20635 1 x12 companion guidev1.2
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MEDI-CAL COMPANION GUIDE
JUNE 2012 005010 1
California Medicaid(Medi-Cal)
Standard Companion Guide Transaction Information
Instructions Related to Transactions Based onASC X12 Implementation Guides, Version 005010
Companion Guide Version Number: 1.2
Published: June 2012
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This Companion Guide is Copyright 2010 by The Workgroup for Electronic Data Interchange
(WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited
Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety
provided that this copyright notice is not removed. It may not be sold for profit or used in
commercial documents without the written permission of the copyright holder. This document is
provided as is without any express or implied warranty. Note that the copyright on the
underlying ASC X12 Standards is held by DISA on behalf of ASC X12.
2011 Companion Guide copyright by California Department of Health Care Services
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Preface
The Companion Guide (CG) may contain two types of data, instructions for electronic
communications with the publishing entity (Communications/Connectivity Instructions) and
supplemental information for creating transactions for the publishing entity while ensuring
compliance with the associated ASC X12 IG (Transaction Instructions). Either the
Communications/Connectivity component or the Transaction Instruction component must be
included in every CG. The components may be published as separate documents or as a single
document.
The Communications/Connectivity component is included in the CG when the publishing entity
wants to convey the information needed to commence and maintain communication exchange.
The Transaction Instruction component is included in the CG when the publishing entity wants
to clarify the IG instructions for submission of specific electronic transactions. The Transaction
Instruction component content is limited by ASC X12s copyrights and Fair Use statement.
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Table of Contents
1 TI Introduct ion .......................................................................................................... 51.1 Background ...................................................................................................................5
1.1.1 Overview of HIPAA Legislation ........................................................................... 51.1.2 Compliance according to HIPAA ......................................................................... 51.1.3 Compliance according to ASC X12 ..................................................................... 6
1.2 Intended Use .................................................................................................................62 Included ASC X12 Implementation Guides ............................................................63 Instruction Tables .................................................................................................... 7
3.1 005010X279A1 Health Care Eligibility Benefit Inquiry ................................................... 73.2 005010X279A1 Health Care Eligibility Benefit Response ............................................ 103.3 005010X212 Health Care Claim Status Request ......................................................... 143.4 005010X212 Health Care Claim Status Response ...................................................... 153.5 005010X222A1 Health Care Claim: Professional ........................................................ 163.6 005010X223A2 Health Care Claim: Institutional .......................................................... 263.7 005010X221A1 Health Care Claim Payment/Advice ................................................... 34
4 TI Additional Information ......................................................................................374.1 Business Scenarios ..................................................................................................... 374.2 Payer-Specific Business Rules and Limitations ........................................................... 374.3 Frequently Asked Questions ....................................................................................... 374.4
Other Resources 8
....................................................................................................... 38
5 TI Change Summary ..............................................................................................386 Appendix A Communication/Connectivi ty Instructions (CCI) .........................38
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Transaction Instruction (TI)
1 TI Introduction
1.1 Background
1.1.1 Overview of HIPAA Legislation
The Health Insurance Portability and Accountability Act (HIPAA) of 1996
carries provisions for administrative simplification. This requires the
Secretary of the Department of Health and Human Services (HHS) to adopt
standards to support the electronic exchange of administrative and financial
health care transactions primarily between health care providers and plans.
HIPAA directs the Secretary to adopt standards for transactions to enable
health information to be exchanged electronically and to adopt specifications
for implementing each standard HIPAA serves to:
Create better access to health insurance
Limit fraud and abuse
Reduce administrative costs
1.1.2 Compliance According to HIPAA
The HIPAA regulations at 45 CFR 162.915 require that covered entities not
enter into a trading partner agreement that would do any of the following:
Change the definition, data condition, or use of a data element or
segment in a standard
Add any data elements or segments to the maximum defined data set
Use any code or data elements that are marked not used in the
standards implementation specifications or are not in the standards
implementation specification(s)
Change the meaning or intent of the standards implementation
specification(s)
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1.1.3 Compliance According to ASC X12
ASC X12 requirements include specific restrictions that prohibit trading
partners from:
Modifying any defining, explanatory or clarifying content contained in the
implementation guide
Modifying any requirement contained in the implementation guide
1.2 Intended Use
The Transaction Instruction component of this companion guide must be used in
conjunction with an associated ASC X12 Implementation Guide. The instructions
in this companion guide are not intended to be stand-alone requirements
documents. This companion guide conforms to all the requirements of any
associated ASC X12 Implementation Guides and is in conformance with ASCX12s Fair Use and Copyright statements.
2 Included ASC X12 Implementation Guides
This table lists the X12N Implementation Guides for which specific transaction
instructions apply and which are included in Section 3 of this document.
Unique ID Name
005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271)
005010X212 Health Care Claim Status Request and Response (276/277)
005010X222A1 Health Care Claim: Professional (837)
005010X223A2 Health Care Claim: Institutional (837)
005010X221A1 Health Care Claim Payment/Advice (835)
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3 Instruction Tables
These tables contain one or more rows for each segment for which a supplementalinstruction is needed.
Legend
SHADED rows represent segments in the X12N implementation guide.
NON-SHADED rows represent data elements in the X12N implementation guide.
