MoHealthNet HIPAA Transaction Standard Companion User Guide

MoHealthNet HIPAA Transaction Standard Companion

Product Information

Specifications

• Product Name: MO HEALTHNET EDI COMPANION GUIDE
• HIPAA Transaction Standard Companion Guide
• Implementation Guides Based on ASC X12 version 005010
• Companion Guide Version Number: 2.10
• Published: December 2023

Introduction

• The MO HEALTHNET EDI COMPANION GUIDE is a document intended for billing providers and technical staff who wish to exchange electronic transactions with MO HealthNet. It provides information on how to populate data elements specific to the payer or trading partner and explains how claims are processed within the Missouri Medicaid Management Information System (MMIS) based on the choices made for certain data elements.
• This Companion Guide is relevant to both HIPAA covered and non-covered entities.

Getting Started
In this section, you will find information on how to work with MO HealthNet, including trading partner registration, certification, and testing overview.

1. Working with MO HealthNet
   This subsection provides guidance on how to interact with MO HealthNet when exchanging electronic transactions.

2. Trading Partner Registration
   This subsection explains the process of registering as a trading partner with MO HealthNet.

3. Certification and Testing Overview
   This subsection provides an overview of the certification and testing process for electronic transactions with MO HealthNet.

Connectivity with the Payer
In this section, you will find information on the transmission administrative procedures, communication protocol specifications, and passwords related to connecting with the payer.

1. Transmission Administrative Procedures
   This subsection provides guidance on the administrative procedures for transmitting electronic transactions to MO HealthNet.

2. Communication Protocol Specifications
   This subsection provides specifications for the communication protocols to be used when exchanging electronic transactions with MO HealthNet.

3. Passwords
   This subsection explains the password requirements and guidelines for accessing MO HealthNet’s systems.

Contact Information
In this section, you will find contact information for EDI customer service, provider services, and applicable websites.

1. EDI Customer Service
   This subsection provides contact information for MO HealthNet’s EDI customer service.

2. Provider Services
   This subsection provides contact information for MO HealthNet’s provider services.

3. Applicable Websites
   This subsection lists the websites that are relevant to exchanging electronic transactions with MO HealthNet.

Payer Specific Business Rules and Limitations
In this section, you will find information on business scenarios, payer specific business rules and limitations, and scheduled maintenance related to electronic transactions with MO HealthNet.

1. Business Scenarios
   This subsection provides examples of business scenarios related to electronic transactions with MO HealthNet.

2. Payer Specific Business Rules and Limitations
   This subsection explains the specific business rules and limitations set by MO HealthNet for electronic transactions.

3. Scheduled Maintenance
   This subsection provides information on scheduled maintenance activities that may affect electronic transactions with MO HealthNet.

Acknowledgements
This section acknowledges the contributors and organizations involved in the development of the MO HEALTHNET EDI COMPANION GUIDE.

FAQ

1. Where can I find MO HealthNet policy billing issues?
2. What version of ASC X12 is used in this Companion Guide?
3. Is this Companion Guide applicable to both HIPAA covered and non-covered entities?
4. How do I register as a trading partner with MO HealthNet?
5. What are the communication protocol specifications for exchanging electronic transactions with MO HealthNet?
6. What are the password requirements for accessing MO HealthNet’s systems?
7. Who should I contact for EDI customer service?
8. Where can I find applicable websites for electronic transactions with MO HealthNet?
9. Are there any scheduled maintenance activities that may affect electronic transactions with MO HealthNet?

HIPAA Transaction Standard Companion Guide
Refers to the Implementation Guides Based on ASC X12 version 005010

• Companion Guide Version Number: 2.10
• December 2023

Disclosure Statement
This document is intended for billing providers and technical staff who wish to exchange electronic transactions with MO HealthNet. This document is to be used in conjunction with the ASC X12N Implementation Guides to define transaction requirements. It does not define MO HealthNet policy billing issues. These types of issues can be found in the MO HealthNet Provider Manuals through the MO HealthNet Division’s website at https://www.emomed.com . These documents are for version 5010.
Express permission to use ASC X12 copyrighted materials within this document has been granted.

Preface
This Companion Guide to the ASC X12N Implementation Guides adopted under HIPAA clarifies and specifies the data content being requested when data is transmitted electronically to the MO HealthNet fiscal agent. Transmissions based on this companion document, used in tandem with the ASC X12N Implementation Guides, are compliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

EDITOR’S NOTE:
This page is blank because major sections of a book should begin on a right hand page.

Introduction

1. Scope
   The Companion Guide provides information for populating data elements that are defined as payer or trading partner specific. In addition, it provides explanation of how claims are processed within the Missouri Medicaid Management Information System (MMIS) when specific data elements are populated with each of the valid choices (e.g., claim frequency type). This Companion Guide contains information that is relevant to both HIPAA covered and non- covered entities.

2. Overview
   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 requirement documents. This Companion Guide conforms to all the requirements of any associated ASC X12 Implementation Guide and is in conformance with ASC X12’s Fair Use and Copyright statements.

References

ASC X12 Implementation Guides

• This table lists the X12N Implementation Guides for which specific Transaction Instructions apply and which are included in Section 10 of this document. Implementation guides for 5010 can be purchased from the ASC website at: http://store.x12.org/
• The Companion Guide explains the procedures necessary for trading partners to successfully exchange transactions electronically with MO HealthNet in standard HIPAA compliant formats. These transactions include the following:

Unique ID Name

• [005010X222] Health Care Claim: Professional (837)
• [005010X223] Health Care Claim: Institutional (837)
• [005010X224] Health Care Claim: Dental (837)
• [005010X279] Health Care Eligibility Benefit Inquiry and Response (270/271)
• [005010X221] Health Care Claim Payment/Advice (835)
• [005010X212] Health Care Claim Status Request and Response (276/277)
• [005010X220] Benefit Enrollment and Maintenance (834)
• [005010X218] Payroll Deducted and Other Group Premium Payment for Insurance Products (820)
• [005010X231] Implementation Acknowledgment For Health Care Insurance (999)
• [005010X217] Health Care Services Review – Request for Review and Response (278)

MO HealthNet Provider Manuals
MO HealthNet Provider Manuals can be accessed through the MO HealthNet Division’s website at https://www.emomed.com .

