20635 1 X12 Companion GuideV1.2

7/27/2019 20635 1 X12 Companion GuideV1.2

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MEDI-CAL COMPANION GUIDE

JUNE 2012 005010 1

California Medicaid(Medi-Cal)

Standard Companion Guide Transaction Information

Instructions Related to Transactions Based onASC X12 Implementation Guides, Version 005010

Companion Guide Version Number: 1.2

Published: June 2012


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JUNE 2012 005010 2

This Companion Guide is Copyright 2010 by The Workgroup for Electronic Data Interchange

(WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited

Standards Committee (ASC) X12. 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 express or implied warranty. Note that the copyright on the

underlying ASC X12 Standards is held by DISA on behalf of ASC X12.

2011 Companion Guide copyright by California Department of Health Care Services


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JUNE 2012 005010 3

Preface

The Companion Guide (CG) may contain two types of data, instructions for electronic

communications with the publishing entity (Communications/Connectivity Instructions) and

supplemental information for creating transactions for the publishing entity while ensuring

compliance with the associated ASC X12 IG (Transaction Instructions). Either the

Communications/Connectivity component or the Transaction Instruction component must be

included in every CG. The components may be published as separate documents or as a single

document.

The Communications/Connectivity component is included in the CG when the publishing entity

wants to convey the information needed to commence and maintain communication exchange.

The Transaction Instruction component is included in the CG when the publishing entity wants

to clarify the IG instructions for submission of specific electronic transactions. The Transaction

Instruction component content is limited by ASC X12s copyrights and Fair Use statement.


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Table of Contents

1 TI Introduct ion .......................................................................................................... 51.1 Background ...................................................................................................................5

1.1.1 Overview of HIPAA Legislation ........................................................................... 51.1.2 Compliance according to HIPAA ......................................................................... 51.1.3 Compliance according to ASC X12 ..................................................................... 6

1.2 Intended Use .................................................................................................................62 Included ASC X12 Implementation Guides ............................................................63 Instruction Tables .................................................................................................... 7

3.1 005010X279A1 Health Care Eligibility Benefit Inquiry ................................................... 73.2 005010X279A1 Health Care Eligibility Benefit Response ............................................ 103.3 005010X212 Health Care Claim Status Request ......................................................... 143.4 005010X212 Health Care Claim Status Response ...................................................... 153.5 005010X222A1 Health Care Claim: Professional ........................................................ 163.6 005010X223A2 Health Care Claim: Institutional .......................................................... 263.7 005010X221A1 Health Care Claim Payment/Advice ................................................... 34

4 TI Additional Information ......................................................................................374.1 Business Scenarios ..................................................................................................... 374.2 Payer-Specific Business Rules and Limitations ........................................................... 374.3 Frequently Asked Questions ....................................................................................... 374.4

Other Resources 8

....................................................................................................... 38

5 TI Change Summary ..............................................................................................386 Appendix A Communication/Connectivi ty Instructions (CCI) .........................38


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JUNE 2012 005010 5

Transaction Instruction (TI)

1 TI Introduction

1.1 Background

1.1.1 Overview of HIPAA Legislation

The Health Insurance Portability and Accountability Act (HIPAA) of 1996

carries provisions for administrative simplification. This requires the

Secretary of the Department of Health and Human Services (HHS) to adopt

standards to support the electronic exchange of administrative and financial

health care transactions primarily between health care providers and plans.

HIPAA directs the Secretary to adopt standards for transactions to enable

health information to be exchanged electronically and to adopt specifications

for implementing each standard HIPAA serves to:

Create better access to health insurance

Limit fraud and abuse

Reduce administrative costs

1.1.2 Compliance According to HIPAA

The HIPAA regulations at 45 CFR 162.915 require that covered entities not

enter into a trading partner agreement that would do any of the following:

Change the definition, data condition, or use of a data element or

segment in a standard

Add any data elements or segments to the maximum defined data set

Use any code or data elements that are marked not used in the

standards implementation specifications or are not in the standards

implementation specification(s)

Change the meaning or intent of the standards implementation

specification(s)


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1.1.3 Compliance According to ASC X12

ASC X12 requirements include specific restrictions that prohibit trading

partners from:

Modifying any defining, explanatory or clarifying content contained in the

implementation guide

Modifying any requirement contained in the implementation guide

1.2 Intended Use

The Transaction Instruction component of this companion guide must be used in

conjunction with an associated ASC X12 Implementation Guide. The instructions

in this companion guide are not intended to be stand-alone requirements

documents. This companion guide conforms to all the requirements of any

associated ASC X12 Implementation Guides and is in conformance with ASCX12s Fair Use and Copyright statements.

2 Included ASC X12 Implementation Guides

This table lists the X12N Implementation Guides for which specific transaction

instructions apply and which are included in Section 3 of this document.

Unique ID Name

005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271)

005010X212 Health Care Claim Status Request and Response (276/277)

005010X222A1 Health Care Claim: Professional (837)

005010X223A2 Health Care Claim: Institutional (837)

005010X221A1 Health Care Claim Payment/Advice (835)


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JUNE 2012 005010 7

3 Instruction Tables

These tables contain one or more rows for each segment for which a supplementalinstruction is needed.

Legend

SHADED rows represent segments in the X12N implementation guide.

NON-SHADED rows represent data elements in the X12N implementation guide.

