fmmis 5010 835 companion guide€¦ · fmmis 835 health care claim payment and remittance advice...

FMMIS 835 Health Care Claim

Payment and Remittance Advice

Companion Guide

005010X221A1 Version 2.3

June 28, 2016

Florida Medicaid Management Information System FiscalAgent Services Project

Disclaimer: The information contained in this Companion Guide is subject to change. EDI submit-

ters are advised to check the EDI-Submission Information page on the “My Medicaid Florida” Web

site (http://www.mymedicaid-florida.com/) for the latest updates after go-live of version 5010.

http://www.mymedicaid-florida.com/

FMMIS 835 Health Care Claim Payment and Remittance Advice Companion Guide

Version 2.3 – June 28, 2016

ii

Document Information Page

Required Information Definition

Document: FMMIS 835 Health Care Claim Payment and Remittance

Advice Companion Guide

Document ID:

Version: Version 2.3

QA Reviewer:

QA Review Approval Date:

Location: Located in iTRACE

Owner: Daniel Gray

Author Daniel Gray ([email protected])

Approved by:

Approval Date:

Note: The controlled master of this document is available online via iTRACE.



3

Disclosure Statement

The Agency for Health Care Administration (AHCA) is committed to maintaining the integrity

and security of health care data in accordance with applicable laws and regulations. This

document is intended to serve as a companion guide to the corresponding ASC X12N /

005010X221A1 Health Care Claim Payment and Remittance Advice (835).

This document can be reproduced and/or distributed; however, its ownership by Florida Medicaid

must be acknowledged and the contents must not be modified.



4

Preface

This companion guide to the 005010 ASC X12N Implementation Guide and associated errata and

addenda adopted under HIPAA clarifies and specifies the data content when exchanging

electronically with Florida Medicaid. Transmissions based on this companion guide, used in

tandem with the 005010 ASC X12N Implementation Guides, are compliant with both ASC X12

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.



TOC-1

Table of Contents

1 Introduction ...................................................................................................................... 1-1

1.1 Scope ................................................................................................................. 1-1

1.2 Overview ........................................................................................................... 1-1

1.3 References ......................................................................................................... 1-1

1.4 Additional Information ...................................................................................... 1-1

2 Getting Started ................................................................................................................. 2-1

2.1 Working with Florida Medicaid ........................................................................ 2-1

2.2 Trading Partner Registration ............................................................................. 2-1

2.3 Certification and Testing Overview .................................................................. 2-1

3 Testing with the Payer ..................................................................................................... 3-1

4 Connectivity with the Payer/Communications .............................................................. 4-1

4.1 Process Flow ..................................................................................................... 4-1

4.2 Transmission Administrative Procedures .......................................................... 4-1

4.3 Re-Transmission Procedure .............................................................................. 4-2

4.4 Communication Protocol Specifications ........................................................... 4-2

4.5 Passwords .......................................................................................................... 4-2

5 Contact Information ........................................................................................................ 5-1

5.1 EDI Customer Service ....................................................................................... 5-1

5.2 EDI Technical Assistance ................................................................................. 5-1

5.3 Provider Service Number .................................................................................. 5-1

5.4 Relevant Websites ............................................................................................. 5-1

6 Control Segments / Envelope Definitions for 835 Transactions ................................... 6-1

6.1 ISA - Interchange Control Header Segment ...................................................... 6-1

6.2 IEA - Interchange Control Trailer Segment ...................................................... 6-2

6.3 GS - Functional Group Header .......................................................................... 6-3

6.4 GE - Functional Group Trailer .......................................................................... 6-4

6.5 ST - Transaction Set Header ............................................................................. 6-4

6.6 SE – Transaction Set Trailer ............................................................................. 6-5

7 Florida Medicaid Business Rules and Limitations - 835 Transactions ........................ 7-1

7.1 Business Rules .................................................................................................. 7-1

7.2 Valid Delimiters ................................................................................................ 7-2

8 Acknowledgements and/or Reports ................................................................................ 8-1

8.1 Report Inventory ............................................................................................... 8-1

9 Trading Partner Agreements .......................................................................................... 9-1

9.1 Trading Partners ................................................................................................ 9-1

10 835 Remittance Advice – Transaction Specific Information .................................... 10-1

11 Appendices .................................................................................................................... 11-1



TOC-2

Appendix 1 Implementation Checklist .............................................................................. 1-1

Appendix 2 Business Scenarios .......................................................................................... 2-1

Appendix 3 Transmission Examples .................................................................................. 3-1

Appendix 4 Frequently Asked Questions .......................................................................... 4-1

Appendix 5 Change Summary ........................................................................................... 5-1



1 - 1

1 Introduction

The Health Insurance Portability and Accountability Act (HIPAA), which was passed in 1996,

requires all insurance carriers and payers in the United States to comply with a set of standards

adopted by the Secretary of Health and Human Services. These standards were created to assure

an efficient and secure exchange of electronic health information.