CAQH/CORE
The Committee on Operating Rules for Information Exchange (CORE) is a multi- phase initiative of Council for Affordable Quality Healthcare (CAQH). CAQH aims to reduce administrative burden for providers and health plans. For more information visit http://www.caqh.org/benefits.php .

CORE WSDL
MO HealthNet uses a Web Service Description Language (WSDL) file called CORERule2.2.0 and is available at http://www.caqh.org/ .

Additional Information

Researching Missing/Late Files
To resolve a late or missing 835, you will need to contact the Wipro Technical Help Desk at 573-635-3559. If you are inquiring about a missing or late EFT payment, you will need to contact your financial institution.

Getting Started

1. Working with MO HealthNet

2. To begin exchanging EDI transactions with MO HealthNet, a biller must select one of four options for the exchange of electronic transactions. The first option is via an Internet connection (eMOMED) through an Internet Service Provider (ISP) of the billers’ choice. The second option utilizes Sterling Commerce’s Connect:Direct software to link directly to Wipro Infocrossing Healthcare Services Data Center. The third option utilizes Secure File Transfer Protocol (SFTP). The fourth option utilizes Web Services Connectivity.

3. Billers opting to use the Internet connection option are responsible for any costs involved in obtaining and use of the ISP to connect to the Internet. No additional cost is charged by MO HealthNet or its fiscal agent to use the Internet connection solution. A biller choosing this option must complete an eMOMED Access Agreement at
   https://www.emomed.com . For assistance with this form, call the Wipro Infocrossing Technical Help Desk at 573-635-3559.

4. Billers opting to use the Connect:Direct software solution should be aware that they are responsible for all setup and on-going cost involved in the purchasing and maintaining of the software, as well as for paying a monthly port charge to Wipro Infocrossing as long as the connection is available for use. Billers should complete, sign, and mail the Application for MO HealthNet Connect:Direct Access Account and be contacted by technical support before purchasing the software. This application is available by emailing the Wipro Infocrossing Technical Help Desk at help.desk@momed.com . Upon receipt of the signed application, a Wipro Infocrossing technical support person will make contact asking for information needed to ensure the correct software is purchased.

5. Billers opting to use the SFTP connection are responsible for any costs involved with obtaining a SFTP server including a monthly charge to Wipro Infocrossing to use the SFTP connection. A biller choosing to use SFTP should contact the Wipro Infocrossing Technical Help Desk at help.desk@momed.com .

6. Billers opting to use Web Services Connectivity are responsible for any costs involved in the connection. No additional cost is charged by MO HealthNet or its fiscal agent to use the Web Services Connectivity solution. A biller choosing this option must complete the eMOMED Access Agreement at https://www.emomed.com , then email the Wipro Infocrossing Technical Help Desk at help.desk@momed.com for assistance.

7. Trading Partner Registration

8. In addition to selecting a connection method, a biller must complete a Trading Partner Agreement form. The Trading Partner Agreement form is used to communicate trading partner identifiers and to indicate which transactions the biller wishes to exchange. The form is available at https://www.emomed.com . For assistance with this form call the Wipro Infocrossing Technical Help Desk at 573-635-3559.

9. An EDI Trading Partner is defined as any MO HealthNet customer (provider, billing service, software vendor, etc.) that transmits to, or receives electronic data from MO HealthNet.

10. Certification and Testing Overview
    Certification from a third party is not required to exchange EDI transactions with MO HealthNet; however, doing so can help speed the process of approval of the billers’ transactions. Each type of transaction a biller wishes to send to MO HealthNet must pass test requirements before the biller is set up to send production transactions. Successful completion of test requirements requires, at a minimum, that the transactions are HIPAA compliant.

Testing with the Payer

HIPAA 5010 is the only version accepted by MO HealthNet.

1. MO HealthNet Web Portal (eMOMED)
   If the biller has chosen to exchange data through eMOMED:

2. Register for an eMOMED account by selecting “Register Now!” on www.emomed.com .

3. For new eMOMED accounts, log on to the account and request access to appropriate National Provider Identifier(s) (NPI).

4. Complete the Inbound Trading Partner Agreement (eMOMED batch users only) which can be accessed from section 9.2 of this document

5. Once the Trading Partner Agreement has been processed, an email is sent with instructions on testing procedures

6. Connect:Direct Option
   For information on Connect:Direct, please email the Wipro Infocrossing Technical Help Desk at help.desk@momed.com .

7. SFTP Option
   For information on SFTP, please email the Wipro Infocrossing Technical Help Desk at help.desk@momed.com .

8. Web Services Connectivity

9. For information on Web Services Connectivity, please email the Wipro Infocrossing Technical Help Desk at help.desk@momed.com .

10. Batch submissions have a size limitation of 2MB and can be in a zip file. Real time has a size limitation of 3KB.

Connectivity with the Payer

1. Transmission Administrative Procedures
   MO HealthNet processes batch transactions and Internet direct data entry (DDE) submissions every week night. Any expected response transactions can be accessed the following business day. Billers experiencing problems with sending or receiving files may contact the Wipro Infocrossing Technical Help Desk at 573-635-3559 or by email at help.desk@momed.com .

2. Communication Protocol Specifications
   The MO HealthNet Billing website, https://www.emomed.com , uses https (secured http) to send and receive transactions. Billers using Connect:Direct have a direct link to the fiscal agent, resulting in a secure connection.

