5101:3-1-20.2   Responsibilities Related to the Submission of Claims via Electronic Data Interchange (EDI) (Except for Services Provided through a Medicaid Managed Care Program)

Effective Date: May 23, 2007

Most Current Prior Effective Date:   November 15, 2004

(A)      Any covered entity (CE) in the business of performing EDI health care transactions with the Ohio Department of Job and Family Services (ODJFS) under the health insurance portability and accountability act Health Insurance Portability and Accountability Act (HIPAA) of 1996 and meeting the appropriate enrollment criteria in accordance with rule 5101:3-1-20.1 of the Administrative Code is eligible to be enrolled as a Medicaid EDI trading partner and to be issued a Medicaid trading partner number. An EDI trading partner who is in the business of submitting electronic claims for reimbursement is eligible to be issued a Medicaid trading partner number if the entity completes the following:

(1)      A Medicaid trading partner profile form JFS01957 (rev.09/2003)"JFS 01957 Trading Partner Profile" form (rev. 5/2006).

(2)      A declaration of "835 Health Care Claim Payment/Advice" trading partner form JFS06306 (rev. 07/2003)"JFS 06306 Designation of an 835 or 834-820 Trading Partner" form (rev. 12/2006), which is required only if the trading partner will be receiving the 835 remittance advice on behalf of their clients.

(3)      Signs a trading partner agreement. Two originals must be signed by an authorized representative of the trading partner and submitted to ODJFS. A countersigned original will be returned to the trading partner and must be kept on file.

(B)      Once the Medicaid trading partner number is assigned, the trading partner is eligible to submit claims for the testing process in accordance with paragraphs (C) and (D) of this rule.

(C)      Phase I testing requirements:

(1)      Three files per transaction type (837 professional, institutional, and dental) must pass phase I testing.

(2)      Each file must contain a minimum of two hundred fifty to five hundred claims. When submitting claims for the testing, region trading partners may simulate claim scenarios in order to meet the minimum testing requirements as long as the claims contain valid Medicaid provider and recipient numbers. Each file must contain a minimum of fifty to five hundred claims. When submitting claims to the test region, trading partners must adequately test all business rules appropriate to each provider type and service for which it provides clearinghouse services. Claims must contain valid provider identifiers and consumer billing numbers.

(3)      All EDI files must completely pass X12 integrity testing. This process checks basic X12 syntax. Trading partners must adopt any future HIPAA approved version upgrades in reference to the X12 syntax.

(4)      All EDI files must completely pass HIPAA syntactical requirement testing. This process checks for syntax specifically related to HIPAA implementation guides. Trading partners are required to modify their EDI files in accordance with any new federally mandated HIPAA standards.

(5)      All EDI files must completely pass HIPAA situation testing. This process checks to make sure all interdependent elements are present.

(D)      Phases II and III testing requirements:

(1)      Trading partners will use the HIPAA transaction set implementation guides and the ODJFS companion guides (rev. 05/2007) (available online) as determined by ODJFS.the department.

(2)      Test files must contain a representative sample of the trading partners' health care business claims (types of service such as ambulance, home health, laboratory, transportation, etc.).

(3)      A trading partner must be able to successfully receive and translate the "Unsolicited 277,"", the "824 Application Advice,"", the "997 Functional Acknowledgement" transaction sets, the "TA1 segment,"", and the "835 Health Care Claim Payment/Advice."".

(4)      The date of service for each claim cannot be older than six ten months prior to the test submission date.

(5)      Trading partners may submit up to a maximum of one file per day per transaction type (one professional, one institutional, and one dental) to be processed until those files pass the translator with an accepted "997 Functional Acknowledgement."". Resubmissions are permitted until ninety per centpercent of the claims submitted pass the phase II preprocessor and are sent to phase III, the test adjudication process. A ninety per cent pass rate must be reached for each transaction type tested.

(6)      Three files for each transaction type must be fully tested end to end through all three phases of testing, each file passing test adjudication with no more than a ten per cent denial rate. Data must contain claims that are independent of previously sent test files.

(7)      Trading partners must limit testing to those claims for whom they are the designee to receive the 835 electronic remittance advice. The 835 remittance advice will be returned in test.

(E)      In order for trading partners to be notified that they are eligible to submit claims for production they must:

(1) Meet all testing requirements for phases I, II, and III; and

(2) Verify Medicaid provider relationships as determined by ODJFS; and

(3) Confirm their 835 remittance advice destinations with all of their clients.

(F)      Only authorized trading partners that are actively submitting and receiving 837 health care claim transaction sets may submit and receive the 270/271 and the 276/277 transaction sets.

(F)(G) The individual Medicaid provider is ultimately responsible for accurate and valid reporting of all Medicaid claims submitted for payment. A provider using an EDI trading partner must insure through legal contract the responsibilities of the trading partner to report health care claims information as directed by the provider. A copy of all contracts between the provider and the trading partner must be available to ODJFS or its designee upon request. Both the provider and the trading partner must maintain a record of all Medicaid claims submitted for payment.

(G)(H) The trading partner is responsible for following general specifications as defined by the department in the ODJFS in accordance with paragraph (B) of rule 5101:3-1-19 of the Administrative Code HIPAA companion guides, in addition to the standardized EDI data requirements as defined in the national EDI transaction set implementation guides established under HIPAA 1996.

Effective: 05/23/2007

R.C. 119.032 review dates: 03/06/2007 and 05/01/2012

Certification: CERTIFIED ELECTRONICALLY

Date: 05/11/2007

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 10/16/03 (Emer), 1/1/04, 11/15/04