1.1 Scope

This is the technical report document for the ANSI ASC X12N 835 Health Care Claim Payment

and Remittance Advice. This document provides a definitive statement of what trading partners

must be able to support in this version of the 835. This document is intended to be compliant with

the data standards set out by the Health Insurance Portability and Accountability Act of 1996

(HIPAA) and its associated rules.

All required segments within the 835 transactions must always be sent by the payer and received

by the provider or representative HMO plan. Optional information is sent when it is necessary for

processing. Segments that are conditional are only sent when special criteria are met.

This companion guide supplements, but does not replace, the information contained within the

X12N health care implementation guides..

1.2 Overview

This companion guide has been created to assist providers and plan representatives in interpreting

835 files transmitted by Florida Medicaid. These transactions conform to implementation

standards and Florida Medicaid's processing rules. This guide should be used to supplement the

instructions pertaining to the Health Care Claim Payment and Remittance Advice (835) as stated

by the X12 Standards for Electronic Data, Addenda A1 (V. 005010X221A1).

1.3 References

Washington Publishing Company (WPC) - http://www.wpc-edi.com - WPC maintains and

publishes the X12N Implementation Guides containing the standards for electronic health care

transactions.

1.4 Additional Information

The intended audience for this document is the technical and operational staff responsible for

generating, receiving, and reviewing electronic health care transactions.

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



1 - 2

This page intentionally left blank.



2 - 1

2 Getting Started

This section contains Payer-specific business rules and limitations for the 835 remittance advice

transaction.

2.1 Working with Florida Medicaid

This section describes how to interact with Florida Medicaid's Electronic Data Interchange (EDI)

Department.

Florida Medicaid Trading Partners should exchange electronic health care transactions with

Florida Medicaid via the Web Portal or the Safe Harbor connection.

After establishing a transmission method and completing required documentation, each Trading

Partner must successfully complete testing. Additional information is provided in the next section

of this companion guide. After successful completion of testing, production transactions may be

exchanged.

2.2 Trading Partner Registration

To register as a Trading Partner with Florida Medicaid, visit the enrollment section of the public

information section of the Florida Medicaid website at http://www.mymedicaid-florida.com to

obtain and complete the Electronic Data Interchange (EDI) Agreement.

Clearinghouses wishing to register as billing agent providers with Medicaid must also download

and complete the Clearinghouse Provider Enrollment Application.

If there are questions regarding the EDI agreement, please contact our EDI Operations department

at 1-866-586-0961 or email your inquiries to [email protected].

Any questions regarding the Clearinghouse Provider Enrollment Application should be directed

to Florida Medicaid's Enrollment department at 1-800-289-7799, option 4.

2.3 Certification and Testing Overview

All entities who wish to submit electronic transactions to Florida Medicaid in the HIPAA

standard ASC X12 5010 format and receive any corresponding EDI responses must complete

testing to ensure that their connections, systems and software can and will produce data that can

be processed by Florida Medicaid.


mailto:[email protected]



2 - 2

This page left intentionally blank.



3 - 1

3 Testing with the Payer

All submitters wishing to test their electronic transactions before submitting production files to

Florida Medicaid are required to create an account on the EDIFECS Ramp Manager site used for

this purpose: https://sites.edifecs.com/index.jsp?flmedicaid.

The Ramp Manager site contains tools to test all 5010 X12 transaction types accepted by Florida

Medicaid and should be used to diagnose any issues that would cause submitted electronic files to

reject based on front-end (TA1/997 response) error checking.

https://sites.edifecs.com/index.jsp?flmedicaid



3 - 2




4 - 1

4 Connectivity with the Payer/Communications

4.1 Process Flow

4.2 Transmission Administrative Procedures

HP supports several types of data transport depending upon the Trading Partner's need. Providers

and their representatives can submit and receive data via the Web Portal and Value Added

Networks (VANs) or Switch Vendors for interactive transactions.

1. Web Portal: Transaction files are uploaded/downloaded in the Trade Files menu on the secure

Web Portal.

2. VANs or Switch Vendors: These typically support interactive transactions through a

dedicated connection to the fiscal agent. VANs sign a contract with the State and have unique,

VAN specific communication arrangements with the fiscal agent. A list of approved vendors

is listed on the fiscal agent Web site.

Detailed information to assist with EDI related processes are available on the Provider Public

Web site at http://www.mymedicaid-florida.com. Information available includes:

1. Trading Partner Testing Procedures (Ramp Manager) for all new Trading Partners, or Trading

Partners adding a new transaction; and

2. Web Upload/Download instructions for submitters uploading/downloading via the secure

Web Portal.




4 - 2

4.3 Re-Transmission Procedure

This section is currently not applicable to the 835 Health Care Claim Payment and Remittance

Advice file.