3.1 005010X279A1 Health Care Eligibil ity Benefit Inquiry
Loop ID Reference Name Codes Notes/Comments
2100A NM1 Information Source Name
2100A NM109 Identification Code Medi-Cal expects to receive:
610442
2100B NM1 Information Receiver Name
2100B NM101 Entity Identifier Code 1P Medi-Cal expects to receivethe value listed in the codescolumn
NM108 Identification Code Qualifier SV
XX
Medi-Cal expects to receiveone of the values listed in thecodes column
2100B REF Information Receiver
Additional Identification
2100B REF01 Reference Identification
Qualifier
4A For Batch, Medi-Cal expects
to receive the value listed inthe codes column
2100B N3 Information Receiver Address This segment is not requiredfor the payers adjudicationsystem
2100B N4 Information Receiver
City, State and ZIP Code
This segment is not requiredfor the payers adjudicationsystem
2100B PRV Information Receiver Provider
Information
This segment is not requiredfor the payers adjudicationsystem
2000C HL Subscriber Level
2000C HL01 Hierarchical ID Number Medi-Cal expects to receivethe following:
For Leased-Line and Dial-Up:3
For Batch:Increment this for eachSubscriber entered, fromthree and up to 99Subscribers
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Loop ID Reference Name Codes Notes/Comments
2100C NM1 Subscriber Name
2100C NM108 Identification Code Qualifier MI Medi-Cal expects to receivethe value listed in the codescolumn
2100C REF Subscriber AdditionalIdentification
2100C REF01 Reference Identification
Qualifier
18
1L
1W
6P
EA
EJ
IG
N6
NQ
Medi-Cal expects to receiveone of the code values listedin the codes column
2100C N3 Subscriber Address This segment is not requiredfor the payers adjudication
system
2100C N4 Subscriber City, State, and
ZIP Code
This segment is not requiredfor the payers adjudicationsystem
2100C PRV Provider Information This segment is not requiredfor the payers adjudicationsystem
2100C INS Multiple Birth sequenceNumber
This segment is not requiredfor the payers adjudicationsystem
2100C HI Subscriber Health CareDiagnosis Code
This segment is not requiredfor the payers adjudicationsystem
2110C EQ Subscriber Eligibility orBenefit Inquiry Information
2110C EQ021 Product/Service ID Qualifier CJ
HC
ID
IV
N4
ZZ
Medi-Cal expects to receiveone of the code values listedin the codes column
2110C III Subscriber Eligibility orBenefit Additional InquiryInformation
This segment is not requiredfor the payers adjudicationsystem
2110C REF Subscriber Additional
Information
This segment is not required
for the payers adjudicationsystem
DTP Subscriber Eligibility / BenefitDate
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2000D Dependent Level This loop is not required forthe payers adjudicationsystem
Medi-Cal patients/recipientsare identified to the payer bya unique IdentificationNumber
All patients/recipients areconsidered the subscriber andmust be identified in theSubscriber Loop
2100D Dependent Name This loop is not required forthe payers adjudicationsystem
Medi-Cal patients/recipientsare identified to the payer bya unique Identification
Number
All patients/recipients areconsidered the subscriber andmust be identified in theSubscriber Loop
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3.2 005010X279A1 Health Care Eligibil ity Benefit Response
Loop
ID
Reference Name Codes Notes/Comments
2000A HL Information Source Level
2000A HL04 Hierarchical Child Code 1 Medi-Cal will populate this dataelement with value listed in thecodes column
2100A NM1 Information Source Name
2100A NM103 Name Last or Organization
Name
Medi-Cal will populate this dataelement with:
Medi-Cal
NM109 Identification Code Medi-Cal will populate this dataelement with:
610442
2100A PER Information Source
Contact Information
2100A PER02 Name Medi-Cal will populate this dataelement with:
POS Help Desk Toll FreeNumber or Voice AEVS
PER03 Communication Number
Qualifier
TE Medi-Cal will populate this dataelement with value listed in thecodes column
2000B HL Information Receiver Level
2000B HL04 Hierarchical Child Code 1 Medi-Cal will populate this dataelement with value listed in the
codes column2100B NM1 Information Receiver
Name
2100B NM101 Entity Identifier Code 1P Medi-Cal will populate this dataelement with value listed in thecodes column
NM108 Identification Code
Qualifier
XX
SV
Medi-Cal will populate this dataelement with values listed in thecodes column
2100B REF Information Receiver
Additional Identification
Medi-Cal will not send thissegment
2100B PRV Information Receiver
Provider Information
Medi-Cal will not send this
segment2100C HL Subscriber Level
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Loop
ID
Reference Name Codes Notes/Comments
2100C HL01 Hierarchical ID Number Medi-Cal will populate this dataelement with:
For Leased-Line and Dial-Up:
3
For Batch:This will be incremented foreach Subscriber, up to 99Subscribers
HL04 Hierarchical Child Code 0 Medi-Cal will populate this dataelement with value listed in thecodes column
2000C TRN Subscriber Trace Number
2000C TRN03 Originating Company
Identifier
Medi-Cal will populate this dataelement with:
610442
2100C NM1 Subscriber Name
2100C NM108 Identification Code
Qualifier
MI Medi-Cal will populate this dataelement with value listed in thecodes column
2100C N3 Subscriber Address Medi-Cal will not send thissegment
2100C N4 Subscriber City, State, and
ZIP Code
Medi-Cal will not send thissegment
2100C PRV Provider Information Medi-Cal will not send thissegment
2100C HI Subscriber Health Care
Diagnosis Code
Medi-Cal will not send thissegment
2100C DTP Subscriber Date
2100C DTP01 Date/Time Qualifier 102
291
307
458
472
Medi-Cal will populate this dataelement with values listed in thecodes column
2100C MPI Subscriber Military
Personnel Information
Medi-Cal will not send thissegment
2110C EB Subscriber Eligibility orBenefit Information
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Loop
ID
Reference Name Codes Notes/Comments
2110C EB01 Eligibility or BenefitInformation Code
1
6
CB
E
F
I
K
MC
N
R
V
W
Y
Medi-Cal will populate this dataelement with values listed in thecodes column
EB03 Service Type Code 1
9
30
3335
43
45
47
48
50
54
61
69
76
82
83
84
86
88
89
90
91
92
96
98
99
A0
A1
A2
A3
A8
AI
AJ
AK
AL
MH
UC
Medi-Cal will populate this dataelement with values listed in thecodes column
Refer to the Medi-Cal ProviderManual for more detailedinformation regarding servicescovered under the Medi-Calprogram
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Loop
ID
Reference Name Codes Notes/Comments
EB04 Insurance Type Code MA
MB
MC
OT
Medi-Cal will populate this dataelement with values listed in thecodes column
EB05 Plan Coverage Description Medi-Cal will populate this dataelement with one of thefollowing values:
CCSCHDPCMSPFAMILY PACTFAMILY PACT BENEFITSGHPPHAPMEDICARE PART D
2110C HSD Health Care ServicesDelivery
Medi-Cal will not send thissegment
2110C DTP SubscriberEligibility/BenefitDate
