IEHP EDI Network Testing Basics And DHCS Duplicate Logic
IEHP EDI Network Providers will be required to submit test files to ensure the submitter’s systems are properly configured for data submission. Before exchanging production transactions, each plan must complete testing to become certified. This process allows IEHP EDI Network to confirm that the DHCS operational guidance has been properly programmed in their systems. A test file will need to be submitted to IEHP EDI Network containing 25 encounters and must pass 100% of the front end edits. In the event more than 25 encounters are submitted, the file must receive an accepted or partially accepted 999, and 277CA with a minimum of an 80% acceptance rate.
A submitted encounter file will be either accepted or rejected by DHCS.
1. DHCS will NOT return TA1 response is available at this time.
2. DHCS will return 999 – X12 Standard Transactions Acknowledgement Report.
a. The 999 acknowledgement report provides information on the validation of the GS\GE functional groups(s) and the consistency of the data.
3. DHCS will return 277 – X 12 standard transactions.
4. A single 277 will be returned that will only reflect the two (2) ST-SEs that were accepted
5. DHCS will return Encounter Validation Response (EVR) – custom XML error report detailing each error including file position of each record found to be in error, error value and error message.
DHCS Duplicate Logic
Encounters will be evaluated for duplicates at the service line level. If a service line is found to be a duplicate of a previously submitted service line, the entire encounter will be denied. For the purposes of an 837 Institutional service line, a duplicate would have the same following values as a previously submitted service line:
1. Client Identification Number (CIN) – 2010BA NM109
2. Date(s) of Service – 2400 DTP*472 DTP03 (can be a range)
3. Admission Date/Hour – 2300 DTP*435 DTP03 (can be a date or a date/time)
4. Discharge Hour – 2300 DTP*096 DTP03
5. Rendering Provider – can be sourced from a variety of places. The valued stored for purposes of duplicate validation will be the value derived for rendering provider at the service line level. This derived value may have been submitted at a higher level where no other identifier was submitted at either the claim or service line. This derived value may also be either a Medi-Cal Provider ID or State License number depending upon the presence of an NPI. If no NPI is submitted because the provider is atypical, a submitted secondary identifier will be used. The order of priority for secondary identifiers is Medi-Cal Provider ID first and State License Number second.
6. Revenue Code – 2400 SV201
7. Procedure Code – 2400 SV201-2
8. Procedure Modifier(s) – 2400 SV201-3,4,5,6
9. Drug code – 2410 LIN03 – Drug code is used when it is present. Conditional usage of Drug Code – When a submitted encounter is compared to previously submitted encounters and all other key fields match but one of the encounters has a drug code and the other does not – this situation is still identified as a duplicate. If all other key fields match and the drug codes are different, the situation is not a duplicate.