, along with CORE compliant Safe Harbor information, can be found on the EDI page of the Texas Medicaid website at:

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

4.3 Passwords

Texas Medicaid provides instruction on resetting of passwords in section 5.1 of the Texas Medicaid EDI Connectivity Guide found at:

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

5 CONTACT INFORMATION

5.1 Customer Service

5.1.1 Texas Medicaid EDI Help Desk

The EDI Help Desk provides technical assistance only by troubleshooting Texas Medicaid EDI issues. Contact your system administrator for assistance with network, hardware, or telephone line issues.

To reach the Texas Medicaid EDI Help Desk, select one of the following methods:

Fax 1-512-514-4230 or 1-512-514-4228

Call 1-888-863-3638, option 3 (or call 1-512-514-4150, option 3)

The Texas Medicaid EDI Help Desk is available Monday through Friday, 7 a.m. to 7 p.m. CST.

5.1.2 Applicable websites/e-mail

This section contains detailed information about useful web sites and email addresses.

https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf https://www.tmhp.com/sites/default/files/file-library/edi/TMHP_EDI_Connectivity_Guide.pdf

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Texas Medicaid EDI Technical Information, such as code references, vendor file specifications, and additional Companion Guides can be found at:

https://www.tmhp.com/topics/edi

The Texas Medicaid Provider Procedures Manual is found at:

https://www.tmhp.com/resources/provider-manuals

EDI Helpful Links:

Washington Publishing Company – The Washington Publishing Company site includes reference documents pertaining to HIPAA, such as: implementation guides, data conditions, and the data dictionary for X12N standards.

Workgroup for Electronic Data Interchange (WEDI) – This site provides implementation materials and information.

National Uniform Billing Committee (NUBC) – This site is the official source of UB-04 billing information.

Texas Department of State Health Services (DSHS)

Texas Health and Human Services Commission

6 CONTROL SEGMENTS/ENVELOPES

6.1 ISA-IEA

• Texas Medicaid does not support repetition of a simple data element or a composite data structure.

• Texas Medicaid will accept one ISA/IEA in each file and one GS/GE per ISA.

• Texas Medicaid uses “*” (asterisk) as the element separator, and “~” (tilde) as the segment separator.

Page

Loop ID Reference Name Codes Length Notes/Comments

Control Segments

C.3 ISA Interchange Control Header

C.4 ISA01

Authorization Information Qualifier

C.4 ISA03

Security Information Qualifier

C.4 ISA05 Interchange ID ZZ https://www.tmhp.com/topics/edi https://www.tmhp.com/resources/provider-manuals https://wpc-edi.com/ https://www.wedi.org/ https://www.nubc.org/ https://www.dshs.state.tx.us/ https://www.hhs.texas.gov/

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6.2 GS-GE

Page

Loop ID Reference Name Codes Length Notes/Comments

Control Segments

C.7 GS Functional Group Header

C.7 GS02 Application Sender’s Code Provider Submitter ID

C.7 GS03 Application Receiver’s Code 617591011CMSP

This is Texas Medicaid’s Electronic Transmitter Group Identifier.

Loop ID Reference Name Codes Length Notes/Comments

Control Segments Qualifier

C.5 ISA06 Interchange Sender ID Provider Submitter ID

C.5 ISA07 Interchange ID Qualifier ZZ

C.5 ISA08 Interchange Receiver ID

Production =

617591011CMSP

Testing =

617591011CMST

C.5 ISA11 Repetition Separator

| (pipe character)

C.6 ISA14 Acknowledgment Requested 0 (zero)

C.6 ISA15 Interchange Usage Indicator P ISA15=”P” for both

Production and Test

C.6 ISA16 Component Element Separator

: (colon character)

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7 TEXAS MEDICAID SPECIFIC BUSINESS RULES AND

LIMITATIONS

Texas Medicaid will accept up to 5000 transactions per batch. If a file is submitted with more than 5000 transactions the entire file will be rejected and not processed by Texas Medicaid.

X12 files with more than one GS-GE Functional Group will fail to process in the Texas Medicaid system.

The Texas Medicaid Provider Procedures Manual is the providers’ principal source of information about Texas Medicaid. The most recent version is found at:

https://www.tmhp.com/resources/provider-manuals

8 ACKNOWLEDGEMENTS AND/OR REPORTS

Texas Medicaid provides HIPAA responses and acknowledgements that should be utilized by the Trading Partner for reconciliation purposes. Texas Medicaid does not provide proprietary reports as a standard part of the claims data process. Trading Partners should utilize the HIPAA responses provided for each transmission to reconcile claims.

