Electronic Data Interchange (EDI) Frequently Asked Questions (FAQ)

What is the compliance date for Version 5010 and Version D.0?

The federal mandatory compliance date is January 01, 2012.

When will testing begin at Healthcare and Family Services (HFS)?

Test and transition time frames are currently being established for each HFS claimant type, i.e., Rev Vendors, sister agencies, Dentaquest, etc. Watch for updates in the future.

Who will be allowed to test?

Clearinghouses and vendors who are directly connected to HFS will be allowed to test with the department. Testing with individual providers will not be possible at this time.

Will ICD-10 be implemented at the same time with 5010 and D.0?

No. The 5010 implementation has to be completed prior to the ICD-10 implementation. Per the Federal mandate, claims with ICD 10 codes will be accepted by HFS on claims with Dates of Service after October 1, 2013. Hospital Inpatient claims will be based on date of discharge on/after October 1, 2013.

Will HFS create and publish companion guides prior to implementation of 5010?

Companion Guides will be added to the Web site as they become available thru 2011. Check the EDI Web page routinely for updates.

What is the implementation strategy for converting all transactions?

The HIPAA team is targeting to complete the 837I, 837P, 837D, and NCPDP transactions first and then will focus on the other transactions.

How will the 5010 transactions impact MEDI/IEC?

The MEDI/IEC system will be upgraded to accept both 5010 and 4010 files. HFS will continue to accept 4010 files until January 2012. HFS' implementation strategy is to have the capability to accept 5010 claim files ready by September 15, 2011. The ability to accept 5010 Claim Status and Eligibility transmissions will be implemented after October 1, 2011.

Will there be a period where HFS will be accepting both a 4010 format and a 5010 format?

HFS' implementation strategy is to have a dual use period. During this time frame, HFS will accept both formats. Targeted start date for the claim transactions is September 15, 2011.

Will HFS be implementing the Errata to the TR3 guides?

For those transactions that have an Errata mandated, the Errata version is the only one that HFS will test and implement.

Which transaction acknowledgements do you intend to support?

HFS will continue to respond to transactions submitted in a 4010 format with the 997 and 824 acknowledgements. Transactions submitted in the 5010 format will be acknowledged with the 999 and 824. Please See Companion Guides for further information.

When will HFS no longer accept 4010 versions of the HIPAA transactions?

Plans are to continue accepting 4010 transmissions thru December 2011.

When will HFS start using the 5010 version of the 835 transaction?

The process to switch to the 5010 version of the 835 transaction will be implemented on January 1, 2012. Until that time, HFS will continue using the 4010 version of the 835.

How will HFS handle the 5010 configuration of the pay to loop?

HFS will no longer support a separate pay to location. If an address is submitted in the pay to loop, the information will be ignored. Please see Companion Guides for further information.

Is the billing provider taxonomy required on all claims?

Yes. HFS requires that all 837 Institutional and 837 Professional transactions contain the billing provider taxonomy code. The 2000A - PRV segment containing the billing provider taxonomy code is required on all claims.

Are there any changes to how third party payments are to be submitted to Healthcare and Family Services?

There are no changes to how the TPL code and TPL status code are to be reported. Please see Companion Guides for further information.

How can I determine the status of a claim I submitted to Healthcare and Family Services?

There are a couple electronic methods in which HFS makes this information available to those authorized to access it. With any of these methods, it will take seven days from the date of submission for a claim to register within HFS claim status system. Failing to wait these seven days prior to making an inquiry will return incomplete information. Additionally, due to the volume of claims processed by the department, this information is only available for two years from the date of the voucher.

Our Medical Electronic Data Interchange (MEDI) / Internet Electronic Claims (IEC) system can be used to determine the status of your claims. MEDI/IEC allows for either real-time claim status inquiry using Direct Data Entry (DDE) or batch inquiries using the HIPAA-mandated X12 276/277 transactions.

DDE: After the seven day wait period, the DDE system will provide you an immediate response on the status of a single claim for up to 90 days from the Date of Voucher for NIPS/Pharmacy claims and 180 days for Institutional claims. Status checks on claims with a Voucher Date older than 90/180 days must be performed using the batch 276 transaction described below. DDE is available M-F 8 a.m. to 5 p.m. CT.

Batch: After the seven day wait period, the batch system will allow you to perform either a single inquiry for a claim not meeting the DDE date criteria above (example: a claim with a voucher date older than prescribed above) or to perform an inquiry for multiple claims in one batch. Batch inquiries (276) are accumulated throughout the day and their corresponding response transactions (277) are returned the next business day. The uploading of batch files is available 24 hours a day, 7 days a week. Batch files submitted to the Department by 5 p.m. CT M-F will be processed that night and the corresponding responses should be available the next business day.

