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.