The following responses will be received by the Trading Partner:

TA1 Transaction Interchange Acknowledgement

The TA1 will be sent if the submitter ID is not known or if the file received is structurally incorrect.

BID Document

Batch ID Report

The BID file is sent as acknowledgement of file reception. This is not an indicator that the file was accepted; only received. This zero-byte file will provide the Texas Medicaid assigned batch ID within the file name.

*This response will not be returned for files exchanged over the CORE Operating Rule “Safe Harbor” connection method.

999 Transaction Implementation Acknowledgement

This file provides high level transaction set response details for the 837 received. It does not contain transaction (claim) level responses.

277CA

Health Care Claim Acknowledgement The 277CA includes claim level acknowledgements including acceptance/rejection information. This file will not be sent if a negative 999 (rejection) or TA1 file has been returned.

9 TRADING PARTNER AGREEMENTS

This section contains general information concerning Trading Partner Agreements (TPA).

https://www.tmhp.com/resources/provider-manuals

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9.1 Trading Partner

An EDI Trading Partner is defined as any Texas Medicaid customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from, Texas Medicaid.

Submitters have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement.

For example, a Trading Partner Agreement may specify, among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions.

Texas Medicaid Trading Partner Agreement will be found on this web page:

https://www.tmhp.com/resources/forms?field_topics_target_id=96

10 TRANSACTION SPECIFIC INFORMATION

This section uses a table to describe how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed. The tables contain a row for each segment where Texas Medicaid has something additional, over and above the information in the IGs. That information can:

1. Limit the repeat of loops, or segments.

2. Limit the length of a simple data element.

3. Specify a sub-set of the IGs internal code listings.

4. Clarify the use of loops, segments, composite and simple data elements.

5. Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with Texas Medicaid.

In addition to the row for each segment, one or more additional rows are used to describe Texas Medicaid’s usage for composite and simple data elements and for any other information.

This section is used to describe the required data values that will be used by Texas Medicaid for those who submit a dental claim.

Page # Loop ID Reference Name Codes Length Notes/

Comments 74 1000B NM1 Receiver Name

75 1000B NM103

Name Last or Organization Name

Texas Medicaid

75 1000B NM109 Receiver Primary Identifier 617591011CMSP

78 2000A PRV

Billing Provider Specialty Information https://www.tmhp.com/resources/forms?field_topics_target_id=96

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# Loop ID Reference Name Codes Length Notes/

Comments

78 2000A PRV03 Provider Taxonomy Code

The Taxonomy code must be the Taxonomy code on file with Texas Medicaid.

82 2010AA N1 Billing Provider Name

85 2010AA NM109 Billing Provider Identifier

National Provider ID (NPI) must be submitted unless the provider has an Atypical Provider Identifier (API) assigned which will be reported in Loop

2010BB.

114 2010BA NM1 Subscriber Name

116 2010BA NM108 Identification Code Qualifier MI

124 2010BB NM1 Payer Name

125 2010BB NM103 Payer Name TDHS/TDMHM R

125 2010BB NM108 Identification Code Qualifier PI

125 2010BB NM109 Payer Identifier 617591011CMSP

131 2010BB REF

Billing Provider Secondary Identification

131 2010BB REF01 Identification Code Qualifier G2

If the provider has an API instead of an NPI, the API must be sent in the REF02.

169 2300 REF Referral Number

169 2300 REF02 Referral Number 8 Numeric

179 2300 NTE Claim Note

179 2300 NTE01 Claim Note ADD

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Comments

179 2300 NTE02 Claim Note 1-5 Alpha Numeric

To submit the Billing Provider Service Group Code, enter the appropriate Service Group value for the Billing Provider in Positions 24-28 (left justified).

Refer to Long Term Care Reference Codes under the LTC and Acute Care Reference Codes dropdown on the TMHP.com website:

https://www.tmhp.

com/topics/edi

190 2310A NM1 Referring Provider Name

If the Referral Number is not sent on the claim, loop 2310A is not required by Texas Medicaid.

191 2310A NM101 Entity Identifier Code DN

191 2310A NM102 Entity Type Qualifier 1

191 2310A NM103

Referring Provider Last Name

DADS – Default value if there is no Referring Provider and the Referral Number is sent.

191 2310A NM104

Referring Provider First Name

DADS– Default value if there is no Referring Provider and the

If the Referring Provider loop is sent, the Referring Provider Name is mandatory for Texas Medicaid claims https://www.tmhp.com/ https://www.tmhp.com/

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Comments processing.