3.1 005010X279A1 Health Care Eligibil ity Benefit Inquiry

Loop ID Reference Name Codes Notes/Comments

2100A NM1 Information Source Name

2100A NM109 Identification Code Medi-Cal expects to receive:

610442

2100B NM1 Information Receiver Name

2100B NM101 Entity Identifier Code 1P Medi-Cal expects to receivethe value listed in the codescolumn

NM108 Identification Code Qualifier SV

XX

Medi-Cal expects to receiveone of the values listed in thecodes column

2100B REF Information Receiver

Additional Identification

2100B REF01 Reference Identification

Qualifier

4A For Batch, Medi-Cal expects

to receive the value listed inthe codes column

2100B N3 Information Receiver Address This segment is not requiredfor the payers adjudicationsystem

2100B N4 Information Receiver

City, State and ZIP Code

This segment is not requiredfor the payers adjudicationsystem

2100B PRV Information Receiver Provider

Information


2000C HL Subscriber Level

2000C HL01 Hierarchical ID Number Medi-Cal expects to receivethe following:

For Leased-Line and Dial-Up:3

For Batch:Increment this for eachSubscriber entered, fromthree and up to 99Subscribers


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JUNE 2012 005010 8


2100C NM1 Subscriber Name

2100C NM108 Identification Code Qualifier MI Medi-Cal expects to receivethe value listed in the codescolumn

2100C REF Subscriber AdditionalIdentification

2100C REF01 Reference Identification

Qualifier

18

1L

1W

6P

EA

EJ

IG

N6

NQ

Medi-Cal expects to receiveone of the code values listedin the codes column

2100C N3 Subscriber Address This segment is not requiredfor the payers adjudication

system

2100C N4 Subscriber City, State, and

ZIP Code


2100C PRV Provider Information This segment is not requiredfor the payers adjudicationsystem

2100C INS Multiple Birth sequenceNumber


2100C HI Subscriber Health CareDiagnosis Code


2110C EQ Subscriber Eligibility orBenefit Inquiry Information

2110C EQ021 Product/Service ID Qualifier CJ

HC

ID

IV

N4

ZZ

Medi-Cal expects to receiveone of the code values listedin the codes column

2110C III Subscriber Eligibility orBenefit Additional InquiryInformation


2110C REF Subscriber Additional

Information

This segment is not required

for the payers adjudicationsystem

DTP Subscriber Eligibility / BenefitDate



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JUNE 2012 005010 9


2000D Dependent Level This loop is not required forthe payers adjudicationsystem

Medi-Cal patients/recipientsare identified to the payer bya unique IdentificationNumber

All patients/recipients areconsidered the subscriber andmust be identified in theSubscriber Loop

2100D Dependent Name This loop is not required forthe payers adjudicationsystem

Medi-Cal patients/recipientsare identified to the payer bya unique Identification

Number

All patients/recipients areconsidered the subscriber andmust be identified in theSubscriber Loop


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JUNE 2012 005010 10

3.2 005010X279A1 Health Care Eligibil ity Benefit Response

Loop

ID

Reference Name Codes Notes/Comments

2000A HL Information Source Level

2000A HL04 Hierarchical Child Code 1 Medi-Cal will populate this dataelement with value listed in thecodes column

2100A NM1 Information Source Name

2100A NM103 Name Last or Organization

Name

Medi-Cal will populate this dataelement with:

Medi-Cal

NM109 Identification Code Medi-Cal will populate this dataelement with:

610442

2100A PER Information Source

Contact Information

2100A PER02 Name Medi-Cal will populate this dataelement with:

POS Help Desk Toll FreeNumber or Voice AEVS

PER03 Communication Number

Qualifier

TE Medi-Cal will populate this dataelement with value listed in thecodes column

2000B HL Information Receiver Level

2000B HL04 Hierarchical Child Code 1 Medi-Cal will populate this dataelement with value listed in the

codes column2100B NM1 Information Receiver

Name

2100B NM101 Entity Identifier Code 1P Medi-Cal will populate this dataelement with value listed in thecodes column

NM108 Identification Code

Qualifier

XX

SV

Medi-Cal will populate this dataelement with values listed in thecodes column

2100B REF Information Receiver

Additional Identification

Medi-Cal will not send thissegment

2100B PRV Information Receiver

Provider Information

Medi-Cal will not send this

segment2100C HL Subscriber Level


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JUNE 2012 005010 11

Loop

ID


2100C HL01 Hierarchical ID Number Medi-Cal will populate this dataelement with:

For Leased-Line and Dial-Up:

3

For Batch:This will be incremented foreach Subscriber, up to 99Subscribers

HL04 Hierarchical Child Code 0 Medi-Cal will populate this dataelement with value listed in thecodes column

