group minutes x12n tgb/wg2 billing and encounter … · note is ok #54232 – typo in situational...

ASC X12N TGB WG2 MayJun 2017

Revised 01/2016 of20

Group MinutesX12N TGB/WG2 Billing and Encounter Information

May – June 2017Refer to Scheduled Meetings Table for Call in Information

Group LeadershipChair Name Company Term End Date Phone EmailJamie Mosteller(Claims)

Cerner June 2017 610-219-5654

[email protected]

Chris Cioffi(Attachments)

Anthem, Inc. June 2017 301-752-6698

[email protected]

Lynn Chapple United HealthGroup

January 2019 801-982-3516

[email protected]

Secretary Name Company Term End Date Phone EmailKatie Sullivan Cognosante [email protected]

Quorum Requirement StatementThis group enforces quorum requirements for group voting items.

This group does not enforce quorum requirements for group voting items. X

Type of Meeting Date Location/Call in Contact AgendaCurrent Meeting May 4, 2017 712-432-0393

Access Code:219956

Co-chairs Posted to Central Desktopprior to the meeting

Next StandingMeeting

June 04 – June 08,2017

San Antonio, TX Co-Chairs Posted to Central Desktopprior to the meeting

Interim Meeting Thursdays1:00 -2:30 pmEastern

712-432-0393Access Code:219956

Co-Chairs Posted to Central Desktopprior to the meeting

ManagementMeeting

Voting ItemsType Issue DescriptionPublicComments

Public comment review (837), need to approve the workgroup decisions/responsesdetermined during the call.MotionApprove the workgroup’s version 7030 837 responses as discussed on the 05/04/2017interim call.

Vote Motion Made by 2nd By Approve Disapprove AbstainKelly Butler Gloria Davis 40 0 1

Discussion None

Key Discussion Item: Attendance = 41Summary of Discussion: General

No AnnouncementsDecisions

None



Summary of Discussion: Review 837 - 7030 Public Review Comments/Responses

#54138 – section 1.3.1 Kelly met with C5 to talk about standard language, re batch/real-time Recommendation to leave as is for 7030, based on HIPAA rule saying that people must accept

transaction, nothing about batch or real-time Stanley: the TR3 seems to imply that either batch or real-time is ok, but batch is NOT required,

he’d like to review with CMS for future regulation Jamie: If CMS is concerned they can make a comment during this public comment period Rachel: Phase 4 CORE requires batch, real-time is optional Jamie: would this be something that can be brought up in the info forum Kelly: Generally not, since we’re not changing anything Laurie: X12 can’t require batch or real-time, that’s ultimately up to regulation Offered to take it on and work with C5 to see if there’s better language Chris: Reminder that some parts of the industry ARE real-time today

#54229 – 2300 HI diagnosis code (837p) Make sure that ICD-11 code set value is there It is, but since ICD-11 hasn’t been finalized, the code source isn’t available yet Laurie: Change disagree reason to note that it’s premature since ICD-11 hasn’t been finalized Can we have a “mutually defined” code for future expansion? Stanley: Even after WHO finalizes ICD-11, there will be a multi-year process to create the US

version Lack of code source makes it hard to assign even a temporary code set value Laurie: Will follow-up to see if there is something we’re not aware of to be able to add a new

code source #54230 – 2300 HI01 element note

Recommend to put note on HI01 to emphasize this is the primary dx code Kelly: The note added to SV07 in 6020 makes the note unnecessary

#54231 – 2310A-2310D REF segments REF segments are inconsistent with LU qualifier Kelly: Present since 4010, never has been a code note, but used by some Christol Green: Anthem uses the value Workgroup started to develop a code note to explain use case NY Department of Health might use the code and they will let us know if the proposed code

note is ok #54232 – typo in situational rule

Change from “a organization” to “an organization” #54233 – removal of REF segment

The change was intentional in 6020 Kelly will update change log to reflect the removal

#54234 Re-add TR3 note from 5010 that line item control number must be unique Notes were removed in 6020 Laurie: How does this apply with respect to paper-to-electronic conversion? Workgroup agrees with commenter and will also add new note about paper conversion

#54235 Repeat count was reduced to 11 from 20 Count was changed to match number of qualifiers available

#54236 – same as above #54237



This change was intentional, this provider will always have an NPI Will be added to change log

#54238 Notes belong as TR3 note Workgroup agrees

#54239 Examples needs to be corrected Workgroup agrees

#54240 Change situational rule on remaining patient liability This was a big discussion in workgroup previously If we hold for standing meeting, we need to put on agenda so interested parties can discuss

#54242 Update code source owner – workgroup agrees, but for the future since this is in the 7030 base

standard #54243

GS08 code note example needs to be consistent This was a publisher error only on the forum

#54244 ISA09 value – date needs to be updated Workgroup agrees, date will be updated in published TR3

#54247 Duplicate

#54248 Likely to be withdrawn

#54249 CLM16 – needs to be updated to “If not required by this guide, do not send” Workgroup disagrees, workgroup opinion is that providers needs the flexibility to send when

they deem necessaryDecisions

See voting item Workgroup response/decisions are document in public comment spreadsheet

Scheduled MeetingsType of Meeting Date Location/Call in Contact AgendaCurrent Meeting May 11,

2017712-432-0393Access Code:219956

Co-chairs Posted to Central Desktop prior to themeeting


June 4 -8, 2017

San Antonio, TX Co-Chairs Posted to Central Desktop prior to themeeting

Interim Meeting Thursdays1:00 -2:30pmEastern

712-432-0393Access Code:219956

Co-Chairs Posted to Central Desktop prior to themeeting

ManagementMeeting




Public comment review (837), need to approve the workgroup decisions/responsesdetermined during the call.MotionTo approve the workgroup’s responses to 837 public comments as discussed on5/11/2017 call.

