Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 868 Date: March 9, 2011

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1 anual ystem Pub One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 868 Date: arch 9, 2011 hange equest 7289 Transmittal 855, dated ebruary 4, 2011 is being rescinded and replaced by Transmittal 868 dated arch 9, orrection to the Error eport ecord to fix typos and incorrect formulas that were not identified during the s PO reviews. ll other information remains the same. UBJET: July ommon Edits and Enhancements odule (E) and eceipt, ontrol, and Balancing Updates. UY O NGE: The purpose of this hange equest () is to instruct the E developers, Part and B edicare dministrative ontractors (), and the Durable edical Equipment (DE) ommon Electronic Data nterchange (ED) contractor in their continuing development efforts of the E and eceipt, ontrol, and Balancing software and environment requirements. This instruction includes issues identified during the lpha, Beta and User cceptance Testing (UT) test periods. EETVE DTE: July 1, 2011 PLEENTTON DTE: July 5, 2011 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NGE N NUL NTUTON: (N/ if manual is not updated) =EVED, N=NEW, D=DELETED-Only One Per ow. /N/D N/ PTE / ETON / UBETON / TTLE. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: Not pplicable. or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.

2 V. TTENT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

3 ttachment One-Time Notification Pub Transmittal: 868 Date: arch 9, 2011 hange equest: 7289 Transmittal 855, dated ebruary 4, 2011 is being rescinded and replaced by Transmittal 868, dated arch 9, orrection to the Error eport ecord to fix typos and incorrect formulas that were not identified during the s PO reviews. ll other information remains the same. UBJET: July ommon Edits and Enhancements odule (E) and eceipt, ontrol, and Balancing Updates Effective Date: July 1, 2011 mplementation Date: July 5, GENEL NOTON. Background: The enters for edicare and edicaid ervices () is in the process of implementing the next version of the ealth nsurance Portability and ccountability ct transactions. The ecretary of the Department of ealth and uman ervices (D) has adopted ccredited tandards ommittee () X12 Version 5010 and the National ouncil for Prescription Drug Programs (NPDP) Version D.0 as the next P transaction standards for covered entities to exchange P transactions. The final rule was published on January 16, ome of the important dates in the implementation process are: Effective Date of the regulation: arch 17, 2009 Level compliance by: December 31, 2010 Level compliance by: December 31, 2011 ll covered entities have to be fully compliant on: January 1, 2012 Level compliance means that a covered entity can demonstrate that it could create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing. Level compliance means that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards. D has promulgated in the inal ules provisions which permit dual use of existing standards ( X and NPDP 5.1) and the new standards (5010 and D.0) from the arch 17, 2009, effective date until the January 1, 2012 compliance date to facilitate testing subject to trading partner agreement. The purpose of this hange equest () is to instruct the E developers, Part and B edicare dministrative ontractors (), and the Durable edical Equipment (DE) ommon Electronic Data nterchange (ED) contractor in their continuing development efforts of the E and eceipt, ontrol, and Balancing software and environment requirements. This instruction includes issues identified during the lpha, Beta and User cceptance Testing (UT) test periods. This instructs the /B s, ED, and the hared ystem aintainers of the E software in the development and implementation of new error reporting capabilities for version 5010 claims. has been holding weekly work group meetings with the s, ED, and E developers for several months to determine the requirements.