4.4 Communication Protocol Specifications

Florida Medicaid transmits 835 transactions via the following methods:

1. Secure Web Portal;

2. Secure File Transfer Protocol (SFTP) for approved submitters; and

3. The Safe Harbor Connection.

4.5 Passwords

All submitters wishing to receive 835 transactions from Florida Medicaid must have a presence in

the secure Web Portal. Providers, including Billing Agent providers, should have been assigned a

username and password to access the system.

If you need to obtain a secure Web Portal account for your provider ID, contact Florida

Medicaid's Account support group at 1-800-289-7799, option 5.

Those wishing to use SFTP must be approved by AHCA and will be assigned a username and

password to the secure FTP server. All inquiries regarding SFTP access should be directed to the

EDI Operations team ([email protected]).




5 - 1

5 Contact Information

5.1 EDI Customer Service

All EDI customer service inquiries may be directed to the Florida Medicaid EDI Operations

Team:

Phone: 1-866-586-0961

Email: [email protected]

5.2 EDI Technical Assistance

All EDI related technical questions should be directed to the EDI Operations team:

Phone: 1-866-586-0961

Email: [email protected]

If the Operations team is unable to rectify the issue, it will be directed to the proper team for

research and diagnosis.

5.3 Provider Service Number

For recipient eligibility information, claim status, billing and payment inquiries, and questions

about the Florida Medicaid secure Web Portal, including Direct Data Entry (DDE) claims, please

contact Florida Medicaid's Provider Services division at 1-800-289-7799, option 7.

5.4 Relevant Websites

Florida Medicaid (public site) - http://www.mymedicaid-florida.com/

Florida's Agency for Health Care Administration - http://ahca.myflorida.com/

Washington Publishing Company - http://www.wpc-edi.com/




http://ahca.myflorida.com/




5 - 2




6 - 1

6 Control Segments / Envelope Definitions for 835 Transactions

Note the page numbers listed below in each of the tables represent the corresponding page

number in the X12N 835 HIPAA Implementation Guide [835_5010_x221].

6.1 ISA - Interchange Control Header Segment

Communications transport protocol interchange control header segment. This segment within the

X12N implementation guide identifies the start of an interchange of zero or more functional

groups and interchange-related control segments. This segment may be thought of traditionally as

the file header record.

835 Health Care Claim Payment and Remittance Advice

Page Loop ID Reference Name Code/

Value Notes/Comments

C.3 N/A ISA Interchange Control Header

Segment

C.4 N/A ISA01 Authorization Information

Qualifier

00 '00' – No Authorization Information Present

C.4 N/A ISA02 Authorization Information

[space fill]

C.4 N/A ISA03 Security Information

Qualifier

00 '00' – No Security Information Present

C.4 N/A ISA04 Security

Information [space fill]

C.4 N/A ISA05 Interchange ID Qualifier

ZZ 'ZZ' – Mutually Defined

X12N EDI Control Segments

ISA - Interchange Control Header Segment IEA - Interchange Control Trailer Segment

GS - Functional Group Header Segment

GE - Functional Group Trailer Segment

ST - Transaction Set Header

SE - Transaction Set Trailer

TA1 - Interchange Acknowledgement



6 - 2




C.4 N/A ISA06 Interchange Sender ID

77027 ‘77027’ left justified and space filled. Florida Medicaid Sender

ID.

C.5 N/A ISA07 Interchange ID Qualifier

ZZ 'ZZ' – Mutually Defined

C.5 N/A ISA08 Interchange Receiver ID

‘Trading Partner ID’ supplied by FL Medicaid.

C.5 N/A ISA09 Interchange Date The date format is YYMMDD.

C.5 N/A ISA10 Interchange Time The time format is HHMM.

C.5 N/A ISA11 Repetition

Separator

^ ‘^’

C.5 N/A ISA12 Interchange

Control Version

Number

00501 ‘00501’ – Control Version

Number

C.5 N/A ISA13 Interchange Control Number

Interchange Unique Control Number -

Must be identical to IEA02

C.6 N/A ISA14 Acknowledgeme nt Requested

1, 0 ‘1’ – Acknowledgement Requested

‘0’ – No Acknowledgement

Requested

C.6 N/A ISA15 Usage Indicator P ‘P’ – Production Data

C.6 N/A ISA16 Component Element

Separator

: ‘:’ – Component Element Separator

6.2 IEA - Interchange Control Trailer Segment

Communications transport protocol interchange control trailer segment. This segment within the

X12N implementation guide defines the end of an interchange of zero or more functional groups

and interchange-related control segments. This segment may be thought of traditionally as the file

trailer record.



6 - 3




C.10 N/A IEA Interchange Control Trailer

C.10 N/A IEA01 Number of Included Functional Groups

Number of included Functional Groups

C.10 N/A IEA02 Interchange Control Number.

