Summary of the ASC X12 276/277 Claim Status Request and

20.2 - Summary of the ASC X12 276/277 Claim Status Request and Response Process for A/B Medicare Administrative Contractors, DME MACs, CEDI (Rev. 2937, Issued; 04-25-14, Effective: 04-14-14, Implementation: 04-14-14) A. The contractor’s translator must perform editing on the submitted ASC X12 276 claim status request transaction at the ASC X12 standard and implementation levels, and generate an ASC X12 TA1 interchange acknowledgment in batch if an interchange control error was detected. The contractor shall generate an appropriate ASC X12 999 implementation acknowledgment in batch if a syntax error is detected. In the absence of any interchange control or syntax error, an ASC X12 999 implementation acknowledgement is issued in the batch mode only, to confirm receipt of an ASC X12 276 received via batch. See §20.4 for additional translation requirements. Translation does not apply to DDE screens. An ASC X12 TA1 interchange acknowledgment and an ASC X12 999 implementation acknowledgment (issued for an ASC X12 276 claim status request submitted in a batch) must be issued within 1 business day of receipt of the ASC X12 276 claim status request. An ASC X12 TA1 interchange acknowledgment and ASC X12 999 implementation acknowledgment of an ASC X12 276 claim status request submitted in an interactive/online mode must be issued as quickly as the ASC X12 277 claim status response would have been issued had the ASC X12 276 claim status request been valid. Under the current HIPAA adopted ASC X12 version, inclusive of any adopted Errata moving forward, the contractor’s translator shall edit the incoming ASC X12 276 claim status request transaction as documented by the CMS 276/277 Edits spreadsheet (as updated per quarterly release) from the CMS Website: http://www.cms.gov/ElectronicBillingEDITrans/10_ClaimStatus.asp#TopOfPage B. The shared system shall continue to process claim status transactions in current ASC X12 version to include edits to verify that the submitted ASC X12 276 data complies with IG and Medicare requirements. If edits are failed, the shared system must generate an edit report following the model established for TR3 and Medicare program edit reporting for the HIPAA compliant version of the ASC X12 837 claim implementation. The edit report must include any reason(s) for the rejection in a concise but explicit manner that can be understood by provider staff as well as contractor staff. Contractors will forward the edit messages to submitters for correction of the edit condition. The shared system must generate these edit reports within 1 business day. The TR3 edits must be performed as defined in the TR3 segment and data element notes, data element attributes, conditions of use, and overall guiding principles for use of the standards as contained in the introduction section and addenda to the IG. The Medicare program edits must be performed as required by current Medicare program instructions. C. The A/B MAC or, for DME, the CEDI contractor, shall process inbound claim status transactions in the current ASC X12 version(s) (inclusive of any ASC X12 Errata) and beyond to include the edits defined in the CMS 276/277 Edits spreadsheet as translator applicable in order to pass to the Part A or Part B Common Edits and Enhancement Module (CEM) software a CMS defined flat file format (inclusive of Control Record(s) hereafter referred to as CTRD). For Part A and Part B, the CEM software shall perform all edits not marked as Translator on the CMS 276/277 Edits spreadsheet for inbound claim status transactions in order to pass the fully edited inbound claim status transaction on to the appropriate Part A or Part B shared system for appropriate claim status request processing in the shared system. For DME, the CEDI contractor shall also process inbound claim status transactions in the current ASC X12 version(s) (inclusive of any ASC X12 Errata) and beyond to also include edits defined in the CMS 276/277 Edits spreadsheet other than translator applicable in order to pass the fully edited inbound claim status transaction on to the DME shared system for appropriate claim status request processing in the shared system. D. For claim status request and response transactions formatted in the current ASC X12 version(s) and beyond the shared system: • Updates the Control Record database with the CTRD record for the activities being processed (e.g. interchange – ISA segment to IEA) and appropriate content of the Control Record. Stores any ASC X12 276 claim status request data elements required for preparation of a compliant ASC X12 277 claim status response that are either not retained in the Medicare core system, or exceed the size limits for that type of data in the Medicare core system in a temporary file. Completes the application request/inquiry according to the components that outbound claim status response requires, as well as, generates and populates the outbound Control Record for the outbound claim status response. These processes shall comply with the TR3 for the ASC X12 transaction and the CMS defined Control Record definition (inclusive of any quarterly release updates). The shared system shall also perform data scrubbing of outbound data prior to the data exiting the Enterprise Data Center (EDC) and being transferred to the Local Data Center (LDC) as deemed appropriate by CMS and the MACs. The initial instructions for the outbound data scrubbing were contained in Transmittal 702, Change Request 6946. This edit process shall be implemented beginning with the October 2010 release for DME and in the January 2011 release for Part A and Part B shared systems. The processes shall be modified through subsequent releases, as directed via future Change Requests, add to the editing process of the reference file mechanism designed for each shared system to perform the data scrubbing conversion process.