Encounter Identification (IEHP Provider EDI Requirements)
To aid in Encounter Identification, plans must use the HCP number of the plan that the beneficiary was enrolled in at the time of the encounter as the first three characters of CLM01. In accordance with X12 837 Professional data specification rules, unless the encounter is a void or replacement, CLM01 must be unique, a submitted encounter that has the same value in CLM01 as a previously submitted encounter will be denied. During DHCS processing, each encounter will be assigned a unique identification number. This number will be provided back to the submitter in both the 277 and the EVR file. When attempting to correct a previously submitted encounter, plans must use this Encounter-ID as defined below.
Correcting a Submitted Encounter Denied by DHCS
Submitted encounters will be either accepted or denied by DHCS. When DHCS denies a submitted encounter the reasons for the denial will be reported on the available EVR file. Submitted encounters can be subsequently corrected by either a void or a replacement action. When a submitter needs to correct an encounter, the following data must be provided:
- The submitter of the correcting encounter must be the same as the submitter of the encounter being corrected.
- CLM01 must equal the value of CLM01 on the encounter being replaced or voided.
- The Encounter-ID (from either 277 or EVR) of the encounter to be corrected must be placed in the Payer Claim Control Number REF segment in the 2300 loop (REF*F8).
- A value of either “7” (replacement) or “8” (void) must be placed in the Claim Frequency Code in CLM05-03.
DHCS requires that encounters be submitted in files dedicated to a specific Healthcare Plan Code (HCP). The specific HCP will be included in the submitted file name and the file ISA segment as described above in Encounter Identification requirements.