Vote Motion Made by 2nd By Approve Disapprove AbstainKelly Butler Annie Brannan 32 0 0

Discussion None

Key Discussion Item: Attendance: 32Summary of Discussion: General Announcements

NoneDecisions

NoneSummary of Discussion: Public Comment Review (837)

Continued review of public comments and proposed responses to the 837 guides. 2310C REF Situational Rule (includes 3 statements that must be met prior to usage)

The previous understanding of using this segment was for atypical providers without NPI wherean identifier is needed to ID provider.

The service location use was limited based by NPI rule and understanding of how it should work There can be NPIs for multiple location, but if NPI is a subpart of the billing entity, the subpart

should be the billing provider. Billing provider must be at the most detailed level of enumeration When a service location is a subpart of the billing provider they must report themselves

in the billing provider loop instead of the service location. As explained in section 1.10. 2400 SV101-07 – Situational rule allows for providing at sender’s discretion

In an attempt to allow for provider’s to have flexibility to include it at their discretion may slowprocessing

Workgroup was specifically asked to remove OR statement from Situational Rule regardingunspecified codes (comment in 6020). The workgroup agreed to the comment, but didn’t acceptthe full suggested solution.

At that time there was lots of discussion surrounding codes and code definitions that wouldrequire the submission of a description. Some codes might be unspecified, but didn’t require adescription. Workgroup could not come up with a definitive listing that uniformly applied acrossthe industry.

Also, the workgroup felt the rule couldn’t be validated Concern that this opens it up for submitters to send descriptions at any time The real issue is that payers aren’t getting the additional information that is needed CMS has a listing of codes where they need the additional information, but this is a only a listing

for one payer On hold will be discussed at the standing meeting Possible related RFIs: 1467 and 1494

Service Date DTP - TR3 note 1 Comment requests updating dates Harmonization item

2330B N3 – situational rule May be sent at senders discretion, but situational rule also notes that sending means there is an



intent to drop to paper. Comment suggests either removing “intent” statement or change to other format of rule Believe it makes sense that this would be included in other loop, but not sure it makes sense at

the 2330B. Only change from 5010 was to change to the other format of situational rule. Not clear why address was added for the 2330B unless it is known. It is being used today and would allow the payer who is receiving it to update records, but there

are other ways of doing this. Address might be used for an initial contact if nothing else is onrecord.

Agreed to change the situational rule to be “Required when the payer address is available. Ifnot required by this implementation guide, do not send.” This change will apply across all 837guides

Also applied to 2330B N4 2300 HI Principal Diagnosis HI01-09

Comment notes code source of industry list is not present Code source for POA is referenced differently than other code sources, information is in the

semantic note This is how it is done for data element 1271, when not preceded by data element 1270

2300 Occurrence Code- Situational Rule Typo in rule “a Occurrence” should be “an Occurrence” Workgroup agrees to change and cleaned up situational rule.

2400 DTP Service/Assessment Date Comment requests removing DTP02 element note as it is redundant to code note DTP02 element note will be removed Additional comment request updating code notes in DTP02 Workgroup agreed

2410 LIN02 – Drug/Supply Identification Comment notes 837I qualifiers are not consistent with those from 837P This is intentional, workgroup disagrees

2430 SVD – Line Adjudication TR3 Note Comment requests the additional of TR3 note from the 837P that points to front matter section

regarding COB and code bundling and unbundling Appendix A

Comment requests removal of code source 131 for ICD-9 Disagree as value is still in TR3

Another comments suggest updating code source 139 to reflect X12 as owner of code source Requires a DM will be done in future guide

Appendix C.1 Comment request code value in GS08 be specific to guide This is a publishing item and is an issue for online only. Will be accurately reflected in final

publication 2310E REF situational rule – same as above 2310 NM1 Situational Rule

Requests removing the 2nd portion of the situational rule and require when the name or addressis different than the 2010AA

NPI rule is what is driving this rule As long as service facility is not a subpart of the billing provider they can use the service

location Comment requests reverting back to language similar to the 4010, which is not possible due to



the NPI rule Workgroup disagrees

Use of Implementation guide vs TR3 Comment requests standardized usage of the terms Implementation Guide vs TR3 This is bigger than 837 alone and should go to harmonization

DMG03 – requests keeping current set of codes and their meanings Gender Codes There was a previous discussion regarding this There is a WG16 CR that might impact our response Need to reach out to WG6 regarding possible changes

Change Log Errors – Change log corrections CN101 – Changes in log, not in TR3 (837P) TOO – Addition missing from change log (837P) AMT – Additional of Purchase Service Amount missing from change log AMT – Additional of Usual and Customary Charge missing from change log Loop ID 2300 CRC01 EPSDT Screening Service and Referral. Changes noted in change log,

but missing from TR3 Doesn’t appear to be missing No change will be made

Loop ID 2400 PS1 – removed from TR3, but not in change log Need to determine how to include deletion in change log Reference will be wrong as it is a deletion, but will include in change log

