Section 2908.40  Formats for Electronic Medical Bill Processing

a)         For electronic transactions, the following electronic medical bill processing standards shall be used:

1)         Billing:

A)        Professional Billing –

The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Professional (837), May 2006, ASC X12, 005010X222 (no later amendments or editions); and Type 3 Errata to Health Care Claim: Professional (837), June 2010, ASC X12, 005010X222A1 (no later amendments or editions);

B)        Institutional/Hospital Billing –

i)          The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Institutional (837), June 2010, ASC X12N/005010X223 (no later amendments or editions);

ii)         Type 1 Errata to Health Care Claim: Institutional (837), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, October 2007, ASC X12N/005010X223A1 (no later amendments or editions); and

iii)        Type 3 Errata to Health Care Claim: Institutional (837), June 2010, ASC X12, 005010X223A2 (no later amendments or editions);

C)        Dental Billing –

i)          The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Dental (837), June 2010, ASC X12N/005010X224 (no later amendments or editions);

ii)         Type 1 Errata to Health Care Claim: Dental (837), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, October 2007, ASC X12N/005010X224A1 (no later amendments or editions); and

iii)        Type 3 Errata to Health Care Claim: Dental (837), June 2010, ASC X12, 005010X224A2 (no later amendments or editions);

D)        Retail Pharmacy Billing –

i)          The Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2007, National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260, July 2012 (no later amendments or editions); and

ii)         The Batch Standard Batch Implementation Guide, Version 1, Release 2 (Version 1.2), January 2006, National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260, July 2012 (no later amendments or editions).

2)         Acknowledgment:

A)        Electronic responses to ASC X12N 837 transactions:

i)          The ASC X12 Standards for Electronic Data Interchange TA1 Interchange Acknowledgment contained in the standards adopted under subsection (a)(1);

ii)         The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Implementation Acknowledgment for Health Care Insurance (999), June 2007, ASC X12N/005010X231 (no later amendments or editions); and

iii)        The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Acknowledgment (277CA), January 2007, ASC X12N/005010X214 (no later amendments or editions);

B)        Electronic responses to NCPDP transactions: the response contained in the standards adopted under subsection (a)(1)(D).

3)         Electronic Remittance Advice (ERA):

The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment/Advice (835), April 2006, ASC X12N/005010X221 (no later amendments or editions); and Type 3 Errata to Health Care Claim Payment/Advice (835), June 2010, ASC X12/005010X221A1 (no later amendments or editions).

4)         ASC X12 Ancillary Formats:

A)        The ASC X12N/005010X213 Request for Additional Information (277) is used to request additional attachments that were not originally submitted with the electronic medical bill.

B)        Health Claim Status Request and Response

The use of the Health Claim Status Request and Response, 005010X213, shall be by mutual agreement.

5)         Documentation submitted with an electronic medical bill in accordance with Section 2908.60(d) (Electronic Documentation): ASC X12N Additional Information to Support a Health Claim or Encounter (275), February 2008, ASC X12/005010X210 (no later amendments or editions).

b)         Insurance carriers and health care providers may exchange electronic data in a nonprescribed format by mutual agreement. All data elements required pursuant to this Part shall be present in a mutually agreed upon format.

c)         The implementation specifications for the ASC X12N and the ASC X12 Standards for Electronic Data Interchange may be obtained from the ASC X12, 7600 Leesburg Pike, Suite 430, Falls Church VA 22043; Telephone (703) 970-4480 and FAX (703) 970-4488. They are also available through the Internet at http://store.x12.org/. A fee is charged for all implementation specifications.

d)         The implementation specifications for the retail pharmacy standards may be obtained from the National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale AZ 85260; Telephone (480) 477-1000 and FAX (480) 767-1042. They are also available through the Internet at http://www.ncpdp.org. A fee is charged for all implementation specifications.

e)         Nothing in this Section prohibits payers and health care providers, through mutual agreement, from using a direct data entry methodology for complying with these requirements, provided the methodology complies with the data content requirements of the adopted formats and this Part.