2000C TRN Subscriber Trace Number

2000C TRN03 Originating Company

Identifier


610442

2100C NM1 Subscriber Name

2100C NM108 Identification Code

Qualifier

MI Medi-Cal will populate this dataelement with value listed in thecodes column

2100C N3 Subscriber Address Medi-Cal will not send thissegment

2100C N4 Subscriber City, State, and

ZIP Code


2100C PRV Provider Information Medi-Cal will not send thissegment

2100C HI Subscriber Health Care

Diagnosis Code


2100C DTP Subscriber Date

2100C DTP01 Date/Time Qualifier 102

291

307

458

472


2100C MPI Subscriber Military

Personnel Information


2110C EB Subscriber Eligibility orBenefit Information


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JUNE 2012 005010 12

Loop

ID


2110C EB01 Eligibility or BenefitInformation Code

1

6

CB

E

F

I

K

MC

N

R

V

W

Y


EB03 Service Type Code 1

9

30

3335

43

45

47

48

50

54

61

69

76

82

83

84

86

88

89

90

91

92

96

98

99

A0

A1

A2

A3

A8

AI

AJ

AK

AL

MH

UC


Refer to the Medi-Cal ProviderManual for more detailedinformation regarding servicescovered under the Medi-Calprogram


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JUNE 2012 005010 13

Loop

ID


EB04 Insurance Type Code MA

MB

MC

OT


EB05 Plan Coverage Description Medi-Cal will populate this dataelement with one of thefollowing values:

CCSCHDPCMSPFAMILY PACTFAMILY PACT BENEFITSGHPPHAPMEDICARE PART D

2110C HSD Health Care ServicesDelivery


2110C DTP SubscriberEligibility/BenefitDate

2110C DTP01 Date/Time Qualifier 102

291

307

458

472

Medi-Cal will populate this dataelement with one of the valuesshown in the codes column

2110C MSG Message Text

2110C MSG01 Free-form Message Text County Code will be included inthe free form text, along with theeligibility information

2115 III Subscriber Eligibility orBenefit AdditionalInformation



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JUNE 2012 005010 14

3.3 005010X212 Health Care Claim Status Request

Loop

ID


2100A NM1 Payer Name

2100A NM103 Payer Name Medi-Cal expects to receive:

Medi-Cal

NM109 Payer Primary Identifier Medi-Cal expects to receive:

610442

2000D HL Dependent Loop Medi-Cal patients/recipientsare identified to the payer bya unique IdentificationNumber

All patients/recipients areconsidered the subscriberand must be identified in theSubscriber Loop


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JUNE 2012 005010 15

3.4 005010X212 Health Care Claim Status Response


2100A NM1 Payer Name

2100A NM103 Payer Name Medi-Cal will populate this

segment with:

Medi-Cal

NM109 Payer Primary Identifier Medi-Cal will populate this

segment with:

610442

2000D HL Dependent Loop All patients/recipients areconsidered the subscriber andmust be identified in theSubscriber Loop


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JUNE 2012 005010 16

3.5 005010X222A1 Health Care Claim: Professional


1000A NM1 Payer Identification

1000A NM109 Submitter Identifier Medi-Cal expects to receive

the Submitter ID

1000A PER Submitter EDI Contact

Information


for the payers adjudication

system

In the event communication is

required related to this

transaction, Medi-Cal will use

the contact information

submitted in the Billing

Provider Contact Information

in Loop 2010AA

1000B NM1 Receiver Name

1000B NM103 Receiver Name Medi-Cal expects to receive:

Medi-Cal

NM109 Receiver Primary Identifier Medi-Cal expects to receive:

610442

2000A CUR Foreign Currency

Information



system

All amounts within Medi-Cal

electronic transactions

represent U.S. currency

2010AA N3 Billing Provider Address Medi-Cal will use the Provider

Address in the internal

Provider Master File for

mailing of check or other

documents related to this

claim

2010AA N4 Billing Provider City, State

and ZIP Code

Medi-Cal will use the Provider





claim

2010AA REF Billing Provider Tax

Identification

Medi-Cal will use the Tax

Identification Number (TIN) on

file in the internal Provider

Master File for income

reporting on the 1099 forms


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JUNE 2012 005010 17


2010AA REF Billing Provider

UPIN/License Information



system

Medi-Cal only accepts the NPI

and Medi-Cal Provider

Number to identify providers in

our adjudication system

2010AA PER Billing Provider Contact

Information

2010AA PER03 Communication Number

Qualifier

TE Medi-Cal expects to receive

the value shown in the codes

column

In the event communication is

required related to this

transaction, Medi-Cal will

contact you by telephone

2010AB Pay-to Address Name This loop is not required for

the payers adjudication

system






claim

2010AC Pay-to Plan Name This loop is not required for


system

Medi-Cal does not currently

process subrogation payment

requests

2010BA NM1 Subscriber Name

2010BA NM108 Identification Code

Qualifier

MI Medi-Cal expects to receive

the value shown in the codes

column

2010BA REF Subscriber Secondary

Identification



system

2010CA REF Property and Casualty

Claim Number



system

2010CA PER Property and Casualty

Subscriber Contact

Information


for the Payer adjudication

system


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JUNE 2012 005010 18


2010BB NM1 Payer Name

2010BB NM103 Payer Name Medi-Cal expects to receive:

Medi-Cal

NM109 Payer Identifier Medi-Cal expects to receive:

610442

2010BB N3 Payer Address This segment is not requiredfor the payers adjudicationsystem

2010BB N4 Payer City, State and ZIP

Code


2010BB REF Payer Secondary

Identification


2010BB REF Billing Provider Secondary

Identification

This segment should be

submitted for atypicalMedi-Cal providers who arenot eligible to receive an NPI

Medi-Cal expects to receivethe Medi-Cal Provider Numberin this segment for BloodBank, Christian SciencePractitioner and MSSPproviders who are not eligiblefor an NPI