3. Passwords
   In order to submit a batch or real time transmission, a biller needs either their Internet User ID and password or their NDM ID and password. Passwords are not required within a transaction.

Contact Information

1. EDI Customer Service
   For questions pertaining to EDI processes, billers should first reference the appropriate Implementation Guides at http://store.X12.org or the Companion Guides at
   https://www.emomed.com . If answers are not available within these guides, billers may contact the Wipro Infocrossing Technical Help Desk at 573-635-3559.

2. Provider Services
   Billers with questions pertaining to MO HealthNet policies should first access the MO HealthNet Provider Manuals and MO HealthNet Electronic Billing Layout Manuals found at https://www.emomed.com . If answers are not available from these manuals, billers may contact the MO HealthNet Provider Relations hotline at 573-751-2896.

3. Applicable Websites

4. ASC X12N HIPAA Implementation Guides are accessed at http://store.X12.org .

5. This HIPAA Companion Guide is accessed at https://www.emomed.com .

6. MO HealthNet transaction and DDE submission and receipts are accessed at https://www.emomed.com .

7. MO HealthNet Provider Manuals and MO HealthNet Electronic Billing Layout Manuals are accessed at https://www.emomed.com .

Control Segments/Envelopes

ISA-IEA

Batch

• This section describes MO HealthNet’s use of the interchange control segments specifically for batch transactions. It includes a description of expected sender and receiver codes and delimiters.
• Note: MO HealthNet supports the Basic Character Set as described in Appendix B of the ASC X12N Implementation Guides.

Table 1, Incoming Transactions to MO HealthNet

the Trading Partner Agreement.
NA| ISA| ISA07| Use ‘30’
NA| ISA| ISA08| Use ‘431754897’
NA| ISA| ISA13| Each submitter must start with a value of their choice and increment by at least one (1) each time a file is sent.

Table 2, Outgoing Transactions from MO HealthNet

segment terminator.
NA| ISA| ISA05| MO HealthNet uses ‘30’
NA| ISA| ISA06| MO HealthNet uses ‘431754897’
NA| ISA| ISA07| MO HealthNet uses ‘ZZ’
NA| ISA| ISA08| MO HealthNet uses the 9-digit MO HealthNet provider ID.
NA| ISA| ISA11| MO HealthNet uses ‘<’
NA| ISA| ISA16| MO HealthNet uses ‘!’ as a component element separator.

On-Line

• This section describes MO HealthNet’s use of the interchange control segments specifically for on-line transactions. It includes a description of expected sender and receiver codes and delimiters.
• Note: MO Healthnet supports the Basic Character Set as described in Appendix B of the ASC X12N HIPAA Implementation Guides.On-line transactions must be preceded by a 4-byte CICS transaction ID, followed immediately by ‘ISA’. A unique CICS transaction ID is assigned to each POS vendor for each on-line transaction. Contact Wipro Infocrossing Technical Help Desk if you are unsure of the CICS transaction ID(s) for your company.

Table 3, Incoming Transactions to MO HealthNet

Table 4, Outgoing Transactions from MO HealthNet

segment terminator.
NA| ISA| ISA05| MO HealthNet uses ‘30’
NA| ISA| ISA06| MO HealthNet uses ‘431754897’
NA| ISA| ISA07| MO HealthNet returns value sent in ISA05 of incoming transaction.
NA| ISA| ISA08| MO HealthNet returns value sent in ISA06 of incoming transaction.
Loop| Segment| Data Element| Comments
---|---|---|---
NA| ISA| ISA16| MO HealthNet uses ‘!’ as a component element separator.

GS-GE

Batch
This section describes MO HealthNet’s use of the functional group control segments specifically for batch transactions. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how MO HealthNet expects functional groups to be sent and how MO HealthNet sends functional groups. These discussions describe how similar transaction sets are packaged and MO HealthNet’s use of functional group control numbers.

Table 5, Incoming Transactions to MO HealthNe

the Trading Partner Agreement.
NA| GS| GS03| Use ‘431754897’

Table 6, Outgoing Transactions from MO HealthNet

On-Line
This section describes MO HealthNet’s use of the functional group control segments specifically for on-line transactions. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how MO HealthNet expects functional groups to be sent and how MO HealthNet sends functional groups. These discussions describe how similar transaction sets are packaged and MO HealthNet’s use of functional group control numbers.

Table 7, Incoming Transactions to MO HealthNet

Table 8, Outgoing Transactions from MO HealthNet

transaction.

Payer Specific Business Rules and Limitations

1. Business Scenarios
   This section contains all typical business scenarios with transmission examples. The scenarios and examples are intended to be explicit examples of situations that are not described in detail within the implementation guide.

2. Payer Specific Business Rules and Limitations

3. This section contains payer-specific information that is not necessarily tied to specific data elements or segments (which are more appropriately described in section 2). It includes descriptions of business rules, processes, or limitations that impact how the payer uses the content of inbound transactions or creates the content of outbound transactions. This information is intended to help the trading partner understand the business context of the EDI transactions.

4. Category 1: TR3 front matter, notes, or other specifications that identify two or more optional business alternatives for the payer or other sending entity.
   Example: 005010X221 (835)

5. Scheduled Maintenance
   MO HealthNet schedules regular maintenance. Real time processing is not available during this period. MO HealthNet will inform billers of such maintenance via https://www.emomed.com/ or email.

Acknowledgements
The 999 is generated when a biller sends a transaction to MO HealthNet. The 999 indicates if the functional group has been received by MO HealthNet.

Trading Partner Agreements

1. SFTP Vendors
   SFTP Vendors can obtain the Trading Partner Agreements for inbound transactions at https://www.emomed.com/public/publicdocs/messaging/announcements/PU/20160122090301747.pdf .