Loop ID 2330F NM1 Other Payer Supervising Provider – removed from TR3, not in change log Need to determine how to include deletion in change log Reference will be wrong as it is a deletion, but will include in change log

CN101 – Changes in change log, but not in TR3 (837I) Change log will be corrected

Reviewed and agreed to all items back from C5Decisions

See voting item Workgroup response/decisions are documented in public comment spreadsheet


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ManagementMeeting





Vote Motion Made by 2nd By Approve Disapprove AbstainKaren Shutt Todd Omundson 27 0 0

Discussion None

Key Discussion Item: Attendance: 27Summary of Discussion: General Announcements

NoneDecisions


Continued review of public comments and proposed responses to the 837 guides. 2010AA/2010AC/2010AD code note for EI (Dental)

There was a change request (CR) done that should have modified this code note, but the CRfor some reason is still out there.

Will change to what was in the CR Identified multiple comments regarding the HPID and noted these will be done in coordination with

workgroup 6 2000B HL04 - code note for HL04 value of 1 will be updated to be consistent to what was done across

other guides 2000B SBR05 (Insurance Type Code)

Changed to not used in the 7030 for 2000B loop Comment requests leaving as situational with situational rule regarding use during transition

between versions This argument could be made for every element and change that was done. This was done for

one item in the claim status which resulted in more confusion rather than providing clarity. Workgroup feels if you did it for one item you would open the door for doing it for every change

Transitional language would need to be considered across all rules and TR3s. Guides are version specific

2010BB – Comment requests situational rule consistency regarding loop ID references This is bigger than what can be done this version

2420C REF segment removed, but not in change log Change log correction

2300 CLM01 – element note in 5010 included information regarding the recommendation that thisvalue be unique, similar note missing in 7030

It was noted that the recommendation could be included, but doesn’t mean that they will do it.However, if it is strongly recommended this would at least get the industry to consider

Some hospitals don’t use a unique number across claims There are also some legacy applications that can only use a patient account number Putting in a recommendation would not make those systems non-compliant Suggested to include the recommendation with a note to facilitate posting. To some, the statement must not be modified implies that it would be unique, but this is not

necessarily true. Payers don’t typically rely on this number and may assign their own unique



claim number. Agree to add the recommendation of this number being unique back

CLM10 – not used in the dental guide, but is in the professional Trying to determine if there are any regulations where the dental might generate a patient

signature and if there is a reason this is different in the 837P vs. 837I and 837D For professional, when they generate the patient signature when the patient is present

Workgroup members unclear, but suggested possibly for telemedicine or when x-raysare sent out for evaluation

It was present in the 837P since 4010, but had additional values in 4010 On hold until standing meeting

CLM21- Comment requests adding code note for the Z value Claim authorization reference code

Previously done in a REF segment, which didn’t have a value of Z Need to review the CR to determine if there was a business justification for the addition of the Z

value 2300 REF – Claim Identifier for Transmission Intermediaries TR3 note

TR3 note states this segment isn’t used in payer-to-payer COB, but comment suggests this isincorrect

Not all payer-to-payer COB goes directly between payers as there may be a clearinghouse inbetween them

Suggested to remove the note as it is too limiting for no reason 2300 REF02 – State of Claim Jurisdiction

Comment recommends removing element note as it is redundant Agree. This is a shared note and should be removed from all 837s

2300 HI01 – Diagnosis Type Code Comment requests adding industry name to align with professional Industry name is used to provide additional information than what is in the standard. Determined this was not needed, will remove from the 837P for consistency

2310A/2310B/2010E NM1 – TR3 note Comment requests modifying note for consistency Will research and discuss on next call or standing meeting (wait for Nancy Spector’s input)

2310A TR3 Note Comment requests modifying the TR3 note P3 (Primary Care Provider) value was removed from the 837I as it doesn’t apply Suggested language aims to simplify, but does it lose anything by removing the explanation

regarding Primary Care Providers? Workgroup disagrees as the current note provides additional information

2310C –REF segment situational rule contains extra spaces These should be eliminated across all 837s

1.10.1 – Service Location Information Comment requests the addition of information regarding the appropriate use of the secondary

identifiers for service location. Requested information is not clear based on comment. Situational rule provides the details

regarding when the secondary REF can be used Workgroup believes any clarification should be done at the REF segment, not in the front matter Some thought there might be concerns in NY for the all payers claims database and them

unable to tie it back to the provider. A clarification was made that NY’s concern was related tothe Service Provider secondary identifier and was specific to the reporting guide. There is aseparate comment regarding this issue.



On hold until standing meeting. It was noted that CR 1532 requires workgroup vote. ACTION: Chris Cioffi will look into.Decisions


Voting Items

Type Issue DescriptionPublicComments


Vote Motion Made by 2nd By Approve Disapprove AbstainChris Cioffi Marc Leib 38 0 2

Discussion Laurie noted an incorrect reference, but doesn’t change workgroups response

Key Discussion Item: Attendance: 40Summary of Discussion: General Discussion

A request was made to delay any discussion regarding comments for the reporting guide be postponeduntil after the standing meeting.

Decisions


Continued review of public comments and proposed responses to the 837 guides. 2300 CLM21 – code value Z

Kelly reviewed old Change Request (CR) to determine if there was a reason for the Z codebeing added nothing was noted in the old CR

Likely added as part of a previous effort to include a value that could be used when no othersapplied

Concerns about fluctuating regarding publishing requirements, it was suggested to confirmthere wouldn’t be push back as a result from removing the X value.