These providers areconsidered atypical providersand must bill the Medi-Calprogram using their Medi-CalProvider Number

2010BB REF01 Billing Provider Secondary

Identifier

G2 Medi-Cal expects to receivethe value shown in the codescolumn

2000C HL Patient Hierarchical Level This segment is not requiredfor the payers adjudicationsystem

Medi-Cal recipients are allidentified to the payer by aunique Identification Number

All patients/recipients areconsidered the subscriber andmust be identified at theSubscriber Level

2300 DTP Date Initial Treatment

Date


2300 DTP Date Last Seen Date This segment is not requiredfor the payers adjudicationsystem


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2300 DTP Date Acute

Manifestation


2300 DTP Date Last Menstrual

Period

This segment is not requiredfor the payers adjudication

system

2300 DTP Date Last X-ray This segment is not requiredfor the payers adjudicationsystem

2300 DTP Date Disability Dates This segment is not requiredfor the payers adjudicationsystem

2300 DTP Date Last Worked This segment is not requiredfor the payers adjudicationsystem

2300 DTP Date Authorized Return

to Work


2300 DTP Date - Assumed and

Relinquished Care Dates


2300 DTP Date Property and

Casualty Date of First

Contact


2300 DTP Date Repricer Received

Date



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2300 REF Clinical Laboratory

Improvement Amendment

(CLIA) Certificate Number


2300 REF Repricer Claim Number This segment is not requiredfor the payers adjudicationsystem

2300 REF Adjusted Repricer Claim

Number


2300 REF Investigation Device

Exception Number

This segment is not requiredfor the payers adjudicationsystem.

2300 REF Claim Identifiers for

Transmission

Intermediaries


2300 REF Medical Record Number This segment is not requiredfor the payers adjudication

system2300 REF Demonstration Project

Identifiers


2300 REF Care Plan Oversight This segment is not requiredfor the payers adjudicationsystem

2300 K3 File Information This segment is not requiredfor the payers adjudicationsystem

2300 NTE Claim Note

2300 NTE01 Attachment Transmission

Code

Medi-Cal uses one of theoccurrences of this segment to

convey the EmergencyCertification Statement asdefinedby Medi-Cal policyMedi-Cal expects to receiveCER when submittingEmergency CertificationStatement information

2300 CR1 Ambulance Transport

Information


2300 CR2 Spinal Manipulation

Service Information


2300 CRC Homebound Indicator This segment is not requiredfor the payers adjudicationsystem

2300 CRC EPSDT Referral This segment is not requiredfor the payers adjudicationsystem

2300 HI Health Care Diagnosis

Codes



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2300 HI Health Care Diagnosis

Code

2300 HI012

and

HI122

Diagnosis Code Medi-Cal will accept 12diagnosis codes

Only the first two diagnosiscodes submitted in thissegment will be used in theadjudication process

2300 HI Anesthesia Related

Procedure


2300 HCP Claim Pricing/Repricing

Information


2310C PER Service Facility Contact

Information


2310D NM Supervising ProviderName


2320 AMT Coordination of Benefits

(COB) Total Non-Covered

Amount


2320 OI Other Insurance CoverageInformation


2320 MOA Medicare Outpatient

Adjudication Information


2330A NM1Other Subscriber Name

2330A NM108 Identification Code

Qualifier

MI Medi-Cal expects to receivethe value shown in the codescolumn

2330A N3 Other Subscriber Address This segment is not requiredfor the payers adjudicationsystem

2330A N4 Other Subscriber City,

State and ZIP


2330A REF Other Subscriber

Secondary Identifier


2330B N3 Other Payer Address This segment is not requiredfor the payers adjudicationsystem

2330B N4 Other Payer City, State

and ZIP


2330B REF Other Payer Secondary

Identification



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2330B REF Other Payer Referral

Number


2330B REF Other Payer Adjustment

Indicator


system2330C Other Payer Referring

Provider

This loop is not required forthe payers adjudicationsystem

2330D Other Payer Rendering

Provider Name


2330E Other Payer Service

Facility Location


2330F Other Payer Supervising

Provider


2330G Other Payer Billing

Provider


2400 LX Service Line Number Medi-Cal will accept andprocess 6 Claim Service Linesfor Professional Claims

2400 SV1 Professional Services

2400 SV1011 Product or Service ID

Qualifier

HC Medi-Cal expects to receivethe value shown in the codescolumn

SV1013

thru

SV1016

Procedure Modifier Medi-Cal will accept 4Procedure Modifiers but onlythe first two will be utilized in

the adjudication process

See the Medi-Cal ProviderManual for the appropriateusage of Modifier Codes

2400 SV5 Durable Medical

Equipment Service


2400 PWK Line Supplemental

Information


2400 PWK Durable Medical

Equipment Certificate of

Medical NecessityIndicator


system

2400 CR1 Ambulance Transport

Information


2400 CR3 Durable Medical

Equipment Certification



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2400 DTP Date Certification

Revision/Recertification

Date


2400 DTP Begin Therapy Date This segment is not requiredfor the payers adjudicationsystem

2400 DTP Date Last Certification

Date



2400 DTP Date Test Date This segment is not requiredfor the payers adjudicationsystem

2400 DTP Date Last X-ray Date This segment is not requiredfor the payers adjudicationsystem


Date


2400 QTY Ambulance Patient Count This segment is not requiredfor the payers adjudicationsystem

2400 QTY Obstetrical Anesthesia

Additional Units


2400 MEA Test Results This segment is not requiredfor the payers adjudicationsystem

2400 CN1 Contract InformationThis segment is not requiredfor the payers adjudicationsystem

2400 REF Repriced Line ItemReference Number


2400 REF Adjusted Repriced LineItem Reference Number


2400 REF Mammography

Certification Number



Improvement Amendment(CLIA) Number



2400 REF Referring Clinical

Laboratory Improvement

Amendment (CLIA)