2. eMOMED Inbound
   eMOMED users who wish to submit 837 batch files for claims, 270/271 batch and real time files for eligibility, 276/277 batch and real time files for claim status submissions, or 278 batch files for services review can obtain the Inbound Trading Partner Agreement at https://www.emomed.com/public/publicdocs/messaging/announcements/PU/20160122090301747.pdf.

3. eMOMED Outbound
   eMOMED users who wish to receive an electronic version (835) of the printable remittance advice can complete an ERA Enrollment form at [https://www.emomed.com/portal/wps/portal/!ut/p/c5/hU7dEkJAGH0WT_B9bUKXu8gqFkXhxphRDROZptHw9K0HUOdcnl_IQbIrh_pevutnVz4ghVwrNJvySOcEA3O3RRoExt4K1ygh9UwrcAEU57TpUK7qHqIjjia6KlMJdxhBfwUXSFEtTo3R–M79SZziJspIn7jf4Rlj2I6oRBeWJ2PCaOsKl6RKzP53PpjU_Bne4UMcn3xYFADBn7Y9pA3yZDb4ibSxXlC2j3Zk8!/#.](https://www.emomed.com/portal/wps/portal/!ut/p/c5/hU7dEkJAGH0WT_B9bUKXu8gqFkXhxphRDROZptHw9K0HUOdcnl_IQbIrh_pevutnVz4ghVwrNJvySOcEA3O3RRoExt4K1ygh9UwrcAEU57TpUK7qHqIjjia6KlMJdxhBfwUXSFEtTo3R

   M79SZziJspIn7jf4Rlj2I6oRBeWJ2PCaOsKl6RKzP53PpjU_Bne4UMcn3xYFADBn7Y9pA3yZDb4ibSxXlC2j3Zk8!/#.)

4. Web Services Connectivity
   Web Services Connectivity users who wish to submit 270/271 batch and real time files for eligibility and 276/277 batch and real time files for claim status submissions or retrieve an 835 remittance advice can obtain the Trading Partner Agreement at https://www.emomed.com/public/publicdocs/messaging/announcements/PU/20131112135526065.pdf .

Transaction Specific Information

• Through the use of tables, this section describes how to bill or interpret MO HealthNet specific business rules (e.g., how to send/interpret diopters information or fluoride justification). It also describes how to populate or interpret trading partner or payer specific data elements. The tables contain a row for each segment or data element where MO HealthNet has something additional to convey. The intent is to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.
• These tables contain one or more rows for each segment for which a supplemental instruction is needed.

270/271 Health Care Eligibility Benefit Inquiry  and Response
The MO HealthNet system supports the required primary search options for ‘patient is subscriber’ for this transaction. If the four data elements identified are not all submitted, two rules apply. First, the participant’s (subscriber) number may be submitted as the only search criteria. Second, the participant’s name and date of birth are combined to attempt to uniquely identify a participant, so these elements should both be submitted. The MO HealthNet system also supports the required alternate search options for ‘patient is subscriber’ and the name/date of birth search option.

Additional alternate search options supported:

• Social Security Number (SSN)/Date of Birth (DOB):
  • The SSN is sent in the 2100C/REF segment.
• Casehead ID/ Date of Birth (DOB):
  • This method can be used when the MO HealthNet number of someone with the same casehead ID as the subscriber is known. In this event, the casehead ID is sent in the 2100C/REF segment and the DOB of the subscriber is sent in the DMG segment.

The MO HealthNet system only supports CORE generic and explicit mandated service type codes. If a non-supported service type code is submitted in the request, MO HealthNet will respond as a ‘30’.
The MO HealthNet system does not support the use of the 2100D dependent loop for any searches.
MO HealthNet follows the submission limitations noted in Section 1.3.2 of the Implementation Guide: ninety-nine requests in batch and one request in real time. Any requests exceeding these limitations are ignored.

Table 9, 270 Health Care Eligibility Benefit Inquiry and Response

Health Plans only, if the MO HealthNet provider number is sent then the value should be SV.
2100B| NM1| NM109| This value is the NPI. For MO HealthNet Managed Care Health Plans only, if NM108 = SV, then the MO HealthNet provider number should be sent.
2100B| PRV| PRV03| Required when necessary to convey the taxonomy code related to the eligibility/benefit being inquired about in situations such as when the information receiver is using one NPI for multiple MO HealthNet legacy provider numbers.
2100C| NM1| NM108| MO HealthNet only processes ‘MI’
2100C| NM1| NM109| This information provides the greatest chance of finding a unique match in the MO HealthNet system.
2100C| REF| REF01| MO HeatlhNet only processes ‘EJ’, ‘3H’, or ‘SY’
2100C| DMG| DMG02| Use the DOB of the dependent in the casehead search.
2100C| DTP| DTP01-DTP03| If this segment is not used, the MO HealthNet system assumes the current date at the time the transaction is being processed. MO HealthNet only processes these date scenarios:

• The first date of services is less than one year old
• The first and last date of service are not in a future calendar month
• Future dates through the end of the current calendar month.

2110C| EQ| EQ01| MO HealthNet only supports CORE generic and explicit mandated Service Type Codes.

Table 10, 271 Health Care Eligibility Benefit Inquiry and Response

the MO HealthNet database.
2000C| TRN| TRN03| When TRN01=1, this field contains ‘9431754897’
2000C| TRN| TRN04| When TRN01=1, this field contains ‘MO HealthNet’
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2100C| NM1| NM103- NM105, NM109| This data is populated with information contained in the MO HealthNet database.
2100C| N3| N301-N302| This data is populated with information contained in the MO HealthNet database.
2100C| N4| N401-N403| This data is populated with information contained in the MO HealthNet database.
2110C| EB| EB| For both online and batch, the limit of EB segments is 45.
2110C| EB| EB05| This data is populated with two different types of numbers that identify the coverage of the EB segment. When EB01=1, B, or F, and EB04 = MC, this field contains the MO HealthNet Eligibility Code (ME Code).
2110C| REF| REF02| When REF01=M7, this field contains the MO HealthNet Eligibility Code (ME Code).
2120C| PER| PER04| This field is populated with the MO HealthNet Managed Care Health Plan hotline number or the provider’s office number.