2110C DTP01 Date/Time Qualifier 102
291
307
458
472
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
2110C MSG Message Text
2110C MSG01 Free-form Message Text County Code will be included inthe free form text, along with theeligibility information
2115 III Subscriber Eligibility orBenefit AdditionalInformation
Medi-Cal will not send thissegment
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3.3 005010X212 Health Care Claim Status Request
Loop
ID
Reference Name Codes Notes/Comments
2100A NM1 Payer Name
2100A NM103 Payer Name Medi-Cal expects to receive:
Medi-Cal
NM109 Payer Primary Identifier Medi-Cal expects to receive:
610442
2000D HL Dependent Loop Medi-Cal patients/recipientsare identified to the payer bya unique IdentificationNumber
All patients/recipients areconsidered the subscriberand must be identified in theSubscriber Loop
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3.4 005010X212 Health Care Claim Status Response
Loop ID Reference Name Codes Notes/Comments
2100A NM1 Payer Name
2100A NM103 Payer Name Medi-Cal will populate this
segment with:
Medi-Cal
NM109 Payer Primary Identifier Medi-Cal will populate this
segment with:
610442
2000D HL Dependent Loop All patients/recipients areconsidered the subscriber andmust be identified in theSubscriber Loop
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3.5 005010X222A1 Health Care Claim: Professional
Loop ID Reference Name Codes Notes/Comments
1000A NM1 Payer Identification
1000A NM109 Submitter Identifier Medi-Cal expects to receive
the Submitter ID
1000A PER Submitter EDI Contact
Information
This segment is not required
for the payers adjudication
system
In the event communication is
required related to this
transaction, Medi-Cal will use
the contact information
submitted in the Billing
Provider Contact Information
in Loop 2010AA
1000B NM1 Receiver Name
1000B NM103 Receiver Name Medi-Cal expects to receive:
Medi-Cal
NM109 Receiver Primary Identifier Medi-Cal expects to receive:
610442
2000A CUR Foreign Currency
Information
This segment is not required
for the payers adjudication
system
All amounts within Medi-Cal
electronic transactions
represent U.S. currency
2010AA N3 Billing Provider Address Medi-Cal will use the Provider
Address in the internal
Provider Master File for
mailing of check or other
documents related to this
claim
2010AA N4 Billing Provider City, State
and ZIP Code
Medi-Cal will use the Provider
Address in the internal
Provider Master File for
mailing of check or other
documents related to this
claim
2010AA REF Billing Provider Tax
Identification
Medi-Cal will use the Tax
Identification Number (TIN) on
file in the internal Provider
Master File for income
reporting on the 1099 forms
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Loop ID Reference Name Codes Notes/Comments
2010AA REF Billing Provider
UPIN/License Information
This segment is not required
for the payers adjudication
system
Medi-Cal only accepts the NPI
and Medi-Cal Provider
Number to identify providers in
our adjudication system
2010AA PER Billing Provider Contact
Information
2010AA PER03 Communication Number
Qualifier
TE Medi-Cal expects to receive
the value shown in the codes
column
In the event communication is
required related to this
transaction, Medi-Cal will
contact you by telephone
2010AB Pay-to Address Name This loop is not required for
the payers adjudication
system
Medi-Cal will use the Provider
Address in the internal
Provider Master File for
mailing of check or other
documents related to this
claim
2010AC Pay-to Plan Name This loop is not required for
the payers adjudication
system
Medi-Cal does not currently
process subrogation payment
requests
2010BA NM1 Subscriber Name
2010BA NM108 Identification Code
Qualifier
MI Medi-Cal expects to receive
the value shown in the codes
column
2010BA REF Subscriber Secondary
Identification
This segment is not required
for the payers adjudication
system
2010CA REF Property and Casualty
Claim Number
This segment is not required
for the payers adjudication
system
2010CA PER Property and Casualty
Subscriber Contact
Information
This segment is not required
for the Payer adjudication
system
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Loop ID Reference Name Codes Notes/Comments
2010BB NM1 Payer Name
2010BB NM103 Payer Name Medi-Cal expects to receive:
Medi-Cal
NM109 Payer Identifier Medi-Cal expects to receive:
610442
2010BB N3 Payer Address This segment is not requiredfor the payers adjudicationsystem
2010BB N4 Payer City, State and ZIP
Code
This segment is not requiredfor the payers adjudicationsystem
2010BB REF Payer Secondary
Identification
This segment is not requiredfor the payers adjudicationsystem
2010BB REF Billing Provider Secondary
Identification
This segment should be
submitted for atypicalMedi-Cal providers who arenot eligible to receive an NPI
Medi-Cal expects to receivethe Medi-Cal Provider Numberin this segment for BloodBank, Christian SciencePractitioner and MSSPproviders who are not eligiblefor an NPI
These providers areconsidered atypical providersand must bill the Medi-Calprogram using their Medi-CalProvider Number
2010BB REF01 Billing Provider Secondary
Identifier
G2 Medi-Cal expects to receivethe value shown in the codescolumn
2000C HL Patient Hierarchical Level This segment is not requiredfor the payers adjudicationsystem
Medi-Cal recipients are allidentified to the payer by aunique Identification Number
All patients/recipients areconsidered the subscriber andmust be identified at theSubscriber Level
2300 DTP Date Initial Treatment
Date
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Last Seen Date This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2300 DTP Date Acute
Manifestation
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Last Menstrual
Period
This segment is not requiredfor the payers adjudication
system
2300 DTP Date Last X-ray This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Disability Dates This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Last Worked This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Authorized Return
to Work
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date - Assumed and
Relinquished Care Dates
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Property and
Casualty Date of First
Contact
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Repricer Received
Date
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2300 REF Clinical Laboratory
Improvement Amendment
(CLIA) Certificate Number
This segment is not requiredfor the payers adjudicationsystem
2300 REF Repricer Claim Number This segment is not requiredfor the payers adjudicationsystem
2300 REF Adjusted Repricer Claim
Number
This segment is not requiredfor the payers adjudicationsystem
2300 REF Investigation Device
Exception Number
This segment is not requiredfor the payers adjudicationsystem.
