Formats For Electronic Medical Bill Processing

(1) For electronic transactions, the most current version of the following electronic medical bill processing standards shall be used: (a) Billing: 1. Professional Billing – the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Professional (837), May 2006, ASC X12, 005010X222 and Type 3 Errata to Health Care Claim: Professional (837), June 2010, ASC X12, 005010X222A1. 2. Institutional/Hospital Billing – the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Institutional (837), May 2006, ASC X12N/005010X223, Type 1 Errata to Health Care Claim: Institutional (837), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, October 2007, ASC X12N/005010X223A1, and Type 3 Errata to Health Care Claim: Institutional (837), June 2010, ASC X12, 005010X223A2. 3. Dental Billing – the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Dental (837), May 2006, ASC X12N/005010X224, Type 1 Errata to Health Care Claim: Dental (837), ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, October 2007, ASC X12N/005010X224A1, and Type 3 Errata to Health Care Claim: Dental (837), June 2010, ASC X12, 005010X224A2. Retail Pharmacy Billing – the Telecommunication Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2007, National Council for Prescription Drug Programs and the Batch Standard Batch Implementation Guide, Version 1, Release 2 (Version 1.2), January 2006, National Council for Prescription Drug Programs. (b) Acknowledgment: 1. Electronic responses to ASC X12N 837 transactions: (i) The ASC X12 Standards for Electronic Data Interchange TA1 Interchange Acknowledgment contained in the standards adopted under subsection (a)1. of this section; (ii) The ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Implementation Acknowledgment for Health Care Insurance (999), June 2007, ASC X12N/005010X231; and ELECTRONIC MEDICAL BILLING FOR WORKERS’ CHAPTER 0800-02-26 COMPENSATION (iii) The ASC X12 Standards for Electronic Data Interchange Technical Report Type (iii) Health Care Claim Acknowledgment (277CA), January 2007, ASC X12N/005010X214. 2. Electronic responses to NCPDP transactions: (i) The Response contained in the standards adopted under subsection (1)(a) of this section. (c) Electronic Remittance Advice (ERA) – the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim Payment/Advice (835), April 2006, ASC X12N/005010X221 and Type 3 Errata to Health Care Claim Payment/Advice (835), June 2010, ASC X12, 005010X221A1. (d) ASC X12 Ancillary Formats 1. The ASC X12N/005010X213 Request for Additional Information (277) is used to request additional attachments that were not originally submitted with the electronic medical bill. 2. Health Claim Status Request and Response (e) Documentation submitted with an electronic medical bill in accordance with 0800-02- 26-.05(5) (relating to Medical Documentation): ASC X12N Additional Information to Support a Health Claim or Encounter (275), February 2008, ASC X12, 005010X210. (2) Insurance carriers and health care providers may exchange electronic data in a non- prescribed format by mutual agreement. All data elements required in the Tennessee- prescribed formats shall be present in any mutually agreed upon format. (3) The implementation specifications for the ASC X12N and the ASC X12 Standards for Electronic Data Interchange may be obtained from the ASC X12, 7600 Leesburg Pike, Suite 430, Falls Church, VA 22043; Telephone (703) 970-4480; and FAX (703) 970-4488. They are also available through the Internet at http://store.x12.org/. A fee is charged for all implementation specifications. (4) The implementation specifications for the retail pharmacy standards may be obtained from the National Council for Prescription Drug Programs, 9240 East Raintree Drive, Scottsdale, AZ 85260; Telephone (480) 477-1000; and FAX (480) 767-1042. They are also available through the Internet at http://www.ncpdp.org. A fee is charged for all implementation specifications. (5) Nothing in this section will prohibit payers and health care providers from using a direct data entry methodology for complying with these requirements, provided the methodology complies with the data content requirements of the adopted formats and these rules. (6) Whenever the formats enumerated in section (1) for billing, acknowledgment, remittance, and documentation are replaced with a newer version, the most recent standard shall be used. The requirement to use a new version will commence on the effective date of the new version as published in the Code of Federal Regulations.