Must be identical to the value in ISA13

6.3 GS - Functional Group Header

Communications transport protocol functional group header segment. This segment within the

X12N implementation guide indicates the beginning of a functional group and provides control

information concerning the batch of transactions. This segment may be thought of traditionally as

the batch header record.

835 Dental Health Care Claim



C.7 N/A GS Functional Group Header

C.7 N/A GS01 Functional ID Code HP 'HP' – Health Care Claim

Payment/Advice (835)

C.7 N/A GS02 Application Sender’s

Code ‘77027’ left justified and

space filled. Florida

Medicaid Sender ID.

C.7 N/A GS03 Application Receiver’s Code

‘Trading Partner ID’ supplied by Florida

Medicaid, left justified

space filled.

C.8 N/A GS04 Date The date format is

CCYYMMDD.

C.8 N/A GS05 Time The time format is

HHMM.

C.8 N/A GS06 Group Control

Number Group Control Number –

Must be identical to

GE02.

C.8 N/A GS07 Responsible Agency Code

X ‘X’ – Responsible Agency Code



6 - 4

835 Dental Health Care Claim



C.8 N/A GS08 Version/ Release/ Industry Identifier

Code

005010X2 21A1

Version/ Release/ Industry Identifier Code

6.4 GE - Functional Group Trailer

Communications transport protocol functional group trailer segment. This segment within the

X12N implementation guide indicates the end of a functional group and provides control

information concerning the batch of transactions. This segment may be thought of traditionally as

the batch trailer record.


Page Loop ID Reference Name Code/Value Notes/Comments

C.9 N/A GE Functional Group Trailer

C.9 N/A GE01 Number of Transaction Sets

Included

Number of included Transaction Sets

C.9 N/A GE02 Group Control Number

Must be identical to the value in GS06.

6.5 ST - Transaction Set Header

Communications transport protocol transaction set header segment. This segment within the

X12N implementation guide indicates the start of the transaction set and assigns a control number

to the transaction. This segment may be thought of traditionally as the claim header record.



68 N/A ST Transaction Set Header

68 N/A ST01 Transaction Set Identifier Code

835 835 = Health Care Claim Remittance Advice



6 - 5



68 N/A ST02 Transaction Set Control Number

Transaction Control Number

Increment by 1 when

multiple transaction sets

are submitted.

Must be identical to

SE02.

68 N/A ST03 Implementation Convention

Reference

Must be identical to the value in GS08.

6.6 SE – Transaction Set Trailer

Communications transport protocol transaction set trailer. This segment within the X12N

implementation guide indicates the end of the transaction set and provides the count of

transmitted segments [including the beginning (ST) and ending (SE) segments]. This segment

may be thought of traditionally as the claim trailer record.




228 N/A SE Transaction Set

Trailer

228 N/A SE01 Number of

Included

Segments

Total number of segments

included

in Transaction Set

including ST and SE

228 N/A SE02 Transaction Set

Control Number

Must be identical to the value

in

ST02



6 - 6




7 - 1

7 Florida Medicaid Business Rules and Limitations - 835 Transactions

7.1 Business Rules

This section contains Payer-specific business rules and limitations for the 270 Health Care

Eligibility Inquiry transactions.

Subscriber, Insured

The Subscriber refers to the Recipient in the Florida Medicaid Eligibility Verification System.

The Florida Medicaid Eligibility Verification System does not allow for dependents to be enrolled

under a primary subscriber, rather all enrollees/members are primary subscribers within each

program or Managed Care Organization.

Provider Identification

The Provider Identification refers to the National Provider Identifier (NPI) or Medicaid ID

(Providers without an NPI only).

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

implementation of a National Provider Identifier (NPI). Most health care providers must register

with the National Plan and Provider Enumeration System (NPPES) and receive a unique NPI. The

intent of the HIPAA regulations was to require all health plans to convert their claims processing

systems to use only the NPI for claims processing and reporting for providers required to obtain

an NPI. Because of the complexities of this conversion by health care plans and providers, the use

of the NPI has not yet been strictly enforced.

Medicaid claims submitted on and after January 1, 2011, however, have new requirements for the

use of the NPI.

Beginning on January 1, 2011, the NPI is required on all electronic claim transactions and paper

claims from providers who qualify for an NPI. Florida Medicaid still accepts transactions

containing the Provider's Medicaid ID, but any qualifying claims that lack the NPI are denied.

Starting on May 1, 2011, however, Florida Medicaid no longer accepts electronic claim

transactions (837D, 837I, and 837P) containing the Florida Medicaid ID submitted by providers

who qualify for an NPI. Any electronic claims sent by qualifying providers on or after May 1,

2011 that contain the provider's Florida Medicaid Provider ID are denied, even if they also

contain the NPI.