This element is used by NY Medicaid. Z is not used and not sure under what circumstances it would ever be used


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Workgroup determined to remove the code value Z 2320 – Request to reduce repeats of 2320 RAS segments – referred to WG 3 2320 AMT - Claim Allowed Amount TR3 note

Comment requests modifying TR3 note 1 to use same terms as situational rule for consistency The situational rule uses the term submitter, but TR3 note reference provider This note is only a shared note within the 837 (not the 835), but it is a payment related COB

loop and workgroup can make a recommendation and forward to WG3. Suggested to modify the note by removing the reference to provider and remove redundancies.

Suggested language “This is Loop ID – 2100 Claim Allowed Amount (AMT02) when reported onan 835.”

EDI Control Directory Part of common content Will need to coordinate with TGCWG5. Kelly can research to determine if they have had a

similar comment and if so if previous response can be used or if they need to review Patient Middle Name and Suffix

Comment requests strengthening rules for patient middle name and suffix Comment suggests requiring them if they have a middle name or a suffix rather than requiring

them if needed. Comment if more than just about the claim, but due to increases in the need for Interoperability

beyond payers and providers Would this be returned on the eligibility transaction?

Workgroup felt this might be bigger than just the claim Concerns that some payers or providers may not have this information and what impact this

could potentially have. Nancy S. noted that they agreed that if you have this information you should send it, rather than

trying to determine if the information is needed. Suggested that it be required when known. Stanley N. prefers stronger language as the provider should at least ascertain if they do

have a middle name or suffix A provider asked how payers will handle information if it is different than what they have on

record. If middle initial doesn’t match will the claim reject? This would be a payer decision. Medicare has no plans to reject on the front end if middle initial didn’t match.

Will Medicare send the middle initial for COB? Not known, but they don’t see a reason why theywould not.

This is a shared note across multiple loops (patient, subscriber) and guides. Suggested to forward to the entity workgroup as this is an entity related item.

Workgroup will forward to WG6 Unrelated to current comments, it was noted that there is another location in the guide where

situational rule requires information to be sent when it impacts any downstream payer (837I PRV) Not sure how this rule could be enforced CMS will be submitting a comment regarding item

Laurie B. noted that all comments must be reviewed by the workgroup even if the workgroup hadpreviously responded to a similar comment. This ensures all comment responses are appropriatelyvoted on.

2400 SV101-01 ER code note Workgroup previously discussed and agreed upon an updated code note

1.4.2.3.5 – Example to be corrected 2000B HL TR3 notes

Comment requests modifying TR3 note to include which Loop may be required and which onesare not used. Also attempts to define the subscriber which there was an effort not to do outside



of section 1.5. Workgroup feels current note is sufficient

1.6 – ARM – common content Will forward to TGCWG5

1.4.6 – Obtaining approval for K3 usage Comment requests adding location of K3 in the TR3 Intent of language is to allow for its use in any TR3 where there is a K3 segment and should not

add TR3 specific locations Original Claim Creation Date

Comment questions the necessity of information Added it to ensure that the date wasn’t overlaid by entities during transfer to the payer This information may be used to establish timely filing

Decisions



Public comment review (837), need to approve the workgroup decisions/responsesdetermined during the call.MotionTo approve the workgroup’s responses to 837 public comments as discussed on6/1/2017 call as well as any determinations to coordinate with other workgroups.

Vote Motion Made by 2nd By Approve Disapprove AbstainKelly Butler Gloria Davis 0 1

Discussion None

Key Discussion Item: Attendance: 36Summary of Discussion: General Discussion

San Antonio Agenda Reviewo Primarily agenda will focus on reviewing and adjudicating public commentso Co-chair elections (Jamie and Chris’s positions) Monday AM

Both are running again

Scheduled MeetingsType of Meeting Date Location/Call in Contact AgendaCurrent Meeting June 1,

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o Monday Afternoon joint meeting with WG5 to discuss STC12o Tuesday AM – Attachment updates and discussions

Process questiono As comments are being reconciled who will have access to the 7030 guides?

Public comment versions expired Workgroup drafts are still available to the TRCs Information is still available in viewer

Gloria and Kelly need to meet with workgroup 2 co-chairs to coordinate availability at standing meeting.Decisions


Continued review of public comments and proposed responses to the 837 guides. After 5/25/2017 meeting, Kelly reviewed items marked as duplicate, the following 2 items were

identified and reviewed: 1.4.4.2.1.1. – Transaction set header – agreed to change paragraph 2 to remove TR3

references 2320 AMT - Patient Remaining Liability Amount (situational rule re-written to follow appropriate

format and adding a comma for clarity 2320 Patient Remaining Liability AMT TR3 note 1

Comment requests replacing quotes with parenthesis and changing patient responsible topatient responsibility

Workgroup agrees 2320 AMT COB Total Non-Covered Amount situational rule

Comment recommends changing situational rule for clarity Workgroup agrees

2320 OI segment TR3 note Comment requests updating TR3 note by replacing quotes with parenthesis for consistency Workgroup Agrees

2320 OI03 code notes Code notes are not in alignment with NUBC usage Comment suggests updating note to point to usage as indicated in the NUBC manual. Consider doing the same thing as done for CLM08 Suggest to make it consistent across all TR3s Questions were raised as to whether it was appropriate to point to the NUBC manual in the

837P and 837D TR3s. It is believed the only current reference is for claim frequency code andthe applicable codes are available outside of the NUBC manual

The workgroup does not believe there should be a reference to the NUBC manual anddisagrees with the comment.