2300 REF Claim Identifiers for
Transmission
Intermediaries
This segment is not requiredfor the payers adjudicationsystem
2300 REF Medical Record Number This segment is not requiredfor the payers adjudication
system2300 REF Demonstration Project
Identifiers
This segment is not requiredfor the payers adjudicationsystem
2300 REF Care Plan Oversight This segment is not requiredfor the payers adjudicationsystem
2300 K3 File Information This segment is not requiredfor the payers adjudicationsystem
2300 NTE Claim Note
2300 NTE01 Attachment Transmission
Code
Medi-Cal uses one of theoccurrences of this segment to
convey the EmergencyCertification Statement asdefinedby Medi-Cal policyMedi-Cal expects to receiveCER when submittingEmergency CertificationStatement information
2300 CR1 Ambulance Transport
Information
This segment is not requiredfor the payers adjudicationsystem
2300 CR2 Spinal Manipulation
Service Information
This segment is not requiredfor the payers adjudicationsystem
2300 CRC Homebound Indicator This segment is not requiredfor the payers adjudicationsystem
2300 CRC EPSDT Referral This segment is not requiredfor the payers adjudicationsystem
2300 HI Health Care Diagnosis
Codes
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2300 HI Health Care Diagnosis
Code
2300 HI012
and
HI122
Diagnosis Code Medi-Cal will accept 12diagnosis codes
Only the first two diagnosiscodes submitted in thissegment will be used in theadjudication process
2300 HI Anesthesia Related
Procedure
This segment is not requiredfor the payers adjudicationsystem
2300 HCP Claim Pricing/Repricing
Information
This segment is not requiredfor the payers adjudicationsystem
2310C PER Service Facility Contact
Information
This segment is not requiredfor the payers adjudicationsystem
2310D NM Supervising ProviderName
This segment is not requiredfor the payers adjudicationsystem
2320 AMT Coordination of Benefits
(COB) Total Non-Covered
Amount
This segment is not requiredfor the payers adjudicationsystem
2320 OI Other Insurance CoverageInformation
This segment is not requiredfor the payers adjudicationsystem
2320 MOA Medicare Outpatient
Adjudication Information
This segment is not requiredfor the payers adjudicationsystem
2330A NM1Other Subscriber Name
2330A NM108 Identification Code
Qualifier
MI Medi-Cal expects to receivethe value shown in the codescolumn
2330A N3 Other Subscriber Address This segment is not requiredfor the payers adjudicationsystem
2330A N4 Other Subscriber City,
State and ZIP
This segment is not requiredfor the payers adjudicationsystem
2330A REF Other Subscriber
Secondary Identifier
This segment is not requiredfor the payers adjudicationsystem
2330B N3 Other Payer Address This segment is not requiredfor the payers adjudicationsystem
2330B N4 Other Payer City, State
and ZIP
This segment is not requiredfor the payers adjudicationsystem
2330B REF Other Payer Secondary
Identification
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2330B REF Other Payer Referral
Number
This segment is not requiredfor the payers adjudicationsystem
2330B REF Other Payer Adjustment
Indicator
This segment is not requiredfor the payers adjudication
system2330C Other Payer Referring
Provider
This loop is not required forthe payers adjudicationsystem
2330D Other Payer Rendering
Provider Name
This loop is not required forthe payers adjudicationsystem
2330E Other Payer Service
Facility Location
This loop is not required forthe payers adjudicationsystem
2330F Other Payer Supervising
Provider
This loop is not required forthe payers adjudicationsystem
2330G Other Payer Billing
Provider
This loop is not required forthe payers adjudicationsystem
2400 LX Service Line Number Medi-Cal will accept andprocess 6 Claim Service Linesfor Professional Claims
2400 SV1 Professional Services
2400 SV1011 Product or Service ID
Qualifier
HC Medi-Cal expects to receivethe value shown in the codescolumn
SV1013
thru
SV1016
Procedure Modifier Medi-Cal will accept 4Procedure Modifiers but onlythe first two will be utilized in
the adjudication process
See the Medi-Cal ProviderManual for the appropriateusage of Modifier Codes
2400 SV5 Durable Medical
Equipment Service
This segment is not requiredfor the payers adjudicationsystem
2400 PWK Line Supplemental
Information
This segment is not requiredfor the payers adjudicationsystem
2400 PWK Durable Medical
Equipment Certificate of
Medical NecessityIndicator
This segment is not requiredfor the payers adjudication
system
2400 CR1 Ambulance Transport
Information
This segment is not requiredfor the payers adjudicationsystem
2400 CR3 Durable Medical
Equipment Certification
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2400 DTP Date Certification
Revision/Recertification
Date
This segment is not requiredfor the payers adjudicationsystem
2400 DTP Begin Therapy Date This segment is not requiredfor the payers adjudicationsystem
2400 DTP Date Last Certification
Date
This segment is not requiredfor the payers adjudicationsystem
2400 DTP Date Last Seen Date This segment is not requiredfor the payers adjudicationsystem
2400 DTP Date Test Date This segment is not requiredfor the payers adjudicationsystem
2400 DTP Date Last X-ray Date This segment is not requiredfor the payers adjudicationsystem
2400 DTP Date Initial Treatment
Date
This segment is not requiredfor the payers adjudicationsystem
2400 QTY Ambulance Patient Count This segment is not requiredfor the payers adjudicationsystem
2400 QTY Obstetrical Anesthesia
Additional Units
This segment is not requiredfor the payers adjudicationsystem
2400 MEA Test Results This segment is not requiredfor the payers adjudicationsystem
2400 CN1 Contract InformationThis segment is not requiredfor the payers adjudicationsystem
2400 REF Repriced Line ItemReference Number
This segment is not requiredfor the payers adjudicationsystem
2400 REF Adjusted Repriced LineItem Reference Number
This segment is not requiredfor the payers adjudicationsystem
2400 REF Mammography
Certification Number
This segment is not requiredfor the payers adjudicationsystem
2400 REF Clinical Laboratory
Improvement Amendment(CLIA) Number
This segment is not required
for the payers adjudicationsystem
2400 REF Referring Clinical
Laboratory Improvement
Amendment (CLIA)
Facility