Please note that paper claims are not affected by this change.

For all non-healthcare providers where an NPI is not assigned, the claim must contain the Florida

Medicaid Provider Number with the appropriate loops within the REF segment where REF01

equals G2.



7 - 2

Compliance Checking

Outbound 835 transactions are validated through Strategic National Implementation Process

(SNIP) Level 4.

7.2 Valid Delimiters

The delimiters documented below are used for Florida Medicaid, unless otherwise requested by a

trading partner.

Definition ASCII Decimal Hexadecimal

Segment Separator ~ 126 7E

Element Separator * 42 2A

Compound Element Separator : 58 3A

Repetition Separator ^ 94 5E



8 - 1

8 Acknowledgements and/or Reports

As an outbound payer transaction, there are no applicable acknowledgements for the HIPAA X12

835 file.

8.1 Report Inventory

All providers who submit claims to Florida Medicaid for payment may also view their remittance

advice information by downloading the ICE Remittance Advice, which is generated weekly and

is made available in the REPORTS menu of their secure Web Portal account (https://

home.flmmis.com).

https://home.flmmis.com/





8 - 2




9 - 1

9 Trading Partner Agreements

9.1 Trading Partners

A Trading Partner is defined as any entity (providers, billing services, software vendors,

clearinghouses, etc) that has an agreement with the payer to transmit electronic data files to, or

receive electronic data files from, Florida Medicaid.

For Florida Medicaid's purposes, any provider that transmits their electronic files directly to the

payer (i.e., via the Secure Web Portal) can be considered their own Trading Partner.

To register as a Trading Partner with Florida Medicaid, an entity representative must complete the

EDI agreement available for download from Florida Medicaid's public website and submit it to

the appropriate address.

The EDI agreement specifies which electronic transactions the submitter wishes to be able to

submit and receive from Florida Medicaid.

The agreement also allows Medicaid Providers to assign existing Trading Partners to their profile,

giving these entities the right to submit electronic files to Florida Medicaid on their behalf.

Florida Medicaid EDI Agreement:

http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/EDI%20REGISTRATION/

Electronic%20Data%20Interchange%20Agreement_01102012.pdf.

http://portal.flmmis.com/FLPublic/Portals/0/StaticContent/Public/EDI%20REGISTRATION/Electronic%20Data%20Interchange%20Agreement_01102012.pdf





9 - 2




10 - 1

10 835 Remittance Advice – Transaction Specific Information

This section specifies X12N 835 fields for which Florida Medicaid has specific rules and

requirements.



69 N/A BPR Financial Information

70 N/A BPR01 Transaction Handling Code

I, H ‘I’ – Remittance Information Only

‘H’ – Notification

Only

71 N/A BPR02 Monetary Amount (Total Actual

Provider Payment

Amount)

Check Amount Total payment amount for paid and denied

claims always

contains the correct

total payment amount

for the week.

71 N/A BPR03 Credit/Debit Flag C ‘C’ - Credit

72 N/A BPR04 Payment Method Code

ACH, CHK ‘ACH’ – Automated Clearing house

‘CHK’ - Check

76 N/A BPR16 Date (Check Issue or EFT Effective Date)

Cycle Date

77 N/A TRN Reassociation Trace Number

77 N/A TRN01 Trace Type Code 1 ‘1’ – Current Transaction Trace

Number

77 N/A TRN02 Reference Identification(Check

or EFT Trace

Number)

Check Number or Internal

Trace Number

The RA number is moved to the payment

number when the paid

amount is zero.

78 N/A TRN03 Originating

Company Identifier

(Payer Identifier)

593452939 ‘593452939’ – Florida

Medicaid Tax ID

82 N/A REF Receiver Identification



10 - 2



82 N/A REF01 Reference Identification

Qualifier

EV ‘EV’ – Receiver Identification Number

82 N/A REF02 Reference Identification

Florida Medicaid

Receiver ID

If different than Florida Medicaid

Provider ID

85 N/A DTM Production Date

85 N/A DTM01 Date/Time Qualifier 405 ‘405’ - Production

86 N/A DTM02 Cycle Date Cycle Date

87 1000A N1 Payer Identification

87 1000A N102 Name State of Florida Medicaid

89 1000A N3 Payer Address

89 1000A N301 Address Information Suite 100

90 1000A N4 Payer City, State, Zip Code

90 1000A N401 City Name Tallahassee

91 1000A N402 State or Province Code

FL

91 1000A N403 Postal Code 323093574

102 1000B N1 Payee Identification

103 1000B N103 Identification Code Qualifier

FI, XX FI – Federal Taxpayer’s

Identification Number

XX – Health Care

Financing

Administration

National Provider

Identifier

103 1000B N104 Identification Code If N103 =’FI’ – Federal Tax ID

If N103 =’XX’ – NPI

107 1000B REF Payee Additional

Information



10 - 3



107 1000B REF01 Reference Identification

Qualifier

PQ, TJ ‘PQ’ – Provider Medicaid ID

‘TJ’ – Federal

Taxpayer’s


108 1000B REF02 Reference Identification

(Additional Payee

Identifier)