Additional comments have been submitted for the 837P and 837I regarding the codes in OI03(and CLM08) and workgroup would prefer to make changes to the 837D when adjudicatingthose comments by applying it across the 837 guides Similar comments will need to be submitted for the PACDR guides.

There were multiple comments that need to be worked in coordination with workgroup 3 2320 LQ and number of repeats

Comment suggests reducing the number of repeats from 99 to 25 2430 RAS segment repeats

Comment requests reducing number of repeats 2430 AMT COB Service allowed amount

Comment requests change to segment name There were multiple comments that need to be worked in coordination with workgroup 6



2330B NM108 – Other Payer Name Comment is related to HPID

2330B REF - Other Payer Secondary ID and HPID 2330B DTP Payment Effective Date situational rule

Comment requests updating situational rule to reflect correct segment name in 2430 loop Workgroup agrees

2330B REF Other Payer Claim Control Number Situational Rule Comment requests consistency in situational rule Workgroup felt the proposed rule would limit when the information could be sent and

determined the current rule was sufficient. 2330B REF02 Other Payer’s Claim Control Number

Comment requests consistency between segment name, situational rule, and industry name(Payer vs Payer’s).

Segment name will be changed to be Other Payer’s Claim Control Number Are there references to the segment used elsewhere that will need to be updated? ACTION: Kelly will research for other possible impacts

Segment situational rule will be modified to refer to Other Payer’s Claim Control Number These changes will apply across all 837s

2330C NM1 – Other Payer Referring Provider TR3 note Comment recommends modifying 2330C NM1 TR3 note for consistency when referring to the

NUCC manual See National Uniform Claim Committee (NUCC) 1500 Health Insurance Claim Form

Reference Instruction Manual for definition of professional providers. The definitions are also posted to the website as well as in the manual. Suggested it might be

better to reference website vs. the manual. Also suggested to include link to the NUCC main page rather than definitions to avoid possible

broken link in future Definitions can be navigated to directly from the home page Workgroup agrees

1.4.2.3.3 – Front matter – Example for adjudicated line split where adjudicated procedure is different Believe there is another comment that removes these items from TR3 to external site ACTION: Kelly to research

1.4.6 – K3 approval Comment requests adding location reference to where the K3 is within the TR3 Intent of section is that it can be the same across all guides and therefore specific TR3

references are not appropriate 1.6 – Common Content

Comment requests for location of the ARM to be included Will be forwarded to TGCWG5

2000B HL TR3 Note across the guides Comment requests updating TR3 note that includes specifying what a subscriber is. Previously reviewed for the professional 837. Workgroup disagreed

2400 REF02 Line Item Control Number Comment requests removal of quotes around value

2400 AMT – TR3 note Comment requests update to TR3 note to point to the correct location Agreed

2420A/2420C NM1 TR3 note



Comment requests updating for consistency in referring to NUCC Agreed

2420A/2420B REF Comment recommends referring to REF02 rather than REF01 Agreed

2420A/2420B/2420D REF01 - Element Note Note refers to REF04 and suggests making it a TR3 note Previous update to the TR3 note, does it already cover? Suggested that the current element note is clearer than the segment TR3 note and suggested

to replace segment TR3 note with the element note. 2420D NM Situational Rule for service location

Comment asks if situational rule for the line level should be similar to what is captured at theclaim.

Should be name/and or address as noted at the claim level? Not clear why reference to the subpart information was left off situational rule at the service line There were previous discussions surrounding how it should work based on NPI rule and will be

discussed further at the standing meeting Deferred to standing meeting

2430 SVD Situational Rule Missing comma in situational rule Will be fixed

2430 AMT Remaining Patient Liability Amount Situation Rule Comment requests modifying rule to be consistent with the claim level Agree splitting out the item as a separate AND statement makes it more clear

2010BA REF Property & Casualty Claim TR3 note Comment requests changing the “and” to “&” Agreed

1.12.6 Pre-Determination Comment suggests it doesn’t align with realistic business practices When this was determined there was a lot of discussion surrounding what info it should be Leave open for discussion at standing meeting

Decisions

See voting item Workgroup responses/decisions are documented in public comment spreadsheet


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Pittsburgh, PA Co-Chairs Posted to Central Desktop prior to themeeting

Interim Meeting Thursdays1:00 -2:30pm

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Public comment review (837), need to approve the workgroup decisions/responses asdetermined during the meeting.MotionTo approve the workgroup’s responses/decisions to 837 public comments asdiscussed during 6/22/2017 conference call.

Vote Motion Made by 2nd By Approve Disapprove AbstainKelly Butler Karen Shutt 42 0 0

Discussion None

Key Discussion Item: Attendance = 42Summary of Discussion: Public Comment Review (837)

Continued review of public comments and proposed responses to the 837 guides. Not all reviewed comments were finalized Only comments requiring additional discussion are detailed below. Workgroup decisions and responses are captured in the master spreadsheet

Reviewed comment responses that were worked in coordination with workgroup 6 For HPID related comments

All will use the same standard language (to align with 5010 errata for handling HPID),but based on the context of the comment will either be to agree or disagree asappropriate.