4 Estimates for this should include a breakdown as part of the Level of Effort (LOE) response, utilizing the following table to be included in the Estimate-pecific omments portion of the LOE template, to follow the nvestment Lifecycle Phases. nvestment Lifecycle Phase Total ours Total ost Pre-mplementation/ eview Design & Engineering Phase Development Phase Testing Phase mplementation Phase Note that the Pre-mplementation/ eview costs will not be funded under the unique funding situation for the 5010/D.0 project, but instead out of the s pot of hours for Pre-mplementation/ eview. B. Policy: ealth nsurance eform: odifications to the ealth nsurance Portability and ccountability ct (P): inal ules published in the ederal egister on January 16, 2009, by the D at 45 Part BUNE EQUEENT TBLE Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers The /B contractors shall generate an error record as output from their translator corresponding to each instance of a 277 T error (as documented in the 837 Edits preadsheet) occurring at the T-E level during translation from the X12 format to the flat file for version claim transactions The DE ED contractor shall generate an error record as output from their translator corresponding to each instance of a 277 T and/or a 277 error (as documented in the 837 Edits preadsheet) occurring at the T-E level during translation from the X12 format to the flat file for version claim transactions The DE ED contractor shall generate an error record as output from their translator for all business level edits encountered during translation from the NPDP D.0 format to the flat file for version D.0 transactions The /B contractors shall place the error records in an input folder (to be developed by the E developers) for inclusion in the Error ecord X X E V W ED ED

5 Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers data base for future reporting The DE ED contractor shall place the error in the Error ecord data base for future reporting The hared ystem aintainers of the ommon Edits and Enhancement odule (E) software shall generate an error record as output from the E to each instance of a 277 error (as documented in the 837 Edits preadsheet) occurring at the T-E level during the E processing of the translated flat file for version claim transactions The hared ystem aintainers of the E software shall create a process for the collection of error records from both the /B s translator output and the E software error records for the purposes of database normalization prior to insertion in the newly developed Error eporting Database The hared ystem aintainers of the E software shall create a process for the extraction of error records from the newly developed Error eporting Database for the purposes of creating the /B s Top 10 Error eport and the ubmitter Error ate eport. These extract files shall be in a omma eparated Value (V) format in icrosoft Excel Version 2003 or higher in compliance with the /B s tatement of Work under deliverables The /B s and the ED contractor shall post to its internet web page(s) the /B s Top 10 Error eport. This extract file shall be in a omma eparated Value (V) format in icrosoft Excel Version 2003 or higher in compliance with the /B s tatement of Work under deliverables The /B s shall use the V from business requirement to generate the readable report for postings and listserv messages The hared ystem aintainers of the E software shall create a process for the purging of error records from the newly developed Error eporting Database. This purge process shall be parameter driven in order for the /B s to control the size and performance of the database in its LD environment The hared ystem aintainers of the E software shall create a process for the backing-up of records X X E V W ED E E E ED E E

6 Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers contained the newly developed Error eporting Database as appropriate for the LD environment which shall include processes to synchronize E Editing processes with the Error eporting processes The ED contractor shall create a process for the extraction of error records from the newly developed Error eporting Database for the purposes of creating the ED/DE s Top 10 Error eport. This extract file shall be in a oma eparated Value (V) format in icrosoft Excel Version 2003 or higher in compliance with the DE s and ED tatement of Work under deliverables The ED contractor shall create a process for the purging of error records from the newly developed Error eporting Database. This purge process shall be parameter driven in order for the ED contractor to control the size and performance of the database in its LD environment The ED contractor shall create a process for the backing-up of records contained the newly developed Error eporting Database as appropriate for the LD environment which shall include processes to synchronize ED Editing processes with the Error eporting processes The hared ystem aintainers of the E software shall create a Edit Business Description table (to be driven from the Part and Part B edits spreadsheets) within the newly developed Error eporting Database The hared ystem aintainers of the E software shall create a process in the newly developed Error eporting Database to crosswalk from the edit numbers, being reported on the ETD reports, and populate the edit business description on the extract from the /B s Top 10 Error eport and the ubmitter Error ate eport The hared ystem aintainers of the E software shall create a purge process (if already developed, this could mimic the process put in place for the Dupe table from 7090) keying on values ET11 and ET13 from the Error ate eport ecord. E V W ED ED ED E E E