For crosswalk information on status codes, please refer to the provider notice dated January 27, 2005, found under All Medical Assistance Providers Notices. Please visit the MEDI/IEC Web site for more information.

Some of the departments' Recipient Eligibility Verification (REV) vendors have electronic systems that provide claim status information to their customers. For more information on REV vendors, please contact one of these vendors.

Finally, you can contact the Bureau of Comprehensive Health Services toll-free at 1-877-782-5565. However, due to the volume of calls the Department is experiencing, it is highly recommended that you use one of these other methods.

When billing for DHS services, will Community Mental Health Centers use a specific layout?

• Layout for the NTE Segment in Loop 2400 (pdf)

Please see Reimbursement Guides for further information regarding billing.

What are the major changes for the 837 Institutional transaction with HIPAA 5010?

With the implementation of HIPAA 5010, the largest change to the transaction set is that the QTY segment where covered days and non-covered days were being sent in was removed. Illinois Medicaid is now looking for the covered days and non-covered days to be sent in the value code segment. All claims requiring the reporting of covered and non-covered days will need to submit the covered days value code of 80 and for non-covered days value code of 81 with the corresponding number of days in the value amount fields.

In HIPAA 5010 the Admission Date segment now allows for both a date and a date and time qualifier, are there any guidelines for when each should be used for the 837 Institutional transaction?

For institutional claims the Admission date and time qualifier (DT) and value must be used on all Inpatient claims. For an outpatient claim the Admission Date only (D8) qualifier and value will be accepted.

What changed in the Errata versions for institutional claims?

The most significant change in the 837 Institutional Errata versions was that Admission Type code became required on all claims. The value is to be reported in the 2300 CL1 segment on every claim.

Are POA values still required to be sent in on the K3 segments on Institutional claims?

No. POA values have their respective places in the 5010 837 Institutional transaction on the diagnosis segments. Refer to the implementation guide for how to submit those values. The K3 segment no longer should carry those values.

Taxonomy

​An appropriate taxonomy code must be provided for both Institutional and Professional 837 claims. For further details see 837I or 837P Companion Guides.

Subscriber

​The patient is always the subscriber. See 837I or 837P Companion Guide

Payer

​The destination payer must be 'Illinois Medicaid'. See 837I, 837P or EDI Control Companion Guides

Outpatient Series Claim

​For 5010, the number of series days for which outpatient services were provided must be reported in Loop 2300, HI Segment. See 837I Companion Guide (pdf).

TPL/Status Code

​The 3-digit TPL code followed by the 2-digit Status Code assigned by HFS to other payers, must be reported in Loop 2330B, REF02. In addition, the TPL Date is required in Loop 2330B, DTP03. See 837P Companion Guide.

How do you bill Physician fee-for-service claims when services are rendered outside the FQHC setting?

​Physicians who bill fee-for-service, under their own name and NPI and designate the FQHC, RHC, or ERC as their payee, must report their name and NPI as the Rendering Provider in Loop 2310B. The NPI linked to the physician's appropriate 16-digit payee number must be reported as the Billing Provider in Loop 2010AA. The Billing NPI reported in Loop 2010AA must not be linked to the FQHC's, RHC's, or ERC's provider number. Please contact the Provider Participation Unit to initiate any NPI Link to Payee changes at: 217-782-0538.

Example:

Loop 2010AA, NM1*85 – Billing Provider

NPI associated to the 16-digit payee number

Loop 2310B, NM1*82 - Rendering Provider

Physician NPI

What are the major changes for the 837P Professional transaction with HIPAA 5010?

Line level claim balancing will be enforced. The sum of Third party payments, (delete space) adjustments, and patient responsibility amounts must equal the line item charge amount. Another item is that the place of service code at the 2400 line level must be different than that at the 2300 claim level.

How should an Atypical Provider submit a claim when not eligible for enumeration (has no NPI)?

An Atypical provider will still submit the Billing Provider loop (2010AA) without submitting the NM108 and NM109 values. The HFS Provider Number must be submitted in the 2010BB Payer loop using the Billing Provider Secondary Identification REF segment with a reference indicator of G2, which identifies the Provider Commercial Number. Please see 837P Companion Guide for further information.

Does the NTE Segment on a transportation claim still require the pick-up and drop off address information in a 5010 transportation 837 professional transaction?

No. A 5010 transaction has segments defined for the pick-up address and drop off address for transportation claims. HFS expects those values to be used to report the pick-up and drop-off address. Please see 837P Companion Guide for further information regarding the NTE segment for transportation claims.

Blue Cross/Blue Shield THIN Production Issues

​The department has been informed that BC/BS THIN experienced two system problems during the period December 13, 2004, through December 31, 2004. One problem was a result of conversions that were implemented by BC/BS THIN beginning December 15, 2004. As a result of this problem, not all claims were transmitted successfully by BC/BS THIN to HFS. The department encourages providers to work directly with BC/BS THIN to ensure that all claims have been transmitted to HFS successfully and reconciled. HFS is actively working with BC/BS in order to assist them in resolving this situation.