276/277 Health Care Claim Status Request and Response

• The MO HealthNet system utilizes certain fields in the 276 transaction in order to find a valid claim match. At a minimum, the National Provider Identifier (NPI), participant (subscriber) number, and claim first date of service are required to find a claim. When the 2200D/DTP segment is present, the subsequent date is handled as if it is the last date of service. If there is no last date of service, then the first date of service is used to fill in the date range. Including the claim ICN (loop 2200D, segment REF) offers an even-greater chance of finding a match in the system. If more than one of the search criteria fields is sent, a hierarchy is used to attempt to match. The first attempt is by the claim ICN, if it was sent. If the claim ICN was not sent, then all claims are selected for the provider/participant/first date of service – last date of service combination.
• It is stated in the 276 transaction that a claim status request may be requested at the claim detail level (loop 2210D). The MO HealthNet system does not handle a request that is detail line specific at this time.
• On the 277, the data found in loops 2100C and 2100D is from the MO HealthNet database files.
• For online submissions of the 276 transaction, only one occurrence of the 2100C and 2100D loops is processed. If an ICN is not used for selection, there is no limit on the actual date range of the 2200D loop, segment DTP; although, it should be noted that the larger the date range is, the greater the response time.

Table 11, 276 Health Care Claim Status Request and Response

Health Plans only, this value may be SV – SV Provider Number.
2100C| NM1| NM109|

• This value should be the NPI.
• For Managed Care Health Plans only, if the value in NM108 is SV, the managed care health plan provider number needs to be sent.

2100D| NM1| NM108| MO HealthNet only processes ‘MI’
2200D| DTP| DTP03| There are no limits on the range at this time, but range may impact online response time if search is too large.

Table 12, 277 Health Care Claim Status Request and Response

Number.
2100C| NM1| NM109| MO HealthNet uses the National Provider Identifier (NPI). For Health Plans only, if NM108 = SV, the MO HealthNet provider number needs to be sent.

820 Payroll Deducted and Other Group Premium Payment for Insurance

Table 13, 820 Payroll Deducted and Other Group Premium Payment for Insurance Products

Financial Control Number and ICN are used here for Financial transactions.

834 Benefit Enrollment and Maintenance

Table 14, 8.5 834 Benefit Enrollment and Maintenance

manner.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2300| HD| HD04| The plan coverage description consists of ME Code, Assignment Type, Day Specific Eligibility, and Transfer/Disenrollment Code. If no Plan Coverage Description is available, MO HealthNet fills these fields with X’s. Values for these fields can be found in the Health Plan Record Layout Manual under section C-45.
2100G| N3| N301| If address is incorrect defaults to PO BOX 6500.
2100G| N4| N402| If state incorrect, defaults to MO.
2100G| N4| N403| If zip code is incorrect, defaults to 65102-6500.
2750| N1| N102| REDETERMINATION
2750| DTP| DTP02| D8
2750| DTP| DTP03| Participant’s annual redetermination date in CCYYMMDD format.

835 Health Care Claim Payment Advice

Table 15, 835 Health Care Claim Payment Advice

Managed Care Health Plans only the value in NM108 Can be MC or PC,
2100| NM1| NM109| This value should be the NPI. For Managed Care Health Plans only, if the value in NM108 is MC or PC, the managed care health plan provider number will be sent.
2100| CLP| CLP06| If not sent on the incoming claim or if ‘ZZ’ is sent, this defaults to MC, except for drug claims. Drug claims received through POS have ’13’ plugged. All other drug claims have ‘MC’ plugged.
2100| CLP| CLP08| If not sent on the incoming claim, this defaults to space, except for drug claims. Drug claims always have spaces.
2100| CLP| CLP09| If not sent on the incoming claim, this defaults to space, except for drug claims. Drug claims always have spaces.
2110| SVC| SVC06| Will be sent when the adjudicated procedure code provided in SVC01 is different from the submitted procedure code from the original claim
| PLB| PLB03-2| Financial control number prefixed with ‘FCN:’ or AR number prefixed with ‘AR:’

837 General Information

Dollar amounts at the detail level in excess of 99,999.99 and at the header level in excess of 9,999,999.99 are truncated from the left.

• It is recommended to transmit only a maximum of 1,000 claims within an ST/SE transaction set envelope, due to the possibility that the entire envelope could be rejected if just one claim segment were found invalid by our translator.
• It is also recommended to limit the number of ST/SE transaction set envelopes to a maximum of 20 per GS/GE function group envelopes and a maximum of 1 GS/GE function group envelope per ISA/IEA interchange control envelope, due to WTX performance processing.
• Multiple ISA/IEA interchange control envelopes per transaction are acceptable.
• For dates of service prior to July 17, 2016, all providers except Managed Care Health Plans and NEMT Brokers are required to use XX as the NM108 qualifier and their NPI as the NM109 value in all provider identification loops, where applicable to include, but not limited to:
  • Professional – 2010AA, 2310A, 2310B, 2310C, 2310D, 2420A, 2420C, 2420D, 2420F
  • Dental – 2010AA, 2310A, 2310B, 2310D, 2310E, 2420A, 2420B, 2420C
  • Institutional – 2010AA, 2310A, 2310B, 2310C, 2310D, 2310E, 2310F, 2420A, 2420B, 2420C, 2420D.
• For dates of service after July 17, 2016, all providers except NEMT brokers are required to use XX as the NM108 qualifier and their NPI as the NM109 value in all provider identification loops, where applicable to include, but not limited to:
  • Professional – 2010AA, 2310A, 2310B, 2310C, 2310D, 2420A, 2420C, 2420D, 2420F
  • Dental – 2010AA, 2310A, 2310B, 2310D, 2310E, 2420A, 2420B, 2420C
  • Institutional – 2010AA, 2310A, 2310B, 2310C, 2310D, 2310E, 2310F, 2420A, 2420B, 2420C, 2420D.
• Managed Care Health Plans and NEMT Brokers only: Managed Care Health Plans and NEMT Brokers must submit their atypical NPI (MXXXXXXXXX) in 2010AA.
  Note: MO Healthnet supports the Basic Character Set as described in Appendix B of the ASC X12N HIPAA Implementation Guides.