192 2310A NM108 Identification Code Qualifier

XX– Default value if there is no Referring Provider and the

192 2310A NM109

Provider Identifier

1568578417– Default value if there is no

Provider and the

197 2310B NM1 Rendering Provider Name

197 2310B NM104

Rendering Provider First Name

If the Rendering Provider loop is sent the Rendering Provider Name is mandatory for Texas Medicaid claims processing.

198 2310B NM109

Rendering Provider Primary Identifier

NPI must be submitted unless the provider has an API assigned which will be reported in Loop 2310B Rendering Provider Secondary Identification.

Either the NPI or API are required for claims processing

199 2310B PRV

Rendering Provider Specialty

199 2310B PRV03 Reference Identification 1223G0001X

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Comments

200 2310B REF

Rendering Provider

Identification

201 2310B REF01 Reference Identification G2

If the provider has an API instead of an NPI, the API must be sent in the REF02.

282 2400 SV3 Dental Service

286 2400 SV306 Quantity

Texas Medicaid can accept a maximum of 99,999.99 for the units count for claims processing.

316 2420A NM1 Rendering Provider Name

317 2420A NM104

Rendering Provider First Name

If the Rendering Provider loop is sent the Rendering Provider name is mandatory for Texas Medicaid claims processing.

318 2420A NM109

Rendering Provider Primary Identifier

NPI must be submitted unless the provider has an API assigned which will be reported in Loop 2420A Rendering Provider Secondary Identification.

Either the NPI or API are required for claims processing.

319 2420A PRV

Rendering Provider Specialty

319 2420A PRV03 Reference Identification 1223G0001X

320 2420A REF

Rendering Provider

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Comments Identification

321 2420A REF01 Reference Identification

If the provider has an API instead of an NPI, the API must be sent in the REF02.

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11 APPENDICES

11.1 Transmission Examples

The 837D transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, claim level, and claim service line level. Billing providers who sort claims using this hierarchy will use the 837D more efficiently because information that applies to all lower levels in the hierarchy will not have to be repeated within the transaction.

Texas Medicaid Note:

As an assumption for these file formats if the Subscriber is the same individual as the Patient, then the Patient Loop is not to be populated per HIPAA compliance. Information sent in the 2000C loop will be ignored by Texas Medicaid.

In the following example carriage return line feeds are inserted in place of ~ character for improved readability purposes.

ISA*00* *00* *ZZ*111111111 *ZZ*617591011CMSP

*151209*1310*|*00501*111111111*0*P*:

GS*HC*111111111*617591011CMSP*20151209*1310*9*X*005010X224A2

ST*837*0001*005010X224A2

BHT*0019*00*1*20151209*1310*CH

NM1*41*2*ORGANIZATION NAME*****46*111111111

PER*IC*TMC*TE*9999999999

NM1*40*2*TEXAS MEDICAID*****46*617591011CMSP

HL*1**20*1

NM1*85*2*ORGANIZATION NAME*****XX*1111111111

N3*100 MAIN STREET

N4*TOWN*TX*123456789

REF*EI*111111111

HL*2*1*22*0

SBR*P*18*******MC

NM1*IL*1*LAST NAME*FIRST NAME****MI*111111111

N3*100 MAIN STREET

N4*TOWN*TX*12345

DMG*D8*19500211*F

NM1*PR*2*TEXAS MEDICAID*****PI*1111111

CLM*1111*251***99:B:1*Y*C*Y*Y

DTP*472*D8*20150720

REF*9F*11111111

NTE*ADD*YN0000000000000000 10

NM1*DN*1*LAST NAME*FIRST NAME****XX*1111111111

LX*1

SV3*AD:D9999::KX*251**00**251

DTP*472*D8*20150720

SE*26*0001

GE*1*9

IEA*1*111111111

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11.2 Change Summary

The following is a log of changes made since the original version of the document was published.

Change Date

1 Example transaction updated. 07/10/2014

2 Added 2400 LX Service Line Texas Medicaid will accept up to 28 Service Lines per claim.

03/02/2015

3 Updated to CAQH CORE Operating Rules Phase IV Template.

10/01/2016

4 Pg. 16 - Added 2300 NTE Claim Note instructions for Billing Provider Service Group Code entry.

Pg. 18 – Added Transmission X12 example of Group Code value ‘10’ beginning in position 24.

Removed yellow highlight from page 16 and 18.

02/01/2019

5 Updated information for loop 2310A Referring Provider requirements. Updated requirements for Rendering Provider information in loops 2310B and 2420A. Added default values for referring provider when there is no Referring Provider available.

05/15/2021

6 Updated http links to https links and updated formatting.

08/10/2023