Managed care organizations - Encounter submissions

The professional, institutional, and dental encounter claims must comply with State or federal requirements and use HIPAA standard transaction formats. The HIPAA Electronic Data Interchange (EDI) “Implementation Guide” is the federal guide that directs all states on the submission of HIPAA compliant X12 data files.  (Note: these are the federal requirements referred to in the contract in section 3.6.1 (B) (3).) This federal guide can be purchased from Washington Publishing Company at the website; http://www.wpc-edi.com/. Navigate to “Consolidated Guides.” which is under HIPAA>5010. The current 5010 versions of the document can be found there.

The following MHCP guide is intended to serve as a companion document to the corresponding HIPAA Implementation Guide. The guide further specifies the requirements to be used when submitting encounter data files and does not contradict, disagree, oppose, or otherwise modify the HIPAA Implementation Guide.

837 Encounter Companion Guide to the HIPAA Implementation Guide: Professional, Institutional and Dental Claims (DHS-6761) (PDF)

The encounter pharmacy claims must be submitted in the required National Council for Prescription Drug Programs (NCPDP) Batch format.

NCPDP Batch 1.2 Encounter Companion Guide (DHS-6761A) (PDF) (An MHCP Requirement Legend has been added to the guide.)

When submitting encounter batch claims, MHCP requires that you adhere to the file transfer protocol (FTP) specifications as well as the file naming convention document in the Secure FTP MN-ITS User Guide (PDF).

After submitting your X12 837 files or NCPDP Batch files you will receive an acknowledgement of the receipt of the files, as well as your status, in your MN–ITS Mailbox (Transaction Responses). The following companion guides will assist you in understanding the acknowledgement transaction types. Your X12 837 files will receive a 999 functional acknowledgement and the NCPDP files will receive the N12R acknowledgement.

N12R pharmacy claims response to NCPDP batch receipt (DHS-6761J) (PDF)

Once the encounter claims have been processed you will receive a remittance advice (RA) in your MN–ITS mailbox (Transaction Responses/835) detailing the claim processing results. In addition a monthly capitation payment transaction is sent to your mailbox (Transaction Responses/820). The following links include the companion guides for the RA and the capitation payment and additional documents to assist in interpreting the transaction files.  

Capitation Payment (X12 820) (DHS-6761I) (PDF)

Remittance Advice Remark Code Guide (DHS-6761B) (PDF)

Before a new MCO or their biller can submit encounter claims they must work with the DHS Encounter Data Quality unit to test the batch file submission. This testing must be done via the MN–ITS web application. Successful completion of the encounter file submission testing is what triggers the appearance of a main menu item in MN–ITS (Batch) for production encounter file submissions. Please note that the testing process outlined in this document checks transaction syntax only. 

Overview File Testing Process (DHS-6761C) (PDF)

DHS is now ready for the MCOs and their subcontractors who submit on their behalf to start testing syntax for TPL data elements and MCO Paid Dates on all 837 claim types. Please refer to the two documents below for more detail and instructions.

Overview for Testing Syntax for TPL Data Elements and MCO Paid Dates 

5010 Testing Companion Guide

DHS has a biweekly warrant cycle that can accommodate either biweekly or monthly file submission schedules. The documents below include a detailed file submission, processing, and remittance delivery document and a sample month calendar of the submission and data processing timelines. 

Encounter Claims Data Biweekly Processing Cycle

Sample Warrant Cycle Calendar (DHS-6761D) (PDF)

Documents to assist encounter data stakeholders in understanding the DHS processes for the submission and processing of encounter claims will be added to this section as they become available.

Review instructions for correcting encounter data and submission errors (DHS-6761E) (PDF)

Disclaimer of Reliability. These documents are designed to provide useful information to MCOs, but they are not intended to be definitive, official documentation of department policy. In any situation where the official printed documents of DHS, its agents or other governmental agencies (including your MCO contract to provide managed care medical care services) differ from the text contained in this document, the official printed documents take precedence and should be considered correct.

DHS contracted with Deloitte to develop ten quality assurance protocols, with associated methods and measurements, to support DHS’ management and monitoring of the quality of data submitted by its MCOs. MCOs can apply these protocols as they adjudicate claims and create encounter data files that are submitted to DHS. The protocols are designed to provide DHS with data that is more timely, complete, accurate, and consistent.

Encounter Data Quality Assurance Protocol (DHS-6761F) (PDF)

837 and NCPDP MCO Denied Loops and Segments (DHS-6761G) (PDF) 

Penalties for Uncorrected Erroneous Encounter Claim Data (DHS-6761H) (PDF)