Table 16, 837 General Information

is a reissue, claims fail duplicate editing within the MMIS if they were previously processed.
1000B| NM1| NM109| Use ‘431754897’
2000A| PRV| PRV03| Billing/Pay to provider: Providers 10 digit taxonomy code (Code designating the provider type, classification, and specialization) The segment is situational, however, MO HealthNet requires this segment if provider is using one NPI for multiple MO HealthNet legacy provider numbers.
2010AA| NM1| NM108| Must use ‘XX’.
2010AA| NM1| NM109| Fee for Service providers must use NPI. Managed Care Health Plans and NEMT Brokers must use the atypical NPI you have been assigned (MXXXXXXXXX).
2300| CLM5| CLM05-3|

• When any value other than ‘7’ or ‘8’ is used, the claim processes as an original claim.
• When ‘7’ is used, a credit is generated using the number found in 2300 REF02 when REF01 is F8. The new claim is processed as an original claim. If an incorrect original reference number is given, the new claim fails duplicate editing in the MMIS. When ‘8’ is used, a credit only is generated using the number found in 2300 REF02 when REF01 is F8.
• Managed Care Health Plans should send the CLM05-3 as 1, 7, or 8 just the same as the fee for service claims. A MCVOID record is created from the 837 received when the frequency is either ‘7’ or ‘8’.

837 Professional Specific Information

Table 17, 837 Professional Specific Information

‘F8’ should also be used if the biller wishes to send a previous ICN to show timely filing conditions were met.
2300| NTE| NTE01| For Managed Care Health Plans professional encounters containing capitated services, enter ‘ADD’ in NTE01 and ‘CAPITATED SERVICES’ in NTE02.
2300| NTE| NTE02| For Managed Care Health Plans professional encounters containing capitated services, enter ‘CAPITATED SERVICES’ in NTE02 and ‘ADD’ in NTE01.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2300| REF| NA| The Service Authorization Exception Code Segment does not apply to MO HealthNet claims.
2300C| HL| NA| MO HealthNet identifies each subscriber with a unique identification number. Therefore, the patient is considered to be the subscriber so the Patient Hierarchical Level should not be sent.
2310A| REF| REF01| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. Qualifier ‘G2’ will be used for the Managed Care Health Plans to send their managed care health plan provider number.
2310A| REF| REF02| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. The managed care health plan provider number should be sent in this field.
2310B| PRV| PRV03| MO Healthnet requires this segment if provider is using one NPI for multiple MO HealthNet Legacy provider numbers.
2310B| REF| REF01| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. Qualifier ‘G2’ will be used for the health plans to send their managed care health plan provider number.
2310B| REF| REF02| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. The managed care health plan provider number should be sent in this field.
2300| HCP| NA| The Claim Pricing/Repricing Information segment is not used by MO HealthNet.
2400| SV1| SV101-1| Qualifier Code ‘HC’ should be used for J-Code procedure codes with a date of service of 2/1/08 or after. Retail pharmacies billing NDC codes for drugs should use the HIPAA compliant NCPDP VD.0 submission form.
2400| SV1| SV101-2| Physicians billing for drugs should use the appropriate ‘J’ HCPCS procedure codes, but will also be required to use the NDC, Decimal Quantity, and Prescription Number if the date of service is on or after 2/1/08.
2400| SV1| SV101-3 SV101-4 SV101-5

SV101-6

| Reference the appropriate MO HealthNet Provider Manual to determine when these are required.
2400| SV1| SV104| Units and minutes containing decimals are truncated.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2400| NTE| NTE01| For Managed Care Health Plans professional encounters containing capitated services, enter ‘ADD’ in NTE01 and ‘CAPITATED SERVICES’ in NTE02.
2400| NTE| NTE02| For Managed Care Health Plans professional encounters containing capitated services, enter ‘CAPITATED SERVICES’ in NTE02 and ‘ADD’ in NTE01.
2420A| PRV| PRV03| MO Healthnet requires this segment if provider is using one NPI for multiple MO HealthNet Legacy provider numbers.
2420F| REF| REF01| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. Qualifier ‘G2’ will be used for the health plans to send their managed care health plan provider number.
2420F| REF| REF02| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. The managed care health plan provider number should be sent in this field.

837 Dental Specific Information

Table 18, 837 Dental Specific Information

for MO HealthNet.
2300| NTE| NTE01|

• For Fee-For-Service (FFS) dental claims, where topical fluoride treatment for adults is done, enter ‘ADD’ here and provide the conditions or criteria for the treatment in NTE02. Up to 5 occurrences of the NTE segment are used. Reference the MO HealthNet Provider Manual: Section 15: Billing Instructions-Dental for additional information.
• For dental encounters containing capitated services, enter ‘ADD’ in NTE01 and ‘CAPITATED SERVICES’ in NTE02.

• For Fee-For-Service (FFS) dental claims, where topical fluoride treatment for adults is done, enter ‘ADD’ in NTE01 and provide the conditions or criteria for the treatment here. Up to 5 occurrences of the NTE segment are used. Reference the MO HealthNet Provider Manual: Section 15: Billing Instructions – Dental for additional information.
• For dental encounters containing capitated services, enter ‘CAPITATED SERVICES’ in NTE02 and ‘ADD’ in NTE01.