If REF01 =’PQ’ – Provider Medicaid ID

If REF01 =’TJ’ – Tax

ID

123 2100 CLP Claim Payment Information

123 2100 CLP01 Claim Submitter’s Identifier (Patient

Control Number)

Patient Account

Number

124 2100 CLP02 Claim Status Code 1, 2, 4, 22 ‘1’ – Processed as Primary (Regular

Medicaid Claims)

‘2’ – Processed as

Secondary (Medicare

Crossover Claims)

‘4’ – All Denied

(Regular & Crossover

Claims)

‘22’ - Reversal of a

previous claim

submission

126 2100 CLP06 Claim Filing Indicator Code

MC ‘MC’ - Medicaid

128 2100 CLP11 Diagnosis Related Group (DRG)

Institutional Claims only

129 2100 CAS Claim Adjustment

131-135 2100 CAS02, CAS05,

CAS08,

CAS11,

CAS14,

CAS17

Claim Adjustment Reason Code

Adjustment Reason Codes can be found on

http://www.wpc-

edi.com




10 - 4



132-136 2100 CAS03, CAS06,

CAS09,

CAS12,

CAS15,

CAS18

Monetary Amount (Adjustment

Amount)

Displays the Adjustment (cutback)

Amount.

The X12N 835

contains information

regarding the

difference between the

submitted charge,

(Loop 2100, Segment

CLP03) and the

approved payment

amount, (Loop 2100,

Segment CLP04).

For example: If a

provider bills $750.00

for a procedure that

allows a maximum of

$500.00, $250.00 is

reported as a cutback

amount.

137 2100 NM1 Patient Name

137 2100 NM101 Entity Identifier Code

QC ‘QC’ - Patient

138 2100 NM103 Name Last or Organization Name

Recipient last name as stored on Florida

Medicaid file. If

recipient not found on

file, the value is the

recipient last name

submitted on claim.

138 2100 NM104 Name First Recipient first name as stored on Florida

Medicaid file. If

recipient not found on

file, the value is the

recipient first name

submitted on claim.

139 2100 NM108 Identification Code Qualifier

‘MR’ – Medicaid Recipient




10 - 5



139 2100 NM109 Identification Code Florida Recipient 10- digit Medicaid ID

146 2100 NM1 Service Provider Name


82 “82” – Rendering Provider


XX, MC ‘XX’ – National ProviderIdentification

Number

‘MC’ – Provider

Medicaid ID

149 2100 NM109 Identification Code If NM108 = ’XX’ – NPI ID

If NM108 = ’MC’ –

Medicaid ID

153 2100 NM1 Corrected Priority Payer Name


PR “PR” – Payer


PI ‘PI’ – Payor Identification

154 2100 NM109 Identification Code TPL Carrier Code

159 2100 MIA Inpatient Adjudication

Information

160 2100 MIA01 Quantity (Covered Days or Visits

Count)

Default to ‘0’

Note: Institutional

only

161 2100 MIA04 Monetary Amount (Claim DRG

Amount)

Use this monetary amount for the DRG

dollar amount.

Note: Institutional

only



10 - 6



161 2100 MIA05 Reference Identification

(Remark Code)

HIPAA Remark Code for Inpatient and

Institutional Regular

and Crossover claims.

Remark Codes can be

found on http://

www.wpc-

edi.com

164 2100 MIA20 Reference identification

(Remark Code)

HIPAA Remark Code for Inpatient and

Institutional Regular

and Crossover claims

(2)

166 2100 MOA Outpatient Adjudication

Information

167 2100 MOA03 Reference Identification

(Remark Code)

HIPAA Remark Code for Outpatient/

Professional

Crossover claims.

Remark Codes can be

found on http://

www.wpc-

edi.com

167 2100 MOA04 Reference Identification

(Remark Code)

HIPAA Remark Code for Outpatient/

Professional

Crossover claims (2)

169 2100 REF Other Claim Related Identification

169 2100 REF01 Reference Identification Code

(Other Claim Related

Identifier)

EA ‘EA’ – Medical Record ID Number

170 2100 REF02 Reference Identification (Other

Claim Related

Identifier)

Medical Record ID Number as submitted

on claim.









