Converting Health Insurance Portability and Accountability Act

60 - Converting Health Insurance Portability and Accountability Act (HIPAA) Individual Relationship Codes to Common Working File (CWF) Medicare Secondary Payer (MSP) Patient Relationship Codes (Rev. 12078; Issued:06-14-23; Effective: 05-29-23; Implementation: 05-29-23) CMS has realized that its Common Working File (CWF) HUSP transaction does not allow for the correct association of HIPAA individual relationship codes, as found in the HIPAA 837 institutional and professional claims implementation guides, with corresponding MSP Type Codes, such as working aged (A), end-stage renal disease (B), and disability (G). Therefore, effective July 6, 2004, all A/B MACs (A) that receive incoming electronic HIPAA, DDE, or hard copy claims that are in the HIPAA ASC X12 837 format shall convert the incoming individual relationship codes to their equivalent CWF patient relationship codes. Until further notice, A/B MACs (A) shall continue to operate under the working assumption that all providers will be including HIPAA individual relationship codes on incoming claims. Before CMS’ systems changes are effectuated, A/B MACs (A) may receive SP edits (i.e., SP-33 and SP-52) that indicate that an invalid patient relationship code was applied. A/B MACs (A) are to resolve those edits by manually converting the HIPAA individual relationship code to the CWF patient relationship code, as specified in the conversion chart below. If the A/B MAC (A) receives MSP edits and can determine that the HIPAA individual relationship code rather than the CWF patient relationship code was submitted on the incoming claim, it shall manually work the MSP edits incurred by converting the HIPAA individual relationship code to the appropriate CWF patient relationship code. Until Part A shared system changes are effectuated to convert HIPAA individual relationship codes to CWF patient relationship codes, A/B MACs (A) may move claims with a systems age of 30 days or older that have suspended for resolution of patient relationship code, including SP-33 or SP-52 edits, to condition code 15 (CC-15). The A/B MAC (A) contractor system shall utilize the conversion charts, found below, to cross-walk incoming HIPAA individual relationship codes to the CWF patient relationship code values. For MSP Occurrences with accretion dates PRIOR to 4/4/2011: HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Valid Values 18 01 Patient is Insured 01 02 Spouse 19 03 Natural Child, Insured has financial responsibility 43 04 Natural Child, insured does not have financial responsibility 17 05 Step Child 10 06 Foster Child 15 07 Ward of the Court 20 08 Employee 21 09 Unknown 22 10 Handicapped Dependent 39 11 Organ donor 40 12 Cadaver donor 05 13 Grandchild HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Valid Values 07 14 Niece/Nephew 41 15 Injured Plaintiff 23 16 Sponsored Dependent 24 17 Minor Dependent of a Minor Dependent 32,33 18 Parent 04 19 Grandparent 53 20 Life Partner 29 N/A Significant Other 30 N/A ? 31 N/A ? 36 N/A ? G8 N/A ? Other HIPAA Individual Relationship Codes N/A ? For MSP Occurrences with accretion dates 4/4/2011 AND SUBSEQUENT: HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Description 18 01 Self; Beneficiary is the policy holder or subscriber for the other GHP insurance reflected by the MSP occurrence –or- Beneficiary is the injured party on the Workers Compensation, No-Fault, or Liability claim 01 02 Spouse 19 03 Child 43 03 Child 17 03 Child 10 03 Child 15 04 Other 20 04 Other 21 04 Other 22 04 Other 39 04 Other HIPAA Individual Relationship Codes Convert To CWF Patient Relationship Codes Description 40 04 Other 05 04 Other 07 04 Other 41 01 Self; Beneficiary is the policy holder or subscriber for the other GHP insurance reflected by the MSP occurrence –or- Beneficiary is the injured party on the Workers Compensation, No-Fault, or Liability claim 23 04 Other 24 04 Other 32,33 04 Other 04 04 Other 53 20 Life Partner 29 N/A Significant Other 30 N/A ? 31 N/A ? 36 N/A ? G8 N/A ? Other HIPAA Individual Relationship Codes N/A ? A/B MACs (A) allow CWF patient relationship codes, since these files should be populated with information sent back to the A/B MACs (A)’ systems via the automated transaction.