There was a question regarding how the HPID was defined/handled in the 5010 errata?In general, absent regulation, its use is limited to willing trading partners.

Some didn’t want HPID reported using the NM108/NM109 (preferred moving to aREF), however X12 management decision is to keep the HPID information in thetransaction as done in the 5010 errata.

It was noted that recent NCVHS recommendation to HHS is to rescind the rule regardingHPID, but this will take time.

At this point don’t believe workgroup has an option to do differently. Comments requesting modification of situational rule for middle name and name suffix

Comment requests to require when person has a middle name or suffix vs. the currentrule which requires when it is needed to identify the individual

Disagree will follow the current consistent format Comments requiring input from worker’s comp

2 comments were deferred until next week’s call ACTION: Lynn to add worker’s comp related comments to agenda for 6/29/2017

2300 REF Payer Claim Control Number Comment requests modifying situational rule to accommodate new frequency codes such as

noted in RFI #2173 (i.e., Q – reopening) In addition to using the claim frequency code of Q, an institutional claim also requires the use of

additional codes (condition codes) The only codes allowed for use on the 837P and 837D are 1, 7, and 8.

EasternManagementMeeting



Do any payers need Q for the professional? Not sure, but it is currently only establishedfor the institutional.

Rose volunteered to check if a reopening is needed on for professional The current subset of claim frequency codes for professional and dental was determined

by the workgroup Even if determined it should apply to professional, it would be in the future.

The current subset of codes is included in both the 1500 manual as well as being listedon the NUBC website

The RFI was generated because providers were having issues when submitting 837I claimswith claim frequency code of Q. When submitted along with the payer’s claim control number,claims were rejected by validation, but if submitted without the payer’s claim control numberthey were being returned by the payers as the info was needed. Some interpreted that areopening is in fact a type of a replacement of a previously adjudicated claim, but othersinterpreted differently which is the basis of the RFI.

Would it make sense to have the rule say when it is not needed, such as required when it is notan original bill? This would result in creating an unintended requirement for other claimfrequency codes such as 2nd bill, 3rd bill and final bills as well. There are about 30 frequency codes and it isn’t as simple as saying not the original.

Suggested to apply the proposed new situational rule across the 837s, but at this time it wouldonly be applicable to the 837I since a reopening does not apply to the 837P or 837D. Need to consider if this would create an issue for the industry if the situational rule

included an item that wasn’t applicable to the type of claim transaction. Considered referring to the NUBC manual which defines the claim frequency values, but this

won’t specify when the payer’s control number should be used. 837I with a Q frequency code would also have condition codes to explain the reasoning for

reopening. In addition to the Q not being a valid frequency code for professional and dentalclaims, the required condition codes are not part of the approved subset of condition codes thatcan be used on the professional claim.

Is it necessary to specify the details regarding why it is considered a previously adjudicatedclaim? Suggested using more generic language and potentially removing reference to theCLM05-03. This would move away from the work that has been done to point to other locationsin the TR3 for the purpose of validation. Trying to determine if there is a better, yet more generic way to define previously

adjudicated without specifying the exact language of the code values in CLM05-03. ACTION: Matt to check Medicare’s payer claim control number needs.

Workgroup members are ok with new situational rule for the 837I. For CMS, concern that they don’t support replacement, void or reopening Todd noted that a reopening is the same as a replacement, but it is outside of timely

filing limits. This is defined in the UB manual. Only the subset of approved claim frequency codes (which doesn’t include Q)

are defined outside of the UB manual. Suggested to change the language to more closely align with the NUBC

language The 837I needs to be able to capture this information for a reopened claim, but not sure

how it should apply across other 837s Do we need to consider the other payer claim control number? No, situational rule for

other payer claim control number isn’t tied to CLM05-03. Suggested to table so that folks can research. Consider posting different options on

iMeet and determine preferred language/approach. ACTION: Lynn to post start of discussion on iMeet



Reporting guide comments ACTION: Jamie to reach out to reporting guide folks regarding their availability to discuss items

impacting the reporting guide 2000B SBR09 – Addition of qualifier for Unknown 571 – ZZ was used in 5010 to fill gap between versions for a value of unknown. Now UK has been

added for unknown, but the ZZ qualifier is still there, but the commenter mentions U, not the UK. Disagree

PER04, 06, and 08 – Increased data length Comment requests constraining the length of PER04, 06, and 08 to what it was in 5010 DE 364 maximum length was increased in the standard and was rolled into the 7030 TR3s No business need for the increase based on the qualifiers currently being utilized in the 837 Workgroup agreed to limit to 256 characters as was supported in the 5010 version

1.4.2.2. – Front Matter Comment requests the paragraph beginning with “Payment adjustments” be modified to

reference using specific CARC codes prior to pointing to use of a default value. Suggested that this might be a duplicate comment.

ACTION: Kelly to check spreadsheet for possible duplicate commentsDecisions

See voting items Workgroup responses/decisions are documented in public comment spreadsheet


Public comment review (837), need to approve the workgroup decisions/responses asdetermined during the meeting.MotionTo approve the workgroup’s responses/decisions to 837 public comments asdiscussed during 6/29/2017 conference call.