10 - 7





Identifier)

SY ‘SY’ – Social Security Number


Claim Related

Identifier)

Recipient SSN



Identifier)

9C ‘9C’ – Adjusted Repriced Claim

Reference


Claim Related

Identifier)

Adjusted ICN



Identifier)

F8 ‘F8’ – Original Reference Number


Claim Related

Identifier)

Duplicate ICN

173 2100 DTM Statement From or To Date

174 2100 DTM01 Date/Time Qualifier 232, 233 ‘232’ – Claim Statement Period Start

‘233’ – Claim

Statement Period End

174 2100 DTM02 Claim Date If DTM=’232’ value contains Start Date.

If DTM=’233’ value

contain End Date.

If invalid date

received on original

claim, value contains

default date of

19000101.



10 - 8



175 2100 DTM Coverage Expiration Date

175 2100 DTM01 Date/Time Qualifier 036 ‘036’ – Expiration

175 2100 DTM02 Date If DTM=’036’ value contains Recipient’s

last year and month of

eligibility.

184 2100 QTY Claim Supplemental Information Quantity

184 2100 QTY01 Quantity Qualifier CA “CA” – Covered (Actual)

185 2100 QTY02 Quantity Covered Days

Note: Institutional

only.

186 2110 SVC Service Payment Information

187 2110 SVC01-1 Product/Service ID Qualifier

AD, HC, N4, NU

“AD” – American Dental Association

Codes

“HC” – Health Care

Financing

Administration

“N4” (Encounters

Only) – National

Drug Code (NDC),

Universal Product

Code (UPC)

“NU” – National

Uniform Billing

Committee (NUBC)

UB92

188-189 2110 SVC01-3 - SVC01-6

Procedure Modifier Up to four (4) Procedure Code

Modifiers per Detail.



10 - 9




AD, HC, N4, NU

“AD” – American Dental Association

Codes

“HC” – Health Care

Financing

Administration

“N4” – National Drug

Code (NDC)

“NU” – National

Uniform Billing

Committee (NUBC)

UB92


Reports original code billed on claim.

192 2110 SVC06-3 - SVC06-6

Procedure Modifier Up to four (4) Procedure Code

Modifiers per Detail.

193 2110 SVC07 Quantity (Original Units of Service

Count)

Units of Service are reported here if

different than the

original billed units.

196 2110 CAS Service Adjustment

198-203 2110 CAS02, CAS05,

CAS08,

CAS11,

CAS14,

CAS17

Claim Adjustment Reason Code

Adjustment Reason Codes can be found on

http://www.wpc-

edi.com

199-203 2110 CAS03, CAS06,

CAS09,

CAS12,

CAS15,

CAS18

Monetary Amount (Adjustment

Amount)

Difference between the line billed charged

and line Medicaid

paid amount.

206 2110 REF Line Item Control Number

206 2110 REF0 1 Reference Identification

6R '6R' - Provider Control Number




10 - 10



206 REF02 Reference Identification

Original Line Item Control Number from

835-claim line

207 2110 REF Rendering Provider Information

207 2110 REF01 Reference Identification

Qualifier

1D, HPI

‘1D’ – Medicaid Provider Number

‘HPI’ - NPI

208 2110 REF02 Reference Identification

If REF01=’1D’ – Florida Medicaid

Provider ID

If REF01=’HPI’ -

NPI

211 2110 AMT Service Supplemental

Amount

211 2110 AMT01 Amount Qualifier Code

B6, ZK, ZL, ZM, ZN, ZO

"B6" - Allowed Actual

"ZK" - IGT Payment

Amount

"ZL" - DRG Base

Payment Amount

"ZM" - Outlier

Payment Amount

"ZN" - Self-Funded

IGT Payment

"ZO" - Maximum

Policy Adjuster

212 2110 AMT02 Monetary Amount Quality

Amount

213 2110 QTY Service Supplemental

213 2110 QTY01 Quantity Qualifier ZO Maximum Policy Adjuster. Present only

if AMT01 = ZO

213 2110 QTY02 Quantity Quantity Amount

215 2110 LQ Health Care Remark Codes



10 - 11



215 2110 LQ01 Code List Qualifier Code

HE “HE” – Claim Payment Remark

Codes

216 2110 LQ02 Industry Code (Remark Code)

Remark Codes if needed to

communicate

additional information

about the denial or

adjustment of a claim

or service line that

cannot be thoroughly

explained by a Claim

Adjustment Reason

Code.

Remark Codes can be

found on http://

www.wpc-

edi.com

217 Summary PLB Provider Adjustment

218 Summary PLB01 Reference Identification

(Provider Identifier)

FL Medicaid Provider ID or

NPI

218 Summary PLB02 Date (Fiscal Period Date)

Accounts Receivable Financial Cost

Settlement Fiscal Year

End Date OR Set-up

date for A/R

transaction.

For a Negative Net

Payment Amount this

field contains the

Remittance Date.






10 - 12



223-227 Summary PLB04, PLB06,

PLB08,

PLB10,

PLB12,

PLB14

Monetary Amount (Provider

Adjustment

Amount)

The monetary amount for the adjustment to

the preceding

adjustment code.

