Scope of this Chapter

10.3 - Scope of this Chapter (Rev. 13105; Issued- 04-10-25; Effective: 05-12-25; Implementation: 05-12-25) This chapter will provide an overall description of EDI operations, requirements, roles and responsibilities for Medicare FFS. Medicare FFS is utilizing the following EDI transactions: Transactions (Required Under HIPAA Unless Otherwise Noted) Current Version Short Reference ASC X12 Health Care Eligibility Benefit Inquiry and Response (270/271) 005010X279A1 ASC X12 270/271 eligibility transaction ASC X12 Health Care Claim: Professional (837) 005010X222A1 ASC X12 837 professional claim ASC X12 Health Care Claim: Institutional (837) 005010X223A2 ASC X12 837 institutional claim ASC X12 Health Care Claim: Dental (837) 005010X224A2 ASC X12 837 dental claim ASC X12 Interchange Acknowledgment, TA1(not required under HIPAA) 005010X231A1 ASC X12 TA1 interchange acknowledgment ASC X12-Implementation Acknowledgment For Health Care Insurance (999) (not required under HIPAA) 005010X231A1 ASC X12 999 implementation acknowledgment ASC X12 Health Care Claim Payment/Advice (835) 005010X221A1 ASC X12 835 remittance advice ASC X12 Health Care Claim Status Request and Response (276/277) 005010X212 ASC X12 276/277 claim status; ASC X12 276/277 claim status request and response; ASC X12 276 claim status request; ASC X12 277 claim status response Transactions (Required Under HIPAA Unless Otherwise Noted) Current Version Short Reference ASC X12 Health Care Claim Acknowledgment (277) (not required under HIPAA) 005010X214 ASC X12 277CA claim acknowledgment Telecommunication Standard, National Council for Prescription Drug Programs D.0 Depending upon context: NCPDP claim; NCPDP transaction; other functional NCPDP designation Batch Standard, National Council for Prescription Drug Programs 1.2 Depending upon context: NCPDP claim; NCPDP batch transaction; NCPDP transaction; other functional NCPDP designation These administrative transactions require detailed instructions and specifications. General instructions for the institutional and professional claim transactions, the NCPDP transaction, as well as the error handling/acknowledgment transactions are provided within this chapter. All other transactions have separate chapters dedicated to them. The following IOM Publication 100-04, chapters provide more specific information on the remaining electronic transactions. References to these chapters are provided below. They can be accessed by going to http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only- Manuals-IOMs.html and selecting Publication # 100-04. 1. Chapter 22 - ASC X12 835 remittance advice (includes information for paper remittance advices) 2. Chapter 31 -ASC X12 270/271 eligibility benefit inquiry and response and ASC X12 276/277 claim status request and response Two other related IOM chapters include: Chapter 25 -Completing and Processing the Form CMS-1450 Data Set (includes information related to ASC X12 837 institutional claims) Chapter 26 -Completing and Processing the Form CMS-1500 Data Set (related to ASC X12 837 professional claims) Other sources of detailed information for each of these transactions are the Medicare FFS Companion Guide documents and Medicare FFS edits documentation which can be found at http://www.cms.gov/ElectronicBillingEDITrans/.