Vote Motion Made by 2nd By Approve Disapprove AbstainKelly Butler Elizabeth Templeton 38 0 0

Discussion None


2017712-432-0393Access Code:219956



September25 - 29,2017

Pittsburgh, PA Co-Chairs Posted to Central Desktop prior to themeeting


712-432-0393Access Code:219956


ManagementMeeting



Key Discussion Item: Attendance = 38Summary of Discussion: General Announcements

When requesting OnlyConnect access also cc Jamie and Lynn in your request.Decisions

N/ASummary of Discussion: Public Comment Review (837)

Continued review of public comments and proposed responses to the 837 guides. 29 comments were reviewed or revisited Not all reviewed comments were finalized Only comments requiring additional discussion are detailed below. Workgroup decisions and responses are captured in the master spreadsheet

Reviewed comments requiring input from Worker’s Compensation Rows 215, 217, and 306 – N3 situational rule subscriber address (applies across all impacted

837 TR3s) Comment notes the 2nd portion of the rule requires the translator to validate information

in a lower HL that has not yet occurred and suggests changing to required when2010BA NM102=2 (Non-Person).

There have been some email discussion regarding this item. Concerns regarding how the change impacts the industry. Recommendation was to leave requirement somewhat generic in regards to

worker’s comp, rather than specifying that it must be a specific value inPAT01=20.

Re-write of situational rule was done as part of situational rule work that was done toallow for validation within the transaction.

The email discussion included a suggestion to point to the value in SBR09 rather thansuggested 2010BA NM102=2 as there are scenarios in certain states where thesubscriber may or may not be a person.

For Worker’s Comp, do providers always send the WC value in SBR09? Normally yes.This is included in the IAIABC specifications and state companion guides. However, aswith any rule providers don’t always follow. One company reported seeing 20% notusing WC.

What is wrong with using PAT01=20? The objection was because this is lower in thetransaction, but there are a number of edits that will require validation of informationfound lower in the transaction. Also, PAT01=20 didn’t work because of type 1 or type 2(the type isn’t necessarily the issue but the employment relationship is).

If they are doing worker’s compensation, failure to comply with sending WC in SBR09 isan education issue.

Pointing to 2000B SBR09 = WC is a better solution for translators. Does the workgroup now require pointing to a value vs using a more generic rule that

can be applied differently across the industry? This was an overall effort to try and giveprecise locations within the transaction that could be used to determine when to send (ornot send) particular data.

Supports transaction editing. This won’t prevent other editing from occurring, butat least they can check this.

Row 284 - Payer Claim Control Number Comment requests updating situational rule to account for other frequency codes such as Q -

reopening. An iMeet discussion topic was posted regarding this topic For Medicare Part B, everything is considered an original claim and won’t come into play.



Only one comment made to iMeet discussion and it was in support of the workgroup suggestedresolution. Which was to modify the situational rule to, Required when CLM05-03 (ClaimFrequency Code) indicates the claim is a replacement, void, or reconsideration/reopening of apreviously adjudicated claim. If not required by this implementation guide, do not send.

Determined not to include language regarding timely filing limits associated with the UBdefinition of reopening.

This rule will be shared across all 837 TR3s. Row 595 – 2300 REF Medical Record Number situational rule

Comment requests removing reference to being needed for use in future inquiries Is this actually used? Some may use the medical record number in their communications back

to providers to help them correct or change items/things they submitted. Can also be used as avalidation to group claims across time for a particular patient.

The medical record is on the UB04, not sure of how it is being used/intended usage. The situational rule is pretty loose. Does the medical record number have a use? Would the

payer ever come back to hospital and ask for information? They may ask for information in themedical record, but not typically the entire medical record and the number is used as reference.

Whether a payer uses or not wouldn’t impact how some feel we should respond to thecomment. One payer noted they were not using this information in their communications with the

provider, but doesn’t feel like leaving the value in the transaction is problematic. In reviewing the commenter’s proposed rule, it wasn’t clear why the provider would need to

identify? If we remove the provider, it would take away the sender’s discretion aspect of the rule

and would create a situation where the receiver could decide it is needed. Medical record is also in other transactions (claim status, 835) and will need to consider

impacts across other guides. Undecided, consider for a future guide.

Row 596 –2010BA NM1 TR3 notes Comment regarding redundant TR3 notes in the NM1 that are already in the HL Workgroup previously reviewed similar comments, but had 2 different responses.

For some the workgroup agreed to remove notes (Row 25) For others the workgroup agreed to change note (Rows 24, 27, and 28)

Revised response to align with row 25 Row 603 – 2430 SVD modifier situational rules

Comment requests changing modifier situational rules in SVD to be similar to those in SV2. SV2 and SVD purposes are different , one is submitted and other is adjudicated Might depend on what is expected on the 835. Will coordinate with TGBWG3, but workgroup 2 is in consensus to leave as is.

Row 609 – 2300 HI segment (837D) Comment requests keeping the qualifier ABK – for primary dx

This was intentionally removed. Link is at the service line and established by thepointer.

Disagree, the primary diagnosis code is determined on a dental claim by the diagnosis codepointer on the service line.