This segment is not requiredfor the payers adjudicationsystem
2400 REF Immunization Batch
Number
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2400 REF Referral Number This segment is not requiredfor the payers adjudicationsystem
2400 AMT Postage Claimed Amount This segment is not requiredfor the payers adjudication
system2400 K3 File Information This segment is not required
for the payers adjudicationsystem
2400 NTE Third Party Organization
Note
This segment is not requiredfor the payers adjudicationsystem
2400 PS1 Purchase Service
Information
This segment is not requiredfor the payers adjudicationsystem
2400 HCP Line Pricing/Repricing
Information
This segment is not requiredfor the payers adjudicationsystem
2420B Purchase Service Provider This loop is not required forthe payers adjudicationsystem
2420D Supervising Provider
Name
This loop is not required forthe payers adjudicationsystem
2420E Ordering Provider Name This loop is not required forthe payers adjudicationsystem
2430 AMT Remaining Patient Liability This segment is not requiredfor the payers adjudicationsystem
2440 Form Identification Code This loop is not required for
the payers adjudicationsystem
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3.6 005010X223A2 Health Care Claim: Inst itutional
Loop ID Reference Name Codes Notes/Comments
1000A NM1 Submitter Name
NM109 Submitter Identifier Medi-Cal expects to receive:
Submitter ID
1000B NM1 Receiver Name
NM103 Receiver Name Medi-Cal expects to receive:
Medi-Cal
NM109 Receiver Primary Identifier Medi-Cal expects to receive:
610442
2000A CUR Foreign Currency
Information
This loop is not required for
the payers adjudication
system
All amounts within Medi-Cal
electronic transactions
represent U.S. currency
2010AA N3 Billing Provider Address Medi-Cal will use the Provider
Address from the internal
Provider Master File for
mailing of check or other
documents related to this
claim
2010AA N4 Billing Provider City, State
and ZIP Code
Medi-Cal will use the Provider
Address from the internal
Provider Master File for
mailing of check or other
documents related to this
claim
2010AA REF Billing Provider Tax
Identification
Medi-Cal will use the Tax
Identification Number (TIN) on
file from the internal Provider
Master File for income
reporting on the 1099 forms
2010AB Pay-to Address Name This loop is not required for
the payers adjudication
system
Medi-Cal will use the Provider
Address from the internal
Provider Master File for
mailing checks or other
documents related to this
claim
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Loop ID Reference Name Codes Notes/Comments
2010AC Pay-to Plan Name This loop is not required for
the payers adjudication
system
Medi-Cal does not currently
process subrogation payment
requests
2010BB NM1 Payer Name
NM103 Payer Name Medi-Cal expects to receive
one of the following based on
the claim type for:
Long Term Care
MEDI-CAL LTC
Outpatient
MEDI-CAL OP
Inpatient
MEDI-CAL IP
NM109 Payer Identifier Medi-Cal expects to receive:
610442
2010BB REF Billing Provider Secondary
Identification
This segment should besubmitted for atypicalMedi-Cal providers who arenot eligible to receive an NPI
Medi-Cal expects to receivethe Medi-Cal Provider Numberin this segment for BloodBank, Christian Science
Practitioner and MSSPproviders who are not eligiblefor an NPI
These providers areconsidered atypical providersand must bill the Medi-Calprogram using their Medi-CalProvider Number
2000C Patient Hierarchical Level This loop is not required forthe payers adjudicationsystem
Medi-Cal patients/recipients
are identified to the payer by aunique Identification Number
Medi-Cal patients/recipientsare considered the subscriberand must be identified at theSubscriber Level
2300 DTP Date Initial Treatment
Date
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2300 DTP Date Last Seen Date This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Acute
Manifestation
This segment is not requiredfor the payers adjudication
system
2300 DTP Date Last Menstrual
Period
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Last X-ray This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Disability Dates This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Last Worked This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Authorized Return
to Work
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date - Assumed and
Relinquished Care Dates
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Property and
Casualty Date of First
Contact
This segment is not requiredfor the payers adjudicationsystem
2300 DTP Date Repricer Received
Date
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2300 PWK Claim Supplemental
Information
1. Attachments associatedwith a PWK segmentshould be sent at thesame time the 837 claimtransaction is sent.Medi-Cals businesspractice is that additionaldocumentation receivedmore than 30 days afterthe receipt of your 837claim transmission will notbe considered inadjudication of your claim
2. An Attachment ControlForm (ACF) must be usedwhen submittingsupplemental informationin support of an electronicclaim
3. The Attachment Control
Number (ACN) on thisform must match thecontrol number submittedin the PWK06 dataelement. That controlnumber is assigned by theprovider or the providerssystem
PWK02 Attachment Transmission
Code
BM
EL
FX
Medi-Cals processing andpolicy procedures support themethods for transmission ofattachments shown in thecodes column
2300 CN1 Contract Information This segment is not required
for the payers adjudicationsystem
2300 REF Service Authorization
Exception Code
This segment is not requiredfor the payers adjudicationsystem
2300 REF Mandatory Medicare
(Section 4081) Crossover
Indicator
This segment is not requiredfor the payers adjudicationsystem
2300 REF Mammography
Certification Number
This segment is not requiredfor the payers adjudicationsystem
2300 REF Referral Number This segment is not requiredfor the payers adjudication
system2300 REF Payer Claim Control
Number
This segment is not requiredfor the payers adjudicationsystem
2300 REF Clinical Laboratory
Improvement Amendment
(CLIA) Certificate Number
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2300 REF Repricer Claim Number This segment is not requiredfor the payers adjudicationsystem
