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Issue 2006-05, May 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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2006 Revised American National Standards Institute X12N 837 Institutional Health Care Claim Companion Document
Provider Types Affected
Providers and physicians who bill Medicare fiscal intermediaries (FIs), including regional home health intermediaries (RHHIs), for services
Key Points
- The American National Standards Institute X12N 837 Institutional Health Care Claim Companion Document is being updated to add National Provider Identifier (NPI) and other information.
- This companion document is a set of statements that supplements the X12N 837 Institutional Implementation Guide, and clarifies Medicare contractor expectations regarding data submission, processing, and adjudication.
- It will be available through your Medicare FI or RHHI via their newsletter and Web site. Information will also be provided via listserv communication for those who subscribe to their Medicare FI’s or RHHI’s listserv.
- The information contained in the companion document to the Health Insurance Portability and Accountability Act (HIPAA) X12N 837 institutional claim is intended solely for clarification. It describes specific requirements for processing data in your Medicare FI/RHHI’s system. The information in the companion document is subject to change, and any changes will be communicated to you in your FI’s or RHHI’s provider news bulletin and on their Web site.
- Please note that the companion document supplements, but does not contradict, any requirements in the X12N 837 Institutional Implementation Guide. The descriptions provided in the guide will also indicate whether the specific information is required, optional, or situational (e.g., relevant specifically for RHHIs).
Key Changes to X12N 837 Institutional Implementation Guide
The key changes to the X12N 837 Institutional Implementation Guide described in CR4379 include the following:
- Addition of a new statement indicating “The National Provider Identifier (NPI) must be submitted in the NM109 segment (NM108 = XX)”;
- Revision to the code set statement providing an updated URL for Washington Publishing Company code sets ( http://www.wpc-edi.com/
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- Medicare conversion of all lower-case characters submitted on an inbound 837 file to upper-case and, consequently, only upper-case characters will be sent for coordination of benefits purposes;
- A requirement that all 837 claim data submitted must use the basic character set as defined in the Appendix A of the 837 Institutional Implementation Guide;
- A reminder that Medicare does not require taxonomy codes in order to adjudicate claims, but taxonomy codes will be accepted. However, claims submitted with taxonomy codes that are not valid will be rejected. Valid codes are published at http://www.wpc-edi.com/codes/taxonomy .
- A requirement that all dates submitted on an incoming 837 must be valid calendar dates in the appropriate format based on the respective qualifier or the claim will be rejected;
- Negative values submitted in CLM02 (Total Submitted Charges) may not be processed and may cause claim to be rejected; and
- Addition of a LIN03 statement “The format for National Drug Codes (NDC) is 5-4-2 [11 positions]. Claims that contain NDC codes in any other format will be rejected.”
Background
HIPAA requires that Medicare, and all other health insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of Health and Human Services.
The X12N 837 implementation guides were established as the standards of compliance for submission of claims for all services, supplies, equipment, and health care other than retail pharmacy prescription drug claims.
The implementation guides for each X12 transaction adopted as a HIPAA standard are available electronically at http://www.wpc-edi.com/ . The information in the companion guide may not contradict any other items in the companion document or X12N 837 institutional implementation guide.
Relevant Links
Additional information about electronic transactions and code sets standards can be found at http://www.cms.hhs.gov/TransactionCodeSetsStands/01_Overview.asp#TopOfPage on the CMS Web site.
CR4379 is the official instruction issued to your FI/RHHI regarding changes mentioned in this article. CR4379 may be found by going to http://www.cms.hhs.gov/Transmittals/downloads/R217OTN.pdf  on the CMS Web site.
Please refer to your local FI/RHHI if you have questions about this issue. To find their toll-free phone number, go to http://www.cms.hhs.gov/apps/contacts/ on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM4379
Pub. 100-20, Transmittal# R217OTN, CR# 4379
Related CR Release Date: March 31, 2006
Effective Date: June 29, 2006
Implementation Date: June 29, 2006
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