Current through Reg. 49, No. 38; September 20, 2024
(a) A medical
EDI transmission shall not exceed a file size of 1.5 megabytes. A transaction
set shall not contain more than 100 medical EDI records in a claimant
hierarchical loop.
(b) Insurance
carriers shall submit medical EDI transactions using Secure File Transfer
Protocol (SFTP). All alphabetic characters used in the SFTP file name must be
lower case and the file must be compressed/zipped. Files that do not comply
with these requirements or the naming convention may be rejected and placed in
appropriate failure folders. Insurance carriers must monitor these folders for
file failures and make corrections in accordance with §
134.804(e)
of this title (relating to Reporting Requirements).
(c) SFTP files must comply with the following
naming convention:
(1) Two digit alphanumeric
state indicator of 'tx';
(2) Nine
digit trading partner Federal Employer Identification Number (FEIN);
(3) Nine digit trading partner postal
code;
(4) Nine digit insurance
carrier FEIN or 'xxxxxxxxx' if the file contains medical EDI transactions from
different insurance carriers;
(5)
Three digit record type '837';
(6)
One character Test/Production indicator ('t' or 'p');
(7) Eight digit date file sent
'CCYYMMDD';
(8) Six digit time file
sent 'HHMMSS';
(9) One character
standard extension delimiter of '.'; and
(10) Three digit alphanumeric standard file
extension of 'zip' or 'txt'.
(d) The transaction types accepted by the
division include '00' original, '01' cancel, and '05' replacement.
(e) Insurance carriers are required to use
the following delimiters:
(1) Date Element
Separator--'*' asterisk;
(2)
Sub-element Separator--':' colon; and
(3) Segment Terminator--'~' tilde.
(f) In addition to the
requirements adopted under §
134.803 of
this title (relating to Reporting Standards), state reporting of medical EDI
transactions shall comply with the following formatting requirements:
(1) Loop 2400 Service Line Information must
not contain more than one type of service. Only one of the following data
segments may be contained in an iteration of this loop: SV1 Professional
Service, SV2 Institutional Service, SV3 Dental Service or SV4 Pharmacy
Service.
(2) When reporting
compound medications, Loop 2400 Service Line Information SV4 Pharmacy Drug
Service must include a separate line for each reimbursable component of the
compound medication. The same prescription number for each reimbursable
component of the compound medication, including the compounding fee, must be
reported. The compounding fee must be reported using a default NDC number equal
to '99999999999' as a separate service line.
(3) When reporting pharmacy medical EDI
records, the following data element definition clarifications apply:
(A) DN501 Total Charge Per Bill is the total
amount charged by the pharmacy or pharmacy processing agent;
(B) DN511 Date Insurer Received Bill is the
date the insurance carrier received the bill;
(C) DN512 Date Insurer Paid Bill is the date
the insurance carrier paid the pharmacy or pharmacy processing agent;
(D) DN638 Rendering Bill Provider Last/Group
Name is the name of the dispensing pharmacy;
(E) DN690 Referring Provider Last/Group Name
is the last name of the prescribing doctor; and
(F) DN691 Referring Provider First Name is
the first name of the prescribing doctor.
(4) When ICD-10-CM and ICD-10-PCS codes are
contained on the medical bill, the insurance carrier must report these codes in
the associated ICD-9-CM data elements using the ICD-9-CM code
qualifiers.
(5) If the injured
employee's social security number is unknown, it must be reported in accordance
with §
102.8(a)(1)
of this title (relating to Information Requested on Written Communications to
the Division).
(6) The DN53 data
element must be reported on all medical EDI records.
(7) The provider agreement code must be
reported on all medical EDI records, must not be reported with the value of
"Y", and must only contain one of the following values:
(A) "H" for services performed within a
Certified Workers' Compensation Health Care Network;
(B) "P" for services performed under a
contractual fee arrangement, excluding services performed within a certified
network; or
(C) "N" to indicate no
contractual fee arrangement for services performed.
(8) When an insurance carrier calculated a
reimbursement amount by applying the most recently adopted and effective
Medicare Inpatient Prospective Payment System (IPPS) as required in §
134.404
of this title (relating to Hospital Facility Fee Guideline--Inpatient), the
DN515 (Contract Type Code) must be reported as "01" and the valid Diagnosis
Related Group Code for DN518 must be reported.
(9) On a professional medical bill, an
insurance carrier shall only report up to four (4) diagnosis codes on each
medical EDI record.
(10) On a
professional medical bill, an insurance carrier shall only report to the
Division up to four diagnosis code pointers and those pointers must be reported
numerically. If a professional medical bill containing more than four diagnosis
pointers is reported to the insurance carrier, each diagnosis pointer after the
first four shall be reported to the Division with the value of "1."
(g) This section is effective
September 1, 2015.