2300C| HL| NA| MO HealthNet Identifies each subscriber with a unique identification number. Therefore, the patient is considered to be the subscriber so the Patient Hierarchical Level should not be sent.
2310A| PRV| PRV03| MO Healthnet requires this segment if provider is using one NPI for multiple MO HealthNet Legacy provider numbers.
2310A| REF| REF01| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. Qualifier ‘G2’ will be used for the health plans to send their managed care health plan provider number in the REF02 field of this segment.
2310A| REF| REF02| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. The managed care health plan provider number should be sent in this field.
2310B| REF| REF01| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. Qualifier ‘G2’ will be used for the health plans to send their managed care health plan provider number in the REF02 field of this segment.
2310B| REF| REF02| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment. The managed care health plan provider number should be sent in this field.
2400| SV3| SV301-3 SV301-4 SV301-5 SV301-6| Procedure code modifiers are not used for claims billed on the dental 837
2400| SV3| SV306| Quantities with decimals are truncated.
2400| TOO| NA| Only one tooth number per detail line is processed

by MO HealthNet. Additional tooth numbers are ignored.

2420A| REF| REF01| For dates of service prior to 7/17/16, only Managed Care Health Plans should be using this segment.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2420A| REF| REF02| For dates of service prior to 7/17/16, qualifier ‘G2’ will be used for the Managed Care Health Plans to send their managed care health plan provider number in the REF02 field of this segment.

837 Institutional Specific Information

For nursing home claims, each SV2 segment generates a separate claim.

Table19, 837 Institutional Specific Information

identification number. Therefore, the patient is considered to be the subscriber so the Patient Hierarchical Level should not be sent.
2300| REF| NA| The Service Authorization Exception Code segment is not used for MO HealthNet.
2300| REF

Payer Claim Control

Number

| REF02| Value ‘F8’ is required in REF01 of this segment when CLM-05-3 is ‘7’ or ‘8’. Value ‘F8’ should also be used if the biller wishes to send a previous ICN to show timely filing conditions were met. The previous ICN is what should be sent in this field.
2300| REF

Peer Review Org Approval Nbr

| REF01|

• This field is needed for fee-for-service claims only. Peer Review Organization (PRO) Approval Number Segment:
• For inpatient claims requiring certification, enter the identification qualifier of G4. For these claims, the REF02 segment must be completed with the Affiliated Computer Services (ACS) certification number.
• For all other claims, this segment is not used by MO HealthNet.

2300| REF| REF02| This field is needed for fee-for-service claims only. For inpatient claims, enter the unique 7-digit certification number supplied by HCE
2300| NTE| NTE01| For institutional encounters containing capitated services, enter ‘ADD’ in NTE01 and ‘CAPITATED SERVICES’ in NTE02.
2300| NTE| NTE02| For institutional encounters containing capitated services, enter ‘CAPITATED SERVICES’ in NTE02 and ‘ADD’ in NTE01.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2300| HI| HI01-1| Principal Procedure Information Segment:

• For inpatient claims, the surgical procedure code must always be represented using ICD-9-CM procedures (ICD-10-CM procedures after the federally mandated ICD-10 implementation date). Therefore, this value should always be ‘BR’ for inpatient claims.

2300| HI| HI01-2| Principal Procedure Information Segment: For inpatient claims, the surgical procedure code must always be represented using ICD-9-CM procedures (ICD-10-CM procedures after the federally mandated ICD-10 implementation date).
2300| HI| HI01-1 through HI12-1| Other Procedure Information Segment: For inpatient claims, the surgical procedure code must always be represented using ICD-9-CM procedures (ICD-10-CM procedures after the federally mandated ICD-10 implementation date). Therefore, this value should always be ‘BQ’ for inpatient claims.
2300| HI| HI01-2 through HI12-2| Other Procedure Information Segment: For inpatient claims, the surgical procedure code must always be represented using ICD-9-CM procedures (ICD-10-CM procedures after the federally mandated ICD-10 implementation date).
2310A| NM1| NM101-NM109| This segment is required for inpatient encounters.
2310A| PRV| PRV03| MO HealthNet requires this segment if provider is using one NPI for multiple MO HealthNet legacy provider numbers.
2310E| NM1| NM101| Service Facility Name – This field is required for inpatient and outpatient Managed Care Health Plans encounter claims.
2310E| NM1| NM102| Service Facility Name – This field is required for inpatient and outpatient Managed Care Health Plans encounter claims. The Entity Type Qualifier should be set to 2 – for a non-person entity.
2310E| NM1| NM103| Service Facility Name – This field is required for inpatient and outpatient Managed Care Health Plans encounter claims. Any name can be populated here.
2310E| REF| REF01| Service Facility Name – This field is required for inpatient and outpatient Managed Care Health Plans encounter claims. The Identification Code Qualifier should be set to G2.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2310E| REF| REF02| Service Facility Name – This field is required for inpatient and outpatient Managed Care Health Plans encounter claims. The Employer’s Identification Number should be populated in this field. This number must match a managed care provider number on the managed care provider demographic file or an exception will be posted to the claim.
2400| SV2| SV201| For outpatient and hospice claims, refer to the MO HealthNet Policy manuals for specific requirements. For nursing home claims, select revenue code from

one of the following categories:

1. Select revenue code to indicate reserve time periods:
2. 0180 equals non-covered leave of absence
3. 0182 equals home leave for patient convenience
4. 0183 equals home leave for therapeutic leave
5. 0184 equals hospital leave to an ICF/MR
6. 0185 equals hospital leave for non-ICF/MR facility
7. 0189 equals Medicare qualifying stay days
8. Select revenue code to indicate skilled nursing services:
9. 0190 equals sub acute care general classification
10. 0191 equals sub acute care – level I
11. 0192 equals sub acute care – level II
12. 0193 equals sub acute care – level III
13. 0194 equals sub acute care – level IV
14. 0199 equals sub acute care other Indicating any of the above revenue codes does not alter the amount of your per diem payment. Use these codes when you previously would have indicated a skilled nursing indicator of ‘Y’.
15. Select revenue code to indicate non-skilled nursing time periods
16. 0110 equals room-board/private
17. 0119 equals other/private
18. 0120 equals room-board/semi
19. 0129 equals other/2-bed Indicating any of these does not alter the amount of your per diem payment. Use these codes when you previously would have indicated a skilled nursing indicator of ‘N’ or blank.

