Ohio Admin. Code 5160-1-20 - Electronic data interchange (EDI) trading partner enrollment and testing
(A)
For purposes of this rule, the following definitions
apply:
(1)
"Covered entity," has the same meaning as in
45
C.F.R. 160.103 (as in effect on October 1,
2018).
(2)
"Electronic data interchange (EDI) transactions" are
transactions developed by standards development organizations recognized by the
federal centers for medicare and medicaid services (CMS) and adopted by the
Ohio department of medicaid (ODM). The different EDI transactions are defined
as follows:
(a)
"American national standards institute (ANSI) X12 820
premium payment" is a transaction used to make a payment or send a remittance
advice.
(b)
"ANSI X12 834 monthly member roster or
enrollment/disenrollment in a health plan" is a transaction used to establish
communication between the sponsor of the insurance product and the
payer.
(c)
"ANSI X12 835 health care claims payment/remittance
advice" or "835 remittance advice" is a transaction used to make a payment or
send an explanation of benefits remittance advice.
(d)
"ANSI X12 837
health care claim" is a transaction used to submit health care claim billing or
encounter information, or both, from providers (institutional, professional, or
dental) of health care services to payers, either directly or via
clearinghouses.
(e)
"ANSI X12 270 eligibility, coverage, or benefit
inquiry" is a transaction used to inquire about the eligibility, benefits or
coverage under a subscriber's health care policy.
(f)
"ANSI X12 271
eligibility, coverage, or benefit information response" is a transaction used
to communicate information about, or changes to, eligibility, benefits, or
coverage.
(g)
"ANSI X12 276 health care claim status request" is a
transaction used to request the status of a health care claim.
(h)
"ANSI X12 277
health care claim status notification" is a transaction used to respond to a
request regarding the status of a health care claim.
(i)
"ANSI X12 278
health care services review information request and response" is a transaction
used to transmit health care service information for the purpose of referral,
certification/authorization, notification, or reporting the outcome of a health
care services review.
(3)
"Trading partner"
is a covered entity that submits, receives, routes, or translates EDI
transactions directly related to the administration or provision of medical
assistance provided under a public assistance program.
(B)
Trading partners submitting EDI transactions.
(1)
Trading partners
must meet the definition of a covered entity as defined in paragraph (A)(1) of
this rule.
(2)
To enroll as a medicaid EDI trading partner with ODM
under the Health Insurance Portability and Accountability Act (HIPAA) of 1996,
and be issued a trading partner number, a covered entity must complete and
submit to ODM the following:
(b)
The ODM 06306
"Designation of an 835 or 834-820 Trading Partner" form (rev. 4/2017). This
form is required only if the trading partner will be receiving the 835
remittance advice on behalf of its clients.
(c)
A trading partner
agreement. Trading partner agreements must be signed by an authorized
representative of the trading partner.
(3)
Once the medicaid
trading partner number is assigned, the trading partner is eligible to submit
claims, claim status inquiries, or eligibility inquiries for the testing
process in accordance with paragraph (C) of this rule.
(C)
Testing requirements.
(1)
To become an
active trading partner with ODM, all trading partners must abide by all ODM
testing requirements as outlined in paragraph (C)(2) and in the "Electronic
Data Interchange Trading Partner Information Guide" (6/27/2017). The
"Electronic Data Interchange Trading Partner Information Guide" is available
at
https://medicaid.ohio.gov.
(2)
The testing
requirements that must be met in addition to the requirements listed in the
"Electronic Data Interchange Trading Partner Information Guide" are as
follows:
(a)
Trading partners are required to submit three files per the
following transaction types that must pass testing: 837 (professional,
institutional and dental), 270 (eligibility) and 276 (claim status
inquiry).
(b)
Trading partners are only required to test the
transaction types that they will be submitting in production.
(c)
Each file must
contain a minimum of fifty claims, claim status inquiries, or eligibility
inquiries.
(d)
All EDI files must completely pass X12 integrity
testing, HIPAA syntax, and HIPAA situation testing. Trading partners are
required to modify their EDI files in accordance with any new federally
mandated HIPAA standards.
(e)
During testing, trading partners may submit one claim
file per day, per 837 transaction (one professional, one institutional, and one
dental) and one eligibility inquiry and one claim status inquiry per
day.
(f)
Test files are considered passing when ninety per cent
of the claims submitted pass the test adjudication process. A ninety per cent
pass rate must be reached for each transaction type tested.
(D)
Trading partners that are not actively submitting and
receiving 837 health care claim transaction sets but who are actively
submitting and receiving 270/271 and 276/277 transaction sets must provide, in
a manner specified by ODM, a report of all providers by national provider
identifier (NPI) that the trading partner represents. The first report is due
at the time of initiating a trading partner agreement with ODM. Subsequent
reports are due quarterly based on the calendar year, no later than January
first, April first, July first and October first.
(E)
Trading partners
shall be responsible for any breach of information and be held fully liable for
any and all costs relating to such a breach.
Replaces: 5160-1-20
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 10/16/2003 (Emer.), 01/01/2004, 11/15/2004, 05/23/2007, 12/11/2011, 07/03/2014
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