Facility


2400 REF Immunization Batch

Number



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2400 REF Referral Number This segment is not requiredfor the payers adjudicationsystem

2400 AMT Postage Claimed Amount This segment is not requiredfor the payers adjudication

system2400 K3 File Information This segment is not required


2400 NTE Third Party Organization

Note


2400 PS1 Purchase Service

Information


2400 HCP Line Pricing/Repricing

Information


2420B Purchase Service Provider This loop is not required forthe payers adjudicationsystem

2420D Supervising Provider

Name


2420E Ordering Provider Name This loop is not required forthe payers adjudicationsystem

2430 AMT Remaining Patient Liability This segment is not requiredfor the payers adjudicationsystem

2440 Form Identification Code This loop is not required for

the payers adjudicationsystem


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3.6 005010X223A2 Health Care Claim: Inst itutional


1000A NM1 Submitter Name

NM109 Submitter Identifier Medi-Cal expects to receive:

Submitter ID

1000B NM1 Receiver Name

NM103 Receiver Name Medi-Cal expects to receive:

Medi-Cal

NM109 Receiver Primary Identifier Medi-Cal expects to receive:

610442

2000A CUR Foreign Currency

Information

This loop is not required for


system

All amounts within Medi-Cal

electronic transactions

represent U.S. currency

2010AA N3 Billing Provider Address Medi-Cal will use the Provider

Address from the internal




claim

2010AA N4 Billing Provider City, State

and ZIP Code






claim

2010AA REF Billing Provider Tax

Identification

Medi-Cal will use the Tax

Identification Number (TIN) on

file from the internal Provider

Master File for income

reporting on the 1099 forms

2010AB Pay-to Address Name This loop is not required for


system




mailing checks or other


claim


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2010AC Pay-to Plan Name This loop is not required for


system

Medi-Cal does not currently

process subrogation payment

requests

2010BB NM1 Payer Name

NM103 Payer Name Medi-Cal expects to receive

one of the following based on

the claim type for:

Long Term Care

MEDI-CAL LTC

Outpatient

MEDI-CAL OP

Inpatient

MEDI-CAL IP

NM109 Payer Identifier Medi-Cal expects to receive:

610442

2010BB REF Billing Provider Secondary

Identification

This segment should besubmitted for atypicalMedi-Cal providers who arenot eligible to receive an NPI

Medi-Cal expects to receivethe Medi-Cal Provider Numberin this segment for BloodBank, Christian Science

Practitioner and MSSPproviders who are not eligiblefor an NPI

These providers areconsidered atypical providersand must bill the Medi-Calprogram using their Medi-CalProvider Number

2000C Patient Hierarchical Level This loop is not required forthe payers adjudicationsystem

Medi-Cal patients/recipients

are identified to the payer by aunique Identification Number

Medi-Cal patients/recipientsare considered the subscriberand must be identified at theSubscriber Level


Date



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2300 DTP Date Acute

Manifestation


system

2300 DTP Date Last Menstrual

Period


2300 DTP Date Last X-ray This segment is not requiredfor the payers adjudicationsystem

2300 DTP Date Disability Dates This segment is not requiredfor the payers adjudicationsystem

2300 DTP Date Last Worked This segment is not requiredfor the payers adjudicationsystem

2300 DTP Date Authorized Return

to Work


2300 DTP Date - Assumed and

Relinquished Care Dates


2300 DTP Date Property and

Casualty Date of First

Contact


2300 DTP Date Repricer Received

Date



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2300 PWK Claim Supplemental

Information

1. Attachments associatedwith a PWK segmentshould be sent at thesame time the 837 claimtransaction is sent.Medi-Cals businesspractice is that additionaldocumentation receivedmore than 30 days afterthe receipt of your 837claim transmission will notbe considered inadjudication of your claim

2. An Attachment ControlForm (ACF) must be usedwhen submittingsupplemental informationin support of an electronicclaim

3. The Attachment Control

Number (ACN) on thisform must match thecontrol number submittedin the PWK06 dataelement. That controlnumber is assigned by theprovider or the providerssystem

PWK02 Attachment Transmission

Code

BM

EL

FX

Medi-Cals processing andpolicy procedures support themethods for transmission ofattachments shown in thecodes column

2300 CN1 Contract Information This segment is not required


2300 REF Service Authorization

Exception Code


2300 REF Mandatory Medicare

(Section 4081) Crossover

Indicator


2300 REF Mammography

Certification Number


2300 REF Referral Number This segment is not requiredfor the payers adjudication

system2300 REF Payer Claim Control

Number



Improvement Amendment

(CLIA) Certificate Number



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2300 REF Repricer Claim Number This segment is not requiredfor the payers adjudicationsystem

