Transactions & Code Sets

General Information

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care. The Mental Health Managed Care Programs at DMH that are impacted by HIPAA as well as the Automated Systems for processing Short-Doyle/Medi-Cal claims.

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Implementation Schedule

Resource and time limitations have led the Department of Health Services (DHS), with agreement from DMH and the Department of Alcohol and Drug Programs (ADP), to implement a Phase I /
Phase II approach to achieve full HIPAA compliance for the SD/MC claiming system.

The objective of Phase I is the continuation of timely claim reimbursements after the TCS compliance date. Phase I will allow DMH and ADP to accept claims and return payment information in HIPAA compliant format and data content including national procedure codes. The SD/MC claiming system will be changed only to the extent necessary to successfully process HIPAA compliant claims and create HIPAA compliant payment / advices. Phase II is the long-term remediation solution to meet all functional aspects of HIPAA requirements including: financial balancing, claim inquiry responses, claim replacements and reversals, and system re-engineering.

Dept. of Health Services transaction schedules.
Short Doyle/Medi-Cal & Non-Fiscal Intermediary Projects:TransImpSchedNonFI09-09.pdf
Medical Fiscal Intermediary (FI) : TransImpSchedMedicalFI09-09.pdf

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County Communications

Information Notice 03-10 - New Claim Submission Procedures and the Health Insurance Portability and Accountability Act (HIPAA) Testing and Certification Procedure for the Short-Doyle/Medi-Cal (SD/MC) System

• Enclosure 1 - DMH Short-Doyle / Medi-Cal (SD/MC) HIPAA Phase I County/Vendor Testing and Certification Procedure - Updated Procedures 08/16/05
• Enclosure 2 - DMH Short-Doyle/Medi-Cal (SD/MC) Claim File Submission Requirements
• Enclosure 3 - DMH Short-Doyle/Medi-Cal (SD/MC) System Claims Submission Cutoff Dates for 2003 - Cutoff Dates for 2004
• Enclosure 4 - Short-Doyle / Medi-Cal (SD/MC) HIPAA Phase I RemediationClaims Processing Flow Diagram as of 10/10/03

Letter to CMHDA (09-18-03)

Information Notice 03-09 - Health Insurance Portability and Accountability Act (HIPAA) Transactions and Code Sets (TCS) Compliance for the Short-Doyle / Medi-Cal (SD/MC) Claiming system

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HIPAA Phase 1 Testing Status

DMH SD/MC HIPAA Phase 1 Testing Status (Map)

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Technical / Companion Guides (Mappings & Crosswalks)

A technical guide (companion guide / mapping) is a description of how to translate the proprietary SD/MC claim or EOB information into HIPAA compliant TCS format. There are three guides, each describing one HIPAA compliant transaction mapping. The 837 P guide is for professional service claims, the 837 I guide is for institutional (hospital) service claims, and the 835 guide is for claim payment / advice. The guides are formatted as Excel workbooks. Each workbook contains multiple tabs. The crosswalk for DMH SD/MC service procedures is included in these workbooks.

HIPAA TCS Technical Guides for SD/MC

• DMH Companion Guide for the 837 P, 837 I and 835 Transactions and Code Sets (2.15 MB)
• SDMC 837 P Mapping
• SDMC 837 I Mapping
• SDMC 835 Mapping

Technical Assistance Staff Contact List

DMH staff are available to assist counties with their transition from the current SD/MC claiming system to the new HIPAA compliant SD/MC claiming system. This includes support to understand the technical guides and resolving technical issues regarding HIPAA compliant claim submission and testing procedures. The primary contact person is Vonnie Ryser.

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Contingency Plan

Continuity of service and payment is of highest priority for the Department of Mental Health (DMH). Contingencies will be available to continue current processing to ensure no disruption in payment or services.

The contingency plan is for DMH to use the translator at the Health and Human Services Data Center (HHSDC). The translator solution will allow DMH to accept 837 transactions and send back an 835 remittance transaction. The existing proprietary formats and codes will continue to be accepted from counties unable to meet the HIPAA implementation deadline. This process will ensure continuation of payments for providers submitting claims.

DMH is working collaboratively with Dept. of Health Services (DHS) and Dept. of Alcohol and Drug Programs (ADP) on a phased approach for Short-Doyle/Medi-cal. Refer to the document Short-Doyle/Medi-Cal HIPAA Remediation Phased Approach on DHS website for additional information: www.dhs.ca.gov/hipaa/articles/ShortDoylePhaseI.doc

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CMS Guidance

On 7/24/03, the United States Department of Health and Human Services released the Guidance on Compliance with HIPAA Transactions and Code Sets after the October 16, 2003, Implementation Deadline.