7 . POVDE EDUTON TBLE Number equirement esponsibility (place an X in each applicable column) / D hared- ystem OT E B E aintainers None. E V W V. UPPOTNG NOTON ection : or any recommendations and supporting information associated with listed requirements, use the box below: N/ X-ef equirement Number ecommendations or other supporting information: ection B: or all other recommendations and supporting information, use this space: N/ V. ONTT Pre-mplementation ontact(s): Jason Jackson (410) jason.jackson3@cms.hhs.gov ichael abral (410) Post-mplementation ontact(s): ontact your ontracting Officer s Technical epresentative (OT) or ontractor anager, as applicable and the pre-implementation contacts: Jason Jackson (410) jason.jackson3@cms.hhs.gov ichael abral (410) V. UNDNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers: Not pplicable ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. ttachments - 2

8 Payer D/tate Workload Number Edit Number Number of Edit occurences Business Edit essage

9 - Error eport ecord Element dentifier ontrol ecord ross-walk Description Data Type ecord Position tart ecord Position End Length Picture lause Values ET T Error eport ecord ET01 Error eport ecord D /N Pic X(04) ETD - Error record for T-E level error information ET - Error record for -E level error information (ET records are to contain roll-up information for their associated ETD records) ET02 T02 Transaction Type /N Pic X(05) 837, NPDP ET03 T04 Transaction Line of Business /N Pic X(01) laims only - nstitutional P- Professional N- NPDP ET04 T05 nterchange ender D /N Pic X(15) data element NPDP K1 NPDP batch header ET05 T14 nterchange ontractor D /N Pic X(15) T14 NPDP K7 NPDP batch header ET06 T07 nterchange reate Date NU Pic 9(08) data element Note: 09 is format YYDD (6 bytes) this field will require the (20) to be appended to the beginning of the 09 value so final format is YYDD NPDP K2 NPDP batch header ET07 T08 nterchange reate Time NU Pic 9(04) data element NPDP K3 NPDP batch header ET08 T09 nterchange ontrol Number NU Pic 9(09) data element NPDP NPDP batch header ET09 T10 nterchange Version /N Pic X(05) (12 data element) NPDP - D.0 ET10 T11 nterchange Test/Prod ndicator /N Pic X(01) T- Test P- Production ET11 N/ ycle Date NU Pic 9(07) YYYYDDD (Julian Date) To be populated by the ET12 N/ reate Time NU Pic 9(06) To be populated by the ET13 T15 E ycle Date NU Pic 9(07) YYYYDDD (Julian Date) To be populated by the E ET14 T16 E reate Time NU Pic 9(06) To be populated by the E ET15 T17 Local Data enter Tracking /N Pic X(30) ET16 T20 Total number of UNT segments ent ET17 T22 Total dollar amount sent submitted charges NU Pic 9(09) Total number of the units counted for the transaction type L NPDP- 00 (this value is based on the segment D in positions of the flat file) NU Pic 9(11)v This is the total dollar value T-E NPDP DU ET18 N/ Error percentage holder NU Pic 9(03)v99 ET only - alculation is: (ET24 / ET16) x 100 ET19 N/ Edit eference Number /N Pic X(30) ETD only This is the edit number from the 837 Edit spreadsheet ET20 N/ Edit ount NU Pic 9(04) ETD - number of times the edit set in that T-E ET - number of times the edit set within an -E ET21 N/ Business Edit Language /N Pic X(252) ETD only ET22 T01 ontrol ecord D /N Pic X(04) TD or T ET23 N/ Transaction et ontrol Number /N Pic X(09) ETD - T02 from inbound 837 file ET - Blank ET24 N/ # of laims in Error NU Pic 9(09) ETD - total number of units counted in ET20 with error reported in ET19 ET - ll claims in error - shoud align with T30 from the 277 control record ET25 N/ iller /N Pic X(42) evised 01/24/ of 1 Error Key

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2150 Date: February 4, 2011

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 2150 Date: February 4, 2011 anual ystem Pub 100-04 edicare laims Processing Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 2150 Date: ebruary 4, 2011 hange equest 7319 UBJET: pril Update