2300 REF Adjusted Repricer Claim

Number


system2300 REF Investigation Device

Exception Number


2300 REF Claim Identifiers for

Transmission

Intermediaries


2300 REF Medical Record Number This segment is not requiredfor the payers adjudicationsystem

2300 REF Demonstration Project

Identifiers


2300 REF PRO Approval Number This segment is not requiredfor the payers adjudicationsystem

2300 K3 File Information This segment is not requiredfor the Payers adjudicationprocess.

2300 NTE Claim Note

2300 NTE01 Note Reference Code OP and IP Claims Only

Medi-Cal expects to receiveDGN in the first and secondoccurrence of this segment

NTE02 Claim Note Text OP and IP Claims Only

Medi-Cal expects to receivethe Primary and SecondaryDiagnosis Code Description inthe first and secondoccurrence of this segment

2300 NTE Billing Note

2300 NTE02 Billing Note Text OP and IP Claims only:

Medi-Cal will use this segmentto convey the EmergencyCertification Statement asdefined by Medi-Cal policy

Medi-Cal expects to receiveEMCER in the first fivecharacters followed by theEmergency Certificationdocumentation

If the Emergency CertificationStatement is not needed, otheradditional information may besubmitted in this segment


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2300 CRC EPSDT Referral This segment is not requiredfor the payers adjudicationsystem

2300 HI Admitting Diagnosis This segment is not requiredfor the payers adjudication

system2300 HI Patient's Reason for Visit This segment is not required


2300 HI External Cause of Injury This segment is not requiredfor the payers adjudicationsystem

2300 HI DRG Information This segment is not requiredfor the payers adjudicationsystem

2300 HI Other DiagnosisInformation

Medi-Cal will accept up to 12Diagnosis codes and theirassociated elements in this

segment but will only use oneadditional Diagnosis Code inthe adjudication process

2300 HI Other ProcedureInformation

Medi-Cal will accept up to 12Other Procedure Codes andtheir associated elements inthis segment but will only useone additional ProcedureCode in the adjudicationprocess

2300 HI Occurrence SpanInformation


2300 HI Treatment CodeInformation


2300 HI Claim Pricing/RepricingInformation


2310C NM1 Other Operating Physician This loop is not required forthe payers adjudicationsystem.

2320 AMT Remaining Patient Liability This segment is not requiredfor the payers adjudicationsystem

2320 AMT COB Total Non-CoveredAmount


system

2320 OI Other Insurance CoverageInformation


2320 MIA Inpatient AdjudicationInformation



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2320 MOA Outpatient AdjudicationInformation


2330A NM1 Other Subscriber Name

2330A NM108 Identification Code

Qualifier

MI Medi-Cal expects to receivethe value shown in the codescolumn

2330A N3 Other Subscriber Address This segment is not requiredfor the payers adjudicationsystem

2330A N4 Other Subscriber City,State and ZIP code


2330A REF Other Subscriber

Secondary Identifier


2330B N3 Other Payer Address This segment is not requiredfor the payers adjudicationsystem

2330B N4 Other Payer City, State

and ZIP code


2330B REF Other Payer Secondary

Identification


2330B REF Other Payer Referral

Number


2330B REF Other Payer Adjustment

Indicator


2330C Other Payer Attending

Provider


2330D Other Payer Operating

Physician


2330E Other Payer Other

Operating Physician


2330F Other Payer Service

Facility Location


2330G Other Payer Rendering

Provider Name


2330H Other Payer Referring

Provider


2330I Other Payer Billing

Provider



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2400 LX Service Line Number Medi-Cal accepts andprocesses the followingnumber of claim service linesfor the document typesindicated:

1. Inpatient 22 lines2. Outpatient 22 lines3. Long Term Care 1 line

2400 PWK Line Supplemental

Information


2400 REF Line Item Control Number This segment is not requiredfor the payers adjudicationsystem

2400 REF Repriced Line ItemReference Number


2400 REF Adjusted Repriced LineItem Reference Number This segment is not requiredfor the payers adjudicationsystem

2400 AMT Facility Tax Amount This segment is not requiredfor the payers adjudicationsystem

2400 NTE Third Party OrganizationNotes


2400 HCP Line Pricing/RepricingInformation


2410 REF Prescription of

Compound DrugAssociation Number

2410 REF01 Reference IdentificationNumber

XZ Medi-Cal expects to receivethe value shown in the codescolumn

2420A Operating Physician Name This loop is not required forthe payers adjudicationsystem

2420B Other Operating Physician

Name


2430 AMT Remaining Patient Liability This segment is not requiredfor the payers adjudication

system


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3.7 005010X221A1 Health Care Claim Payment/AdviceLoop ID Reference Name Codes Notes/Comments

Header BPR Financial Information

Header BPR01 Transaction HandlingCode

I Medi-Cal will populate this dataelement with the value shown in

the codes column

This transaction containsremittance information only.Medi-Cal will always send thePayment and Remittanceinformation separately

BPR03 Credit/Debit FlagCode

C Medi-Cal will populate this dataelement with the code valueshown in the codes column

BPR04 Payment MethodCode

ACHCHK


BPR05 Payment FormatCode

CCP Data Elements BPR05 BPR15are only populated when BPR04is ACH

Medi-Cal will populate this dataelement with the code valueshown in the codes column

BPR07 Sender DFIIdentification

Medi-Cal will populate this dataelement with the value:

121000358

BPR08 Account NumberQualifier

DA Medi-Cal will populate this dataelement with the code valueshown in the codes column

BPR09 Sender Bank Acct.number

Medi-Cal will populate this dataelement with the code value:

1436100418

BPR10 Payer Identifier (TaxID)

Medi-Cal will populate this dataelement with the code value:

1680217053

BPR12 (DFI) ID NumberQualifier

01 Medi-Cal will populate this dataelement with the code valueshown in the codes column

Header TRN Check Number

Header TRN03 Payer Identifier Medi-Cal will populate this data

element with the code value:

1680217053


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TRN04 ReferenceIdentification

124567

AMNL

Medi-Cal will send thisinformation to identify the financialprogram payment association.