2300 REF Adjusted Repricer Claim
Number
This segment is not requiredfor the payers adjudication
system2300 REF Investigation Device
Exception Number
This segment is not requiredfor the payers adjudicationsystem
2300 REF Claim Identifiers for
Transmission
Intermediaries
This segment is not requiredfor the payers adjudicationsystem
2300 REF Medical Record Number This segment is not requiredfor the payers adjudicationsystem
2300 REF Demonstration Project
Identifiers
This segment is not requiredfor the payers adjudicationsystem
2300 REF PRO Approval Number This segment is not requiredfor the payers adjudicationsystem
2300 K3 File Information This segment is not requiredfor the Payers adjudicationprocess.
2300 NTE Claim Note
2300 NTE01 Note Reference Code OP and IP Claims Only
Medi-Cal expects to receiveDGN in the first and secondoccurrence of this segment
NTE02 Claim Note Text OP and IP Claims Only
Medi-Cal expects to receivethe Primary and SecondaryDiagnosis Code Description inthe first and secondoccurrence of this segment
2300 NTE Billing Note
2300 NTE02 Billing Note Text OP and IP Claims only:
Medi-Cal will use this segmentto convey the EmergencyCertification Statement asdefined by Medi-Cal policy
Medi-Cal expects to receiveEMCER in the first fivecharacters followed by theEmergency Certificationdocumentation
If the Emergency CertificationStatement is not needed, otheradditional information may besubmitted in this segment
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Loop ID Reference Name Codes Notes/Comments
2300 CRC EPSDT Referral This segment is not requiredfor the payers adjudicationsystem
2300 HI Admitting Diagnosis This segment is not requiredfor the payers adjudication
system2300 HI Patient's Reason for Visit This segment is not required
for the payers adjudicationsystem
2300 HI External Cause of Injury This segment is not requiredfor the payers adjudicationsystem
2300 HI DRG Information This segment is not requiredfor the payers adjudicationsystem
2300 HI Other DiagnosisInformation
Medi-Cal will accept up to 12Diagnosis codes and theirassociated elements in this
segment but will only use oneadditional Diagnosis Code inthe adjudication process
2300 HI Other ProcedureInformation
Medi-Cal will accept up to 12Other Procedure Codes andtheir associated elements inthis segment but will only useone additional ProcedureCode in the adjudicationprocess
2300 HI Occurrence SpanInformation
This segment is not requiredfor the payers adjudicationsystem
2300 HI Treatment CodeInformation
This segment is not requiredfor the payers adjudicationsystem
2300 HI Claim Pricing/RepricingInformation
This segment is not requiredfor the payers adjudicationsystem
2310C NM1 Other Operating Physician This loop is not required forthe payers adjudicationsystem.
2320 AMT Remaining Patient Liability This segment is not requiredfor the payers adjudicationsystem
2320 AMT COB Total Non-CoveredAmount
This segment is not requiredfor the payers adjudication
system
2320 OI Other Insurance CoverageInformation
This segment is not requiredfor the payers adjudicationsystem
2320 MIA Inpatient AdjudicationInformation
This segment is not requiredfor the payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2320 MOA Outpatient AdjudicationInformation
This segment is not requiredfor the payers adjudicationsystem
2330A NM1 Other Subscriber Name
2330A NM108 Identification Code
Qualifier
MI Medi-Cal expects to receivethe value shown in the codescolumn
2330A N3 Other Subscriber Address This segment is not requiredfor the payers adjudicationsystem
2330A N4 Other Subscriber City,State and ZIP code
This segment is not requiredfor the payers adjudicationsystem
2330A REF Other Subscriber
Secondary Identifier
This segment is not requiredfor the payers adjudicationsystem
2330B N3 Other Payer Address This segment is not requiredfor the payers adjudicationsystem
2330B N4 Other Payer City, State
and ZIP code
This segment is not requiredfor the payers adjudicationsystem
2330B REF Other Payer Secondary
Identification
This segment is not requiredfor the payers adjudicationsystem
2330B REF Other Payer Referral
Number
This segment is not requiredfor the payers adjudicationsystem
2330B REF Other Payer Adjustment
Indicator
This segment is not requiredfor the payers adjudicationsystem
2330C Other Payer Attending
Provider
This loop is not required forthe payers adjudicationsystem
2330D Other Payer Operating
Physician
This loop is not required forthe payers adjudicationsystem
2330E Other Payer Other
Operating Physician
This loop is not required forthe payers adjudicationsystem
2330F Other Payer Service
Facility Location
This loop is not required forthe payers adjudicationsystem
2330G Other Payer Rendering
Provider Name
This loop is not required forthe payers adjudicationsystem
2330H Other Payer Referring
Provider
This loop is not required forthe payers adjudicationsystem
2330I Other Payer Billing
Provider
This loop is not required forthe payers adjudicationsystem
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Loop ID Reference Name Codes Notes/Comments
2400 LX Service Line Number Medi-Cal accepts andprocesses the followingnumber of claim service linesfor the document typesindicated:
1. Inpatient 22 lines2. Outpatient 22 lines3. Long Term Care 1 line
2400 PWK Line Supplemental
Information
This segment is not requiredfor the payers adjudicationsystem
2400 REF Line Item Control Number This segment is not requiredfor the payers adjudicationsystem
2400 REF Repriced Line ItemReference Number
This segment is not requiredfor the payers adjudicationsystem
2400 REF Adjusted Repriced LineItem Reference Number This segment is not requiredfor the payers adjudicationsystem
2400 AMT Facility Tax Amount This segment is not requiredfor the payers adjudicationsystem
2400 NTE Third Party OrganizationNotes
This segment is not requiredfor the payers adjudicationsystem
2400 HCP Line Pricing/RepricingInformation
This segment is not requiredfor the payers adjudicationsystem
2410 REF Prescription of
Compound DrugAssociation Number
2410 REF01 Reference IdentificationNumber
XZ Medi-Cal expects to receivethe value shown in the codescolumn
2420A Operating Physician Name This loop is not required forthe payers adjudicationsystem
2420B Other Operating Physician
Name
This segment is not requiredfor the payers adjudicationsystem
2430 AMT Remaining Patient Liability This segment is not requiredfor the payers adjudication
system
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3.7 005010X221A1 Health Care Claim Payment/AdviceLoop ID Reference Name Codes Notes/Comments
Header BPR Financial Information
Header BPR01 Transaction HandlingCode
I Medi-Cal will populate this dataelement with the value shown in
the codes column
This transaction containsremittance information only.Medi-Cal will always send thePayment and Remittanceinformation separately
BPR03 Credit/Debit FlagCode
C Medi-Cal will populate this dataelement with the code valueshown in the codes column
BPR04 Payment MethodCode
ACHCHK
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
BPR05 Payment FormatCode
CCP Data Elements BPR05 BPR15are only populated when BPR04is ACH
Medi-Cal will populate this dataelement with the code valueshown in the codes column
BPR07 Sender DFIIdentification
Medi-Cal will populate this dataelement with the value:
121000358
BPR08 Account NumberQualifier
DA Medi-Cal will populate this dataelement with the code valueshown in the codes column
BPR09 Sender Bank Acct.number
Medi-Cal will populate this dataelement with the code value:
1436100418
BPR10 Payer Identifier (TaxID)
Medi-Cal will populate this dataelement with the code value:
1680217053
BPR12 (DFI) ID NumberQualifier
01 Medi-Cal will populate this dataelement with the code valueshown in the codes column
Header TRN Check Number
Header TRN03 Payer Identifier Medi-Cal will populate this data
element with the code value:
1680217053
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Loop ID Reference Name Codes Notes/Comments
TRN04 ReferenceIdentification
124567
AMNL
Medi-Cal will send thisinformation to identify the financialprogram payment association.
