Receipt Control and Balancing

50.3.2 - Receipt Control and Balancing (Rev. 13105; Issued- 04-10-25; Effective: 05-12-25; Implementation: 05-12-25) Upon receiving an ASC X12 276 claim status request or ASC X12 837 claim (institutional or professional) current standard transaction adopted under HIPAA, the A/B MAC will process the file through their Front End EDI solution, composed of at minimum a COTS translator. The COTS translator creates the appropriate CMS defined flat file, based on transaction type. The CMS defined flat file will include a skeleton Control Record, either a Detail Record (CTRD) or a Resubmission Record (CTRR), for each Interchange Control Header/Interchange Control Trailer (ISA/IEA) present, and the A/B MAC then loads/places this file into the designated folder for the CCEM to pick up and process. The CTRD/CTRR record is placed in the designated transaction outbound folder for the A/B MAC LDC to move via Network Data Mover (NDM) to the EDC. The EDC will run a receipt/control/balancing process upon receipt of a file to ensure that what was sent by the LDC is what the EDC received. Once the EDCs have checked the files, the “Received” portion of the Control Records will be populated, and a copy of the Control Record shall be sent back to the LDC and logged in the Control Record database. If the file balances, the Control Records will be stripped off and the file will be queued up to be pulled into the next processing cycle. If file does not balance, “Received” portion of the Control Records will be populated, and a copy of the Control Record shall be sent back to the LDC and logged in the Control Record database. An alert will be sent to the LDC to indicate there is a problem with a file, and the bad ISA/IEA will be stripped out of the file. Once the LDC has identified and fixed the issues, they resubmit the bad ISA/IEA. The Receipt/Control/Balancing process will also be in place for the outbound ASC X12 835 remittance advice and the ASC X12 277 claim status response. The shared system maintainers (SSMs) will create the appropriate CMS defined flat file, based on transaction type. The CMS defined flat file will include the Control Records. The transactions will be sent to the MAC/CEDI local data center, where they will be passed through the receipt/control/balancing process to ensure if the CMS defined flat file is balanced. During the outbound translation process the A/B MACs shall remove the control records prior to translating the CMS defined flat files to ASC X12 EDI format.