Header CUR Foreign CurrencyInformation

This segment will not be sent. AllMedi-Cal payments are made inUS dollars

Header REF Version Identifier This segment will not be sent

1000A N1 Payer Name

1000A N102 Payer Name Medi-Cal will populate this dataelement with:

State of California Department of

Health Care Services

1000A N3 Payer Address

1000A N301 Address Information Medi-Cal will populate this dataelement with:

714 P Street RM 950

N302 Address Information Medi-Cal will populate this dataelement with:

P.O. Box 942732

1000A N4 Payer City, State andZIP Code

1000A N401 City Name Medi-Cal will populate this dataelement with:

Sacramento

N402 State or ProvinceCode


CA

N403 Postal Code Medi-Cal will populate this dataelement with:

942347320

1000A REF Additional PayerIdentification

This segment will not be sent

1000A PER Payer BusinessContact Information


1000A PER Payer TechnicalContact Information

1000A PER02 Payer Contact Name Medi-Cal will populate this dataelement with:

State of California Medi-CalDepartment


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PER04 Payer ContactCommunicationNumber


8005415555

PER06 Payer Contact

CommunicationNumber

Medi-Cal will populate this data

element with:

www.medi-cal.ca.gov

1000A PER Payer Website This segment will not be sent

1000B N1 Payee Identification

1000B N103 Identification CodeQualifier

XXFI


1000B RDM Remittance DeliveryMethod


2000 TS3 Provider SummaryInformation


2000 TS2 ProviderSupplementalSummary Information


2100 CLP Claims PaymentInformation

2100 CLP02 Claim Status Code 123422


CLP06 Claim Filing IndicatorCode

MC Medi-Cal will populate this dataelement with value shown incodes column

2100 NM1 Patient Name

2100 NM108 Identification CodeQualifier

MR Medi-Cal will populate this dataelement with value shown incodes column

2100 NM1 Insured Name Medi-Cal will not send thissegment

2100 NM1 Crossover CarrierName


2100 NM1 Service ProviderName


XXMC


2100 NM1 Crossover CarrierName


2100 NM1 Corrected PriorityPayer Name


PI Medi-Cal will populate this dataelement with value shown incodes column

2100 NM1 Other SubscriberName



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2100 MIA Inpatient AdjudicationInformation


2100 REF Rendering ProviderInformation


2100 PER Claim Contact

Information

Medi-Cal will not send this

segment

2100 AMT Claim SupplementalInformation


2100 QTY Claim SupplementalInformation Quantity


2110 SVC

2110 SVC011 Product/Service IDQualifier

NUHCN4


2110 DTM Service Date Medi-Cal will not send thissegment

2110 REF Service Identification Medi-Cal will not send this

segment2110 REF Rendering Provider

Information

2110 REF01 ReferenceIdentification Qualifier

1D Medi-Cal will populate this dataelement with value shown in thecodes column

2110 REF Health Care PolicyIdentification


2110 AMT Service SupplementalAmount

2110 AMT01 Amount QualifierCode

TT2

Medi-Cal will populate this dataelement with values shown in thecodes column

2110 QTY Service SupplementalQuantity


2110 LQ Health Care RemarksCode


4 TI Addit ional Information

4.1 Business Scenarios

There is currently no additional information to report in this section.

4.2 Payer-Specific Business Rules and Limi tations


4.3 Frequently Asked Questions



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4.4 Other Resources

https://www.Medi-Cal.ca.gov/signup.asp

http://files.Medi-Cal.ca.gov/pubsdoco/CTM_manual.asp

http://files.Medi-Cal.ca.gov/pubsdoco/Manuals_menu.asp

http://www.wpc-edi.com/

5 TI Change Summary

Version Number Date Reason for Revision Notes/Comments

1.0 7/8/2011 Initial Version

1.1 8/11/2011 ACS and IV&V editscaptured throughoutdocument

1.2 6/14/2012 Removed hyphens in Loop1000A (PER02 and PER04);removed X and Y fromISA04 codes column

Updated commentsfor ISA04

6 Appendix A Communication/ConnectivityInstructions (CCI)

Envelope segments for inbound transaction 005010X279 (270)


Header ISA Interchange Control

Header

Header ISA02 Authorization Information Submitters must enter (left

justified) their three-characterSubmitter (software vendor) ID,

followed by their four-character

Software Version Number,

and with trailing spaces
https://www.medi-cal.ca.gov/signup.asphttp://files.medi-cal.ca.gov/pubsdoco/CTM_manual.asphttp://files.medi-cal.ca.gov/pubsdoco/Manuals_menu.asphttp://www.wpc-edi.com/http://www.wpc-edi.com/http://www.wpc-edi.com/http://files.medi-cal.ca.gov/pubsdoco/Manuals_menu.asphttp://files.medi-cal.ca.gov/pubsdoco/CTM_manual.asphttps://www.medi-cal.ca.gov/signup.asp