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
Header CUR Foreign CurrencyInformation
This segment will not be sent. AllMedi-Cal payments are made inUS dollars
Header REF Version Identifier This segment will not be sent
1000A N1 Payer Name
1000A N102 Payer Name Medi-Cal will populate this dataelement with:
State of California Department of
Health Care Services
1000A N3 Payer Address
1000A N301 Address Information Medi-Cal will populate this dataelement with:
714 P Street RM 950
N302 Address Information Medi-Cal will populate this dataelement with:
P.O. Box 942732
1000A N4 Payer City, State andZIP Code
1000A N401 City Name Medi-Cal will populate this dataelement with:
Sacramento
N402 State or ProvinceCode
Medi-Cal will populate this dataelement with:
CA
N403 Postal Code Medi-Cal will populate this dataelement with:
942347320
1000A REF Additional PayerIdentification
This segment will not be sent
1000A PER Payer BusinessContact Information
This segment will not be sent
1000A PER Payer TechnicalContact Information
1000A PER02 Payer Contact Name Medi-Cal will populate this dataelement with:
State of California Medi-CalDepartment
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Loop ID Reference Name Codes Notes/Comments
PER04 Payer ContactCommunicationNumber
Medi-Cal will populate this dataelement with:
8005415555
PER06 Payer Contact
CommunicationNumber
Medi-Cal will populate this data
element with:
www.medi-cal.ca.gov
1000A PER Payer Website This segment will not be sent
1000B N1 Payee Identification
1000B N103 Identification CodeQualifier
XXFI
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
1000B RDM Remittance DeliveryMethod
This segment will not be sent
2000 TS3 Provider SummaryInformation
This segment will not be sent
2000 TS2 ProviderSupplementalSummary Information
This segment will not be sent
2100 CLP Claims PaymentInformation
2100 CLP02 Claim Status Code 123422
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
CLP06 Claim Filing IndicatorCode
MC Medi-Cal will populate this dataelement with value shown incodes column
2100 NM1 Patient Name
2100 NM108 Identification CodeQualifier
MR Medi-Cal will populate this dataelement with value shown incodes column
2100 NM1 Insured Name Medi-Cal will not send thissegment
2100 NM1 Crossover CarrierName
Medi-Cal will not send thissegment
2100 NM1 Service ProviderName
2100 NM108 Identification CodeQualifier
XXMC
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
2100 NM1 Crossover CarrierName
Medi-Cal will not send thissegment
2100 NM1 Corrected PriorityPayer Name
2100 NM108 Identification CodeQualifier
PI Medi-Cal will populate this dataelement with value shown incodes column
2100 NM1 Other SubscriberName
Medi-Cal will not send thissegment
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Loop ID Reference Name Codes Notes/Comments
2100 MIA Inpatient AdjudicationInformation
Medi-Cal will not send thissegment
2100 REF Rendering ProviderInformation
Medi-Cal will not send thissegment
2100 PER Claim Contact
Information
Medi-Cal will not send this
segment
2100 AMT Claim SupplementalInformation
Medi-Cal will not send thissegment
2100 QTY Claim SupplementalInformation Quantity
Medi-Cal will not send thissegment
2110 SVC
2110 SVC011 Product/Service IDQualifier
NUHCN4
Medi-Cal will populate this dataelement with one of the valuesshown in the codes column
2110 DTM Service Date Medi-Cal will not send thissegment
2110 REF Service Identification Medi-Cal will not send this
segment2110 REF Rendering Provider
Information
2110 REF01 ReferenceIdentification Qualifier
1D Medi-Cal will populate this dataelement with value shown in thecodes column
2110 REF Health Care PolicyIdentification
Medi-Cal will not send thissegment
2110 AMT Service SupplementalAmount
2110 AMT01 Amount QualifierCode
TT2
Medi-Cal will populate this dataelement with values shown in thecodes column
2110 QTY Service SupplementalQuantity
Medi-Cal will not send thissegment
2110 LQ Health Care RemarksCode
Medi-Cal will not send thissegment
4 TI Addit ional Information
4.1 Business Scenarios
There is currently no additional information to report in this section.
4.2 Payer-Specific Business Rules and Limi tations
There is currently no additional information to report in this section.
4.3 Frequently Asked Questions
There is currently no additional information to report in this section.