Row 610 23000 DN104 – element note Comment indicates that the element note duplicates part of situational rule. The only allowed value for DN104 is Y, which indicates that services reported on this claim are

for orthodontic purposes. DN104 semantic note indicates that this is for the appliance description Not clear why DN103 (condition indicator) is not being used instead of the DN104



It wasn’t clear why having the month information wasn’t sufficient. It is believed it might beneeded when the month details aren’t applicable, but is still orthodontics

Need dental input. ACTION: Lynn to reach out to dental folksDecisions

See voting items Workgroup responses/decisions are documented in public comment spreadsheet

B2_TGB_WG2_InterimAttendance_MayJun2017.xlsx

LAST NAME FIRST NAME COMPANY

Thursday,

May 4,

2017

Thursday,

May 11,

2017

Thursday,

May 18,

2017

Thursday,

May 25,

2017

Thursday,

June 1,

2017

Thursday,

June 22,

2017

Thursday,

June 29,

2017

Amezcua Ana Optum X

Bandula Athalage Horizon Blue X X X X X X X

Banks Jodie RelayHealth/McKesson X X

Banks Tammy Optum X

Beatty Gary X12 X

Bendix Jolene Blue Cross MN X X

Benson TonyBlue Cross Blue Shield ofAlabama

X X X X

Brannan Annie (Andrea) Mayo Foundation X X

Brent LindaBlue Cross Blue Shield of SouthCarolina

X X X X X X

Burckhardt Laurie WPS Insurance Corp. X X X X X X

Butler Kelly Change Healthcare X X X X X X X

Caldwell Laura CSC X X X X

Cannady Patrick American Dental Association X

Carter MarkState Farm InsuranceCompanies

X

Chapple Lynn UnitedHealth Group X X X X X

Cianciola Joyce Anthem X

Cioffi Chris Anthem X X X X X

Clore BetsyWake Forest University HealthSciences

X

Cloutier SteveBlue Cross Blue Shiedl ofMichigan

X X

Coats Gwen Gwen Coats, IM X X

Cunningham Terrence AMA X X X X

Davis GloriaQSI/NextGen HealthcareInformation System

X X X

Depeaux JaneHorizon Blue Cross Blue Shieldof NJ

X X X X X

Ehnot Kim Cerner Corporation X X X X

Evans Elitsa McKesson X X X

Evelsizer ChipState Farm InsuranceCompanies

X X

Fiore Cynthia United Health Group X X X X X X

Foerster RachelRachel Foerster & Associates,and CAQH

X X

Printed on: 07/13/2017 Page 1 of 3



Thursday,

May 4,

2017

Thursday,

May 11,

2017

Thursday,

May 18,

2017

Thursday,

May 25,

2017

Thursday,

June 1,

2017

Thursday,

June 22,

2017

Thursday,

June 29,

2017

Fortek Rebecca Mayo Foundation X X X X X

Gracon Christopher J Independent Health X X X X

Green Christol Anthem X X X

Helfrich Patrick Cerner Corporation X

Helm Mary Hewlett Packard Enterprise X X X X X

Hodges Rose Aetna, Inc. X X X X X X

Isgett Robin Palmetto GBA X X X X X

Jones Jan Utah Health Information Network X

Kirnbauer Eric Tesia Clearinghouse, LLC X X X X X

Klischer Matt CMS/HHS X X X X X

Kryltsova Tanya Edifecs Inc. X X X

Laurie Tony Noridian Healthcare Solutions X X X

Leib, M.D., J.D.MarcAmerican Society ofAnesthesiologists

X X X X X

Lengyel-GomezBetty Xerox X

Medrano Jimmy VA X X

Meisheid Anna HHS/CMS X

Mendenhall Gigi Hewlett Packard Enterprise X

Mills Katrina CMS X

Mintz Harvey CSRA X X X X X

Monarch Cindy BCBS Michigan X

Money JillBlue Cross and Blue Shield ofMI.

X

Mosteller Jamie Cerner Corporation X X X

Nachimson Stanley Nachimson Advisors, LLC X X X X X

Nichols MichaelBlue Cross Blue Shield of SouthCarolina

X

Nichols Sharon Availity, LLC X

Olsen Amanda Utah Health Information Network X

Omundson Todd American Hospital Association X X X X X X

Parks Charlene HHS/CMS X X X X X




Thursday,

May 4,

2017

Thursday,

May 11,

2017

Thursday,

May 18,

2017

Thursday,

May 25,

2017

Thursday,

June 1,

2017

Thursday,

June 22,

2017

Thursday,

June 29,

2017

Presser StewartGreater New York HospitalAssociation

X

Rabuffo Mark Aetna, Inc. X X X X

Reitz Brian CMS X X X X X

Richardson Christy Availity, LLC X X X

Rose Tara QSI/NextGen X

Roush Tiffany Utah Health Information Network X X

Rudolph Barbara CHSRA -WI X X X X X X X

Sakhnov Julia Edifecs Inc. X X X X X X X

Sallee Stacey Accenture X

Scheid Tyler AMA X X X X X

Shutt Karen Highmark, Inc. X X X X

Sites Kathy Availity, LLC X X

Spector Nancy American Medical Association X X X X X X

Sullivan Katie Cognosante, LLC X X X X X X

Templeton Elizabeth GuideWell Source X X

Thompson Sue NCPDP X

Titterington Susan Practice Insight, LLC X X

Turoczi Katherine (Kitt) Medical Mutual X

Ullah Mohammad CMS/HHS X X

Walker Duane BCBSM X X X X X X X

Wei Daniel Athena Health X X X X

Weingarth JoAnne Anthem X X X X

Wilson Sherry Jopari Solutions, Inc. X

Woodrome LaurieLaboratory Corporation OfAmerica X X


group minutes x12n tgb/wg2 billing and encounter … · note is ok #54232 – typo in situational...

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