September 27, 2002
The information in this article is no longer accurate/applicable.
NOTE: This article contains information that may now be out-of-date or may have been updated with a more current article or policy. Primarily, 4010A1 will be the format required for ANSI X.12 after October 16, 2003.
October 2002 Changes for X12N 837 (4010)
Coordination of Benefits
Beginning October 7, 2002, X12 N 837 (4010) COB transactions will be updated to meet specific HIPAA data requirements. As a result of this upgrade the X12N 837 (4010) COB transactions are to be generated with complete, HIPAA compliant data elements.
There are situations when an inbound claim received on paper, in non-version
4010 electronic format or 837 (4010) format will lack data elements,
or contain data that do not meet the data attribute (alpha-numeric,
numeric, minimum and maximum lengths, etc) requirements. In most cases,
claims with invalid data are rejected, but in limited cases, a claim
could be accepted and adjudicated. It is also possible to receive data
from the Common Working File that may not meet the X12N 837 (4010)
Implementation Guide requirements for COB. CMS requires that the flat
file created by our system for COB have all of the requirements and
applicable conditional data elements for generating a HIPAA-compliant
X12N 837 outbound COB transaction.
Our system will "gap fill" data when issuing an outbound X12N
837 (4010) COB transaction unless data is available from history, store
and forward repository (SRF) or reference files.
- For "gap filling" purposes, leading and trailing spaces will not be considered significant characters.
- The Implementation Guide states "If either NM108 or NM109 is present, then the other is required." For "gap filling" purposes, the following conditions are being considered - when NM108 is a "situational" or "required" data element: if NM108 contains a valid value and NM109 contains a value with a leading space, NM109 will be "gap filled" with "99".
- All NM103, NM104, NM105, NM107, PER04, PER06, PER08, N201, N301, N302, REF02, CN104, CN106, K301, NTE02, CR109, CR110, CR210, CR211, MOA03, MOA04, MOA05, MOA06, MOA07, HI101-2, HI102-2, HI103-2, HI104-2, HI105-2, HI105-2, HI106-2, HI107-2, HI108-2, HCP04, HCP06, SV101-2, PS101, HCP04, HCP06 and HCP10 fields will be evaluated for compliance and will be "gap filled" with "UNKNOWN".
- All PRV03 fields will be evaluated for compliance and will be "gap filled" with "203B00000X".
- All N401 (exception 2330 loop) fields will be evaluated for compliance and will be "gap filled" with "UNKNOWN".
- All N402 (exception 2330 loop) and CLM11-4 fields will be evaluated for compliance and will be "gap filled" with "FC".
- All N403 (exception 2330 loop) fields will be evaluated for compliance and will be "gap filled" with "00000".
- All N404 (exception 2330 loop) and CLM11-5 fields will be evaluated for compliance and will be "gap filled" with "ZZ".
- All DMGR02 fields will be evaluated for compliance and will be "gap filled" with "19660701".
- CLM01 field will be evaluated for compliance and will be "gap filled" with "0".
- CR702, CR703, HSD06 in 2305 loop fields will be evaluated for compliance and will be "gap filled" with "9".
- SBR03 and SBR04 in 2320 loop fields will be evaluated for compliance and will be "gap filled" with "UNKNOWN".
- CAS02, CAS05, CAS08, CAS11, CAS14, CAS17 in 2320or 2420 loops fields will be evaluated for compliance and will be "gap filled" with "UNKNO".
- N401, N402, N403 and N404 in 2330 loop fields will be evaluated
for compliance and will be "gap filled" with spaces. If
the whole 2330A.N4 segment contains spaces, the segment will not
be created.
- SV101-3, SV101-4, SV101-5, SV101-6 in 2400 loop fields will be evaluated for compliance and will be "gap filled" with spaces.