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4.4 Other Resources
https://www.Medi-Cal.ca.gov/signup.asp
http://files.Medi-Cal.ca.gov/pubsdoco/CTM_manual.asp
http://files.Medi-Cal.ca.gov/pubsdoco/Manuals_menu.asp
http://www.wpc-edi.com/
5 TI Change Summary
Version Number Date Reason for Revision Notes/Comments
1.0 7/8/2011 Initial Version
1.1 8/11/2011 ACS and IV&V editscaptured throughoutdocument
1.2 6/14/2012 Removed hyphens in Loop1000A (PER02 and PER04);removed X and Y fromISA04 codes column
Updated commentsfor ISA04
6 Appendix A Communication/ConnectivityInstructions (CCI)
Envelope segments for inbound transaction 005010X279 (270)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA02 Authorization Information Submitters must enter (left
justified) their three-characterSubmitter (software vendor) ID,
followed by their four-character
Software Version Number,
and with trailing spaces
https://www.medi-cal.ca.gov/signup.asphttp://files.medi-cal.ca.gov/pubsdoco/CTM_manual.asphttp://files.medi-cal.ca.gov/pubsdoco/Manuals_menu.asphttp://www.wpc-edi.com/http://www.wpc-edi.com/http://www.wpc-edi.com/http://files.medi-cal.ca.gov/pubsdoco/Manuals_menu.asphttp://files.medi-cal.ca.gov/pubsdoco/CTM_manual.asphttps://www.medi-cal.ca.gov/signup.asp -
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Loop ID Reference Name Codes Notes/Comments
ISA03 Security Information
Qualifier
00
01
For Leased-Line and Dial-Up
Medi-Cal expects to receive:
00
For Batch, Medi-Cal expects to
receive:
01
ISA04 Security Information For Leased-Line and Dial-Up:
Required Submitter
PIN/Password, left justified and
with trailing spaces
For Batch: leave blank, PIN is
validated against the Medi-Cal
website login password
ISA05 ZZ For Leased-Line and Dial-Up:
Use the Provider Number as isin NM109 Receiver Level
For Batch:
Use the Submitter ID as usedwhen you logged onto theMedi-Cal website
ISA06 Interchange Sender ID For Leased-Line andDial-Up:
NPI or Medi-CalProvider number
For all types of providers, leftjustify and with trailing spaces
For Batch:
Enter the Submitter ID as used
when you logged onto the
Medi-Cal website
ISA07 Interchange ID Qualifier ZZ Medi-Cal expects to receive the
value shown in the codes
column
ISA08 Interchange Receiver ID For Leased-Line and Dial-Up:
610442ACS214, left justify andwith trailing spaces
For Batch:
610442
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Loop ID Reference Name Codes Notes/Comments
ISA14 Acknowledgment
Requested
0
1
For Leased-Line and Dial-UpMedi-Cal expects to receive:
0 No AcknowledgmentRequested
For Batch, Medi-Cal expects toreceive:
1 InterchangeAcknowledgmentRequested
ISA16 Component Element
Separator
Medi-Cal expects to receive:
~as component separator
Header GS Functional Group Header
Header GS02 Application Sender's Code For Leased-Line and Dial-UpMedi-Cal expects to receive:
NPI or Medi-Cal providernumber
For Batch, Medi-Cal expects toreceive:
Submitter ID
GS03 Application Receiver's
Code
Medi-Cal expects to receive:
610442
Envelope segments for outbound transaction 005010X217 (271)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA01 AuthorizationInformation
Qualifier
00 Medi-Cal will populate this data
element with:
00 No Authorization
Information Present
ISA03 Security Information
Qualifier
00 Medi-Cal will populate this data
element with the value shown in
the codes column
ISA05 ZZ Medi-Cal will populate this dataelement with the value shown in
the codes column
ISA06 Interchange Sender ID Medi-Cal will populate this data
element with:
610442
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Loop ID Reference Name Codes Notes/Comments
ISA07 Interchange ID Qualifier ZZ Medi-Cal will populate this data
element with the value shown in
the codes column
ISA08 Interchange Receiver ID Medi-Cal will populate this dataelement with:
For Leased-Line andDial-Up:
Medi-Cal Provider Number orNPI
For Batch:
Sender ID
ISA13 Interchange Control
Number
000000001 Medi-Cal will populate this dataelement with the value shown inthe codes column
ISA14 AcknowledgmentRequested
0 Medi-Cal will populate this dataelement with the value shown inthe codes column
Header GS Functional Group Header
Header GS02 Application Sender's
Code
Medi-Cal will populate this dataelement with:
610442
GS03 Application Receiver's
Code
Medi-Cal will populate this dataelement with:
For Leased-Line andDial-Up:
Medi-Cal Provider Number orNPI
For Batch:
Submitter ID
Envelope segments for inbound transaction 005010X222A1 (837P)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA04 Media Indicator Medi-Cal will populate this data
element with values X or Y
ISA06 Interchange Sender ID Medi-Cal expects to receive:
Submitter ID
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Loop ID Reference Name Codes Notes/Comments
ISA08 Interchange Receiver ID Medi-Cal expects to receive:
610442
Header GS Functional Group Header
Header GS02 Application Senders Code Medi-Cal expects to receive:
Submitter ID
GS03 Application Receiver Code Medi-Cal expects to receive:
610442
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Envelope segments for inbound transaction 005010X223A2 (837I)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA04 Media
Indicator
Medi-Cal will populate this data
element with values X or Y
ISA06 Interchange Sender ID Medi-Cal expects to receive:
Submitter ID
ISA08 Interchange Receiver ID Medi-Cal expects to receive:
610442
Header GS Functional Group Header
GS02 Application Senders
Code
Medi-Cal expects to receive:
Submitter ID
GS03 Application Receiver
Code
Medi-Cal expects to receive:
610442
Envelope segments for inbound transaction 005010X223A2 (837I)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA06 Interchange Sender ID Medi-Cal expects to receive:
Submitter ID, NPI or
Medi-Cal Provider Number
ISA08 Interchange Receiver ID Medi-Cal expects to receive:
610442
Header GS Functional Group Header
Header GS02 Application Senders
Code
Medi-Cal expects to receive:
Submitter ID, NPI or
Medi-Cal Provider Number
GS03 Application Receiver
Code
Medi-Cal expects to receive:
610442
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Envelope segments for inbound transaction 005010X223A2 (837I)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA06 Interchange Sender ID Medi-Cal will populate this
segment with:
Submitter ID
ISA08 Interchange Receiver ID Medi-Cal will populate this
segment with:
610442
Header GS Functional Group Header
Header GS02 Application Senders Code Medi-Cal will populate this
segment with:
Submitter ID
GS03 Application Receiver Code Medi-Cal will populate this
segment with:
610442
Envelope segments for outbound transaction 005010X221A1 (835)
Loop ID Reference Name Codes Notes/Comments
Header ISA Interchange Control
Header
Header ISA06 Interchange Sender ID Medi-Cal will populate this
segment with:
Submitter ID
ISA08 Interchange Receiver ID Medi-Cal will populate this
segment with:
610442
Header GS Functional Group Header
Header GS02 Application Senders Code Medi-Cal will populate this
segment with:
Submitter ID
GS03 Application Receiver Code Medi-Cal will populate this
segment with:
610442
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