278 Health Care Services Review – Request for Review and Response

The use of a separate transaction set (ST to SE) for each patient event, as is stated in the ASC X12 Implementation Guide for this transaction. MO HealthNet supports the sending and receiving of multiple patient events in one transmission, where each patient event represents a single 278 transaction with multiple transactions in a single GS to GE loop.

Additional documentation

• Additional documentation (attachments) must be sent via one of the following methods
• By fax (DME only)
  •  573-635-0207
• By mail (non-DME only)
  •  Infocrossing Healthcare Services, Inc. PO Box 5700 Jefferson City, MO 65102
• A MO HealthNet Prior Authorization Supporting Documents Cover Sheet must accompany additional documentation sent via either method. The form is available for download on the MO HealthNet website at www.dss.mo.gov/mhd/providers/index.htm . Choose the “MO HealthNet forms” link in the right column. As noted on the form, the Prior Authorization number is required. This number is received in the 278 Response Loop 2000E, Data Element REF02. Attachments received without the Cover Sheet or without the Prior Authorization number present cannot be matched to the 278 Health Care Services Review Request.

Table 20, 278 Health Care Services Review – Request for Review

receiver is using one NPI for multiple MO HealthNet legacy provider numbers.
2000E| UM| UM01| Value submitted has no impact on MO HealthNet processing.
2000E| UM| UM02| Value submitted has no impact on MO HealthNet processing.
2000E| PWK| PWK02| Recommend using this data element to inform MO HealthNet of submitter’s intention to send or not send additional documentation. See ‘Additional Documentation’ section above for more details.
Loop| Segment| Data Element| Notes/Comments
---|---|---|---
2000E| MSG| MSG01| Use to provide a detailed explanation of Medical Necessity for services/ equipment/ procedure/ prosthesis where necessary.
2010EA| NM1| NM101| MO Healthnet only processes ’77’, ‘DK’, and ‘SJ’
2000F| NA| NA| MO HealthNet supports a maximum of twelve 2000F Service Level loops. If additional Service Details are needed, an additional 278 Request transaction must be submitted.
2000F| SV1 / SV3| DTP03| The from/through date(s) that services will begin/terminate if authorization is approved.

MO HealthNet does not process each 278 request upon receipt and will therefore return a 278 response to indicate that the health care services review request has been pended.

Table 21, 278 Health Care Services Review – Response

received on the 278 Request.
2010B| PRV| PRV01, PRV03| This data is populated with information received on the 278 Request.
2010C| NM1| NM109| This data is populated with information received on the 278 Request.
2000E| HCR| HCR01| ‘A4’ – Pended
2000E| REF| REF02| This is the number MO HealthNet has assigned to the Prior Authorization. See ‘Additional Documentation’ section above for more details on how to use this number when additional documentation is needed. This number can also be used for referencing the Prior Authorization when contacting MO HealthNet staff.
2010EA| NM1| NM101- NM104, NM109| This data is populated with information received on the 278 Request.
2000F| TRN| NA| MO HealthNet supports a maximum of twelve 2000F Service Level loops. Additional 2000F TRN segment data received on the request will be present on the response, but are not processed for review.

Appendices

Appendix A – Implementation Checklist
The following is a list of the steps required to begin sending production HIPAA compliant ASC X12N transactions to MO HealthNet:

1. Biller completes either the eMOMED Access Agreement or the Application for MO HealthNet Connect:Direct Access Account.
2. Biller completes the Trading Partner Agreement.
3. Wipro Infocrossing Technical Help Desk approves documents in steps 1 and 2 and notifies the biller of User ID and password.
4. Biller sends test file(s).
5. Biller reviews results from test file(s). Results are available within 1- 2 business days.
6. When the biller is satisfied with the results of the test (e.g., test claims are not rejected), the biller contacts the Wipro Info crossing Technical Help Desk to be moved to production for each specific transaction.

Frequently Asked Questions

• Will you be providing a file level acknowledgment for claim files? If yes, what format?
  Yes, we will have the 999 available as the file level acknowledgement.

• Will the 277CA Acknowledgement Transaction be sent?
  No.

• Will you require an acknowledgement for the 835 files?
  No, we will not require an acknowledgement for the 835 files.

• Can your test system support multiple claim files throughout the day?
  Yes, you can submit a test file throughout the day. They are usually processed at 7 am.

• When will MO HealthNet stop accepting ICD-9-CM codes?
  ICD-9-CM codes will no longer be accepted for services provided on or after October 1, 2015. If you have further questions regarding the federal mandated date, please go to:
  https://questions.cms.hhs.gov/app/answers/detail/a_id/10019/%22 .

• When will MO HealthNet start accepting ICD-10-CM codes?
  Providers can send in the ICD-10-CM codes for services provided on or after October 1, 2015. If you have further questions regarding the federal mandated date, please go to:
  https://questions.cms.hhs.gov/app/answers/detail/a_id/10019/%22

Change Summary
This version of the Companion Guide is specific to version 5010. The previous version was specific to version 4010.

References

• X12's Web Pages
• X12's Web Pages
• CAQH
• Plans & Providers | mydss.mo.gov
• MO HealthNet Portal
• MO HealthNet Portal
• MO HealthNet Portal
• MO HealthNet Portal
• MO HealthNet Portal
• MO HealthNet Portal
• Request Rejected

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