Online Direct Data Entry (DDE)

20.1.2 - Online Direct Data Entry (DDE) (Rev. 4260; Issued: 03-22-19; Effective: 04-22-19; Implementation: 04-22-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. The HIPAA uses the term “direct data entry” generically to refer to a type of functionality operated by many different payers under a variety of titles. Within this instruction, the acronym DDE is being used to refer to any type of direct data entry system maintained by contractors, or shared system maintainers, including A/B MAC (A) or (HHH) DDE or equivalent functionality that may have a different title. Although DDE operates online, DDE does not typically operate on a detailed inquiry and response basis. For claim status purposes, data is maintained within an interactive database that providers may access to view screens containing a wide variety of information on their claims. A provider accesses that data by furnishing certain identifying data for security purposes to establish their right to read the data and to specify those claim records the provider wishes to review. The information in this database for specific claims or providers is initiated when a provider enters claim data, and is then updated by a contractor to include subsequent actions taken that affect that claim. DDE was specifically permitted to continue in the HIPAA initial transactions final rule (45 CFR 162.923), with the stipulation that direct data entry is subject to “…the applicable data content and data condition requirements of the standard when conducting the transaction. The health care provider is not required to use the format requirements of the standard." Data content conformity means that the same information permitted or required by the ASC X12 277 claim status response implementation guide must be reported in the claims status screens (the DDE outbound). The DDE outbound may not report a data element for claim status purposes that is not included in the ASC X12 277 claim status response, exceeds the maximum length of the data element in the ASC X12 277 claim status response, does not meet the minimum length for the data element in the ASC X12 277 claim status response, or that does not meet the ASC X12 277 claim status response requirement that the data element be numeric, alpha-numeric, an amount, or meet another characteristic as specified in the ASC X12 277 claim status response. On the inbound, the DDE system can require less information than the ASC X12 276 claim status request, but not more. The inquirer is not required to furnish information in the DDE inquiry that is available by other means to the contractor. Any data element keyed in a DDE system must conform to the requirements. The ASC X12 standard TR3 include data element length and characteristics in their definition of data attributes. Conformity does not mean that a DDE screen that includes claim status information must display each of the data qualifiers or other means of data identification contained in the ASC X12 277 claim status response implementation guide. DDE screens typically identify, explicitly or by context, the type of information being reported in a field, e.g., would identify if a number represents a HCPCS, Medicare beneficiary identifier, amount, grams, date of birth, etc. DDE screens would not be expected to use a qualifier contained in the ASC X12 277 claim status response to identify data type if that is otherwise evident in the design or content of the DDE screen. Shared system maintainers must map the DDE claim status data elements to the ASC X12 276/277 claim status request and response implementation guide to determine if the DDE claim status data elements meet the conformity requirements above. If needed, changes must be made to enable contractor DDE claim status data elements to conform. If a contractor continues to support DDE, it must be offered in addition to batch ASC X12 276/277 claim status request and response, but the contractor must take one of two approaches to assure their claim status data content conforms to the requirements: 1. Eliminate claim status data elements from the DDE screens, unless those data elements are also needed for a purpose other than claim status. For example, if a data element is needed in a DDE screen for claim entry or claim correction, and it is also used to help determine claim status, retain the data element so it can continue to be used for claim entry or correction. If a data element is used solely for claim status, and is not essential for an alternate purpose, eliminate it; or 2. If a contractor elects to continue to display claim status-specific data elements in their DDE screens, those data elements must at a minimum contain/report data that conforms to: • All required and applicable conditional data elements for those segments in the ASC X12 277 claim status response; and • Data content as specified for those data elements in the ASC X12 277 claim status response, as applicable, including compliance with the data attributes for those data elements as defined in the ASC X12 277 implementation guide. Preliminary feedback from contractors suggests that existing DDE screens used for Medicare may already conform to the ASC X12 277 claim status response implementation guide requirements, but data element mapping is required to verify. For example, since industry input was used to develop the ASC X12 277 claim status response implementation guide as well as, presumably the data elements for claim status currently furnished via DDE, it is unlikely that DDE screen field sizes would be larger than the ASC X12 277 claim status response maximum length or shorter than the ASC X12 277 claim status response minimum length. It is also unlikely that a DDE screen would contain a data element considered important for claim status that is not included in the ASC X12 277 claim status response, or vice versa. If a shared system maintainer determines that DDE screen changes are required, the maintainer in conjunction with its users must determine if it would be cost effective to modify the DDE screens to conform to the ASC X12 277 claim status response implementation guide. If not cost effective, the maintainer must eliminate the claim status-only data elements from the DDE screens and require the contractors to use the batch ASC X12 276/277 claim status request and response, an ARU, and/or other non- EDI means to obtain claim status information. If retention is cost effective, the maintainer must modify these screens as necessary to ensure that providers are able to access all applicable data content available in the ASC X12 277 claim status response. The DDE screens must be able to furnish providers information that conforms to the data that would have been issued to the provider in an ASC X12 277 claim status response. See above for the discussion of conformity.