There was also a problem where BC/BS THIN was overlaying the provider taxonomy codes, which occurred December 13, 2004, through December 17, 2004. This problem resulted in providers receiving rejections from the department. The rejection error was “U76.” If you received this rejection for claims submitted during the period referenced, providers may want to work directly with BC/BS THIN to ensure that these rejected claims were reprocessed for payment reconsideration.

Blue Cross/Blue Shield THIN Production Issues Update: December ’04

Blue Cross, Blue Shield THIN (BC/BS THIN) continues to have difficulties with the 837I files that they are submitting to the department. The highest levels of BC/BS (THIN) have been alerted by the department to this problem and the department has made it very clear that we expect BC/BS (THIN) to redouble their efforts to fix these problems immediately and to ensure that these problems do not reoccur in the future. The department continues to work with individual providers to alleviate cash flow problems. Below is a detailed description of the issues being addressed by BC/BS (THIN) and the department.

BC/BS (THIN) will be resubmitting 837I transactions originally submitted to HFS on the dates December 14, 2004, through January 1, 2005, for reprocessing and payment reconsideration. A significant number of claims submitted during this timeframe did not process due to problems with BC/BS file submission. Based on the fact that some of these claims have already been processed through HFS and adjudicated, providers may see an increase in the number of D01 (Duplicate Payment) rejections compared to what they normally receive due to BC/BS (THIN) resubmitting all claims. There may also have been some incorrect payments made to hospitals during this period of time on claims that did process as a result of BC/BS (THIN) overlaying the provider taxonomy code. Hospitals that are enrolled for Category of Service 20 (General Inpatient) and Category of Service 21 (Inpatient Psychiatric) may have been reimbursed at a per diem rate versus a DRG reimbursement. Hospitals that identify an incorrect reimbursement are requested to void the originally submitted claim, with an adjustment, and resubmit a new claim for payment reconsideration.

Blue Cross/Blue Shield THIN Production Issues Update: January 22, 2005

​BC/BS (THIN) has now resubmitted these ‘batches’ of claims to HFS and HFS has taken them into our adjudication system. On January 21, 2005, BC/BS informed HFS that they still have issues with their Direct Data Entry (DDE) system and in particular, with the ‘covered days’ information. BC/BS (THIN) has identified approximately 50,000 claims that were rejected for missing covered days issues (reject codes E84/D09). BC/BS (THIN) is correcting their system and will then attempt to resubmit these to HFS for payment consideration.

Blue Cross/Blue Shield THIN Production Issues Update: January 24, 2005

​BC/BS (THIN) resubmitted the approximately 50,000 claims as noted above to HFS and HFS has taken them into our adjudication system. On January 24, 2005, another issue was identified involving electronic claims from BC/BS (THIN) relating to missing TPL information. This is causing an increased number of claims to be rejected (reject codes R35/R36) in HFS adjudication system.

Blue Cross/Blue Shield THIN Production Issues Update: January 25, 2005

​BC/BS (THIN) has identified approximately 5,000 claims during the timeframe of December 14 – 16, 2004, that rejected for the R35/R36 as noted above. BC/BS (THIN) is correcting their system and will then attempt to resubmit these to HFS for payment consideration. Additionally, BC/BS (THIN) informed HFS that they have identified an issue within their system relating to approximately 350 tertiary claims that they processed on January 21, 2005. These were likely previously rejected by HFS for missing covered days (E84/D09). BC/BS (THIN) is correcting their system and will then attempt to resubmit these to HFS for payment consideration.

Blue Cross/Blue Shield THIN Production Issues Update: January 28, 2005

​BC/BS (THIN) resubmitted the approximately 5,000 claims as noted above to HFS and HFS has taken them into our adjudication system.

Blue Cross/Blue Shield THIN Production Issues Update: February 2, 2005

HFS has adjudicated ALL claims that BC/BS (THIN) has corrected and resubmitted. In order for you to ensure that BC/BS (THIN) has transmitted all of your claims to HFS, you might consider performing claim status inquiries, on each of your claims during this time period (December 14, 2004 to present). You should contact BC/BS (THIN) regarding any ‘missing’ claims.

HFS continues to assist BC/BS (THIN) in resolving these problems and will continue to update this Web site with the latest information.

Blue Cross/Blue Shield THIN Production Issues Update: July 19, 2005 (Resolved)

​The department experienced a problem with some of the claim files that it received from BCBS/THIN beginning June 29, 2005, and ending July 13, 2005. During this time period our translator incorrectly rejected 7 of the 46 files that we received in their entirety. The department has corrected this translator issue and BCBS/THIN retransmitted these files on July 18, 2005.