Amount of increase/

decrease OR amount

received/ recouped

OR

Negative NetPayment

Amount.

Note: As required for

HIPAA compliance,

only amounts that

affect the remittance

check amount is

reported in the PLB

segment.



11 - 1

Appendices

This following sections contain these appendices:

Appendix 1 - Implementation Checklist;

Appendix 2 - Business Scenarios;

Appendix 3 - Transmission Examples;

Appendix 4 - Frequently Asked Questions; and

Appendix 5 - Change Summary.



11 - 2




Appendix_1 - 1

Appendix 1. Implementation Checklist

This appendix contains all necessary steps for going live with Florida Medicaid.

1. Call the EDI Help Desk with any questions at the toll-free number.

2. Check the MEUPS website for the latest updates regarding our system implementation.

3. Confirm you have a Web Portal User Name and/or Provider ID.

4. Make the appropriate changes to your systems/business processes to support the updated

companion guides:

a. If you use third party software, work with your software vendor to have the appropriate

software installed.

b. If testing system-to-system interface, the Trading Partner or provider must work with your

software vendor to have the appropriate software installed at their site(s) prior to perform-

ing testing with Florida Medicaid.

5. Identify the functions you will be testing:

a. Health Care Eligibility/Benefit Inquiry and Information Response (270/271);

b. Health Care Claim Status Request and Response (276/277/277U);

c. Health Care Premium Payment (820);

d. Health Care Benefit Enrollment and Maintenance (834);

e. Health Care Payment/Advice (835);

f. Health Care Claim: Institutional (837I);

g. Health Care Claim: Dental (837D);

h. Health Care Claim: Professional (837P); and

i. Crossover/COBA Claims.

6. Confirm that you have reported all the NPIs you will use for testing by validating them with

Florida Medicaid. If you have multiple Florida Medicaid provider IDs associated to one NPI

and/or taxonomy code, ensure your claim(s) successfully pay to your correct Provider ID.

7. Note: If the entity testing is a billing intermediary or software vendor, they should use the

provider's identifier on the test transaction.

8. When submitting test files, make sure the members/claims you submit are representative of

the type of service(s) you provide to Florida Medicaid members.

9. Schedule a tentative week for the initial test.

10. Confirm the email/phone number of the testing contact and confirm that the person you are

speaking with is the primary contact for testing purposes.



Appendix_1 - 2




Appendix_2 - 1

Appendix 2. Business Scenarios


Advice file.



Appendix_2 - 2




Appendix_3 - 1

Appendix 3. Transmission Examples


Advice file.



Appendix_3 - 2




Appendix_4 - 1

Appendix 4. Frequently Asked Questions

This appendix contains a compilation of questions and answers relative to Florida Medicaid and

its providers. A typical question would involve a discussion about code sets and their effective

dates.

Note: At the time of publication, there were no frequently asked questions.



Appendix_4 - 2




Appendix_5 - 1

Appendix 5. Change Summary

Document

Version # Modified Date Modified By Section, Page(s) and Text Revised

Version 1.0 1/13/2011 Carl Bunche Creation of document - 1st Draft

Version 1.1 3/17/2011 Carl Bunche Updated version number of transaction from “005010X221” to “005010X221A1”.

This change impacted the following data

elements: • GS08; and

• ST03.

Version 1.2 6/29/2011 Reid O’Kelley Removed references to Remote Access Server (RAS).

Version 1.2 7/7/2011 Daniel Gray The following changes were made: • Updated page number references to the 5010

Implementation Guide; and

• Updated New/updated policy information

regarding NPI in Section 8.

Version 1.3 12/20/2011 Daniel Gray The following changes were made: • Corrected typo in Change Log for “REF01” on

page iv;

• Removed reference to 277U from

“Transmission Responses” on page 3-1;

• Removed “if the payee is a non-healthcare

provider” from item 2 of “X12N 835;

• Business Scenarios/Special Considerations on

page 6-1; and

• Corrected field descriptions for erroneous data

elements in “REF01” on page 7-10.

Version 1.4 7/26/2013 Daniel Gray The following changes were made: • Added new values for AMT01 in the 2110 loop

to cover new DRG payment information on page

7-9; and

• Added QTY segment information to the 2110

loop on page 7-10.

Version 2.0 10/21/2013 Daniel Gray The following changes were made: • Made changes to comply with new CAQH/

CORE rules document format.

Version 2.1 2/10/2014 Daniel Gray The following changes were made: • Added new value to CLP02 on page 10-3.

Version 2.2 2/19/2016 Molly Marotta The following changes were made: Edited 4.1 Process Flow Chart on page

13.



Appendix_5 - 1

Version 2.3 6/28/2016 Molly Marotta The following changes were made: Updated N4 code in SVC01-1



Appendix_5 - 2


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