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ISA03 Security Information

Qualifier

00

01

For Leased-Line and Dial-Up

Medi-Cal expects to receive:

00

For Batch, Medi-Cal expects to

receive:

01

ISA04 Security Information For Leased-Line and Dial-Up:

Required Submitter

PIN/Password, left justified and

with trailing spaces

For Batch: leave blank, PIN is

validated against the Medi-Cal

website login password

ISA05 ZZ For Leased-Line and Dial-Up:

Use the Provider Number as isin NM109 Receiver Level

For Batch:

Use the Submitter ID as usedwhen you logged onto theMedi-Cal website

ISA06 Interchange Sender ID For Leased-Line andDial-Up:

NPI or Medi-CalProvider number

For all types of providers, leftjustify and with trailing spaces

For Batch:

Enter the Submitter ID as used

when you logged onto the

Medi-Cal website

ISA07 Interchange ID Qualifier ZZ Medi-Cal expects to receive the

value shown in the codes

column

ISA08 Interchange Receiver ID For Leased-Line and Dial-Up:

610442ACS214, left justify andwith trailing spaces

For Batch:

610442


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ISA14 Acknowledgment

Requested

0

1

For Leased-Line and Dial-UpMedi-Cal expects to receive:

0 No AcknowledgmentRequested

For Batch, Medi-Cal expects toreceive:

1 InterchangeAcknowledgmentRequested

ISA16 Component Element

Separator


~as component separator

Header GS Functional Group Header

Header GS02 Application Sender's Code For Leased-Line and Dial-UpMedi-Cal expects to receive:

NPI or Medi-Cal providernumber

For Batch, Medi-Cal expects toreceive:

Submitter ID

GS03 Application Receiver's

Code


610442

Envelope segments for outbound transaction 005010X217 (271)



Header

Header ISA01 AuthorizationInformation

Qualifier

00 Medi-Cal will populate this data

element with:

00 No Authorization

Information Present

ISA03 Security Information

Qualifier

00 Medi-Cal will populate this data

element with the value shown in

the codes column

ISA05 ZZ Medi-Cal will populate this dataelement with the value shown in

the codes column

ISA06 Interchange Sender ID Medi-Cal will populate this data

element with:

610442


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ISA07 Interchange ID Qualifier ZZ Medi-Cal will populate this data

element with the value shown in

the codes column

ISA08 Interchange Receiver ID Medi-Cal will populate this dataelement with:

For Leased-Line andDial-Up:

Medi-Cal Provider Number orNPI

For Batch:

Sender ID

ISA13 Interchange Control

Number

000000001 Medi-Cal will populate this dataelement with the value shown inthe codes column

ISA14 AcknowledgmentRequested

0 Medi-Cal will populate this dataelement with the value shown inthe codes column


Header GS02 Application Sender's

Code


610442

GS03 Application Receiver's

Code


For Leased-Line andDial-Up:

Medi-Cal Provider Number orNPI

For Batch:

Submitter ID

Envelope segments for inbound transaction 005010X222A1 (837P)



Header

Header ISA04 Media Indicator Medi-Cal will populate this data

element with values X or Y

ISA06 Interchange Sender ID Medi-Cal expects to receive:

Submitter ID


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ISA08 Interchange Receiver ID Medi-Cal expects to receive:

610442


Header GS02 Application Senders Code Medi-Cal expects to receive:

Submitter ID

GS03 Application Receiver Code Medi-Cal expects to receive:

610442


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Envelope segments for inbound transaction 005010X223A2 (837I)



Header

Header ISA04 Media

Indicator

Medi-Cal will populate this data

element with values X or Y

ISA06 Interchange Sender ID Medi-Cal expects to receive:

Submitter ID


610442


GS02 Application Senders

Code


Submitter ID

GS03 Application Receiver

Code


610442




Header

Header ISA06 Interchange Sender ID Medi-Cal expects to receive:

Submitter ID, NPI or

Medi-Cal Provider Number


610442


Header GS02 Application Senders

Code


Submitter ID, NPI or

Medi-Cal Provider Number

GS03 Application Receiver

Code


610442


44/44





Header

Header ISA06 Interchange Sender ID Medi-Cal will populate this

segment with:

Submitter ID

ISA08 Interchange Receiver ID Medi-Cal will populate this

segment with:

610442


Header GS02 Application Senders Code Medi-Cal will populate this

segment with:

Submitter ID

GS03 Application Receiver Code Medi-Cal will populate this

segment with:

610442

Envelope segments for outbound transaction 005010X221A1 (835)



Header

Header ISA06 Interchange Sender ID Medi-Cal will populate this

segment with:

Submitter ID

ISA08 Interchange Receiver ID Medi-Cal will populate this

segment with:

610442


Header GS02 Application Senders Code Medi-Cal will populate this

segment with:

Submitter ID

GS03 Application Receiver Code Medi-Cal will populate this

segment with:

610442

Documents

20635 1 X12 Companion GuideV1.2