Document Level Processing
(NOTE: For additional information, please read FAQ titled TCN/CRN – eMedNY Changes)
eMedNY processes claims (lines) at the Document Level and assigns a 16-digit Transaction Control Number (TCN – formerly known as CRN) that applies to the entire claim. Each line associated with a claim will be assigned the same TCN as the other lines. Thus, the TCN will represent a Document.
Pharmacy: Pharmacy (NCPDP) claim submissions will still be processed on a claim-by-claim basis. (Claims are not rolled up into one Document.) However, a TCN will be assigned to each claim.
NOTE: Once you have read this document, keep in mind that you must be very aware of what (NYS MEDICAID) “PHASE” the document you are adjusting or voiding is from. If the last remittance report you have is from Pre-Phase II, then you will be adjusting or voiding by referencing THE CRN. If the remittance advice was from Phase II, then you will be adjusting or voiding by referencing THE TCN.
FORMAT OF TCN :
- Positions 1 – 5: Julian Date.
- Positions 6 – 14: 9-digit Sequence Number
- Position 15: Media (how claim came in)
0 = Paper
2 = Electronic
3 = POS Online (NCPDP or 837P)
0 = Original
1 = Credit Adjustment or Credit Void (Reversal)
2 = Debit Adjustment (Replacement)
LEGACY AND HIPAA PRE-PHASE II PROCESSING AND CRN CONVERSION TO TCNS :
- In Legacy and HIPAA pre-Phase II processing, claims were processed at the claim line level, and were assigned a unique 15-digit original claim reference number (CRN) for each claim line. In preparation for Phase II Document Level processing, CSC has (internally) converted the CRN on all pre-Phase II claims to a 16-digit TCN. It is important to understand that this conversion was intended to re-identify pre-Phase II claims as “Documents” or if applicable, a one “line” Document (stand-alone claim line) in order to be processed in Phase II for retroactive rate adjustment processing and for the capability of the Trading Partner to subsequently submit Adjustments or Voids.
- Conversion of pre-Phase II Claims:
- Depending on certain conditions, pre-Phase II claims (multiple lines related under one claim) were either “rolled up” into one Document (one TCN for all claim lines), or a claim line was considered a “stand-alone” and was assigned it’s own TCN (it is considered a Document as well). (In this last case, there is a one to one relationship between the CRN and the new TCN.)
- Claims were not “rolled up” into one Document if any of the lines in that claim met one of the following conditions:
- Any one line was adjusted or voided.
- Any one line was not adjudicated on the same date.
- The claim itself is a rate-based claim.
- All of the lines are not of the same claim type.
- To identify a claim that has been “rolled up” (all related lines will have the same TCN, and are considered part of a Document) as opposed to undergoing a one to one conversion, consider the following:
- If positions 13 and 14 of the TCN contain “00” (zeros), then all lines in that claim were rolled up into one Document. This means they can be referenced individually by using the TCN, but must always be referenced by including the other claim lines. THE POINT IS TO ALWAYS WORK WITH THE WHOLE DOCUMENT. (Note: Phase II documents may have zeros in positions 13 and 14 as well, but there are other ways (see below) to differentiate Phase II TCNs from pre-Phase II TCNs.)
- Pre-Phase II TCNs will have a Julian date (positions 1 through 5) of 05082 or less.
- If a pre-Phase II claim had more than 50 lines associated with it, then the TCN will contain “01” in positions 13 and 14 for lines 51 and greater. The first 50 lines would contain “00” in positions 13 and 14. Therefore, the TCN would be the same for a claim of 55 lines, and there will be “00” in positions 13 and 14 of the first 50 lines, and “01” in positions 13 and 14 of the 51 st and greater lines.
- To identify a claim that has not been “rolled up” (which means there is a one to one relationship between the old CRN and the new TCN), then the first 14 characters of the TCN will equal the first 14 characters of the old CRN. Additionally, the 15 th and 16 th byte will conform to the rules described above (see FORMAT OF TCN .)
ADJUDICATION OF DOCUMENTS :
- All claims submitted on or after Julian Date 05083 will be processed as Documents. For instance, a Professional (837P) claim submitted with four Procedure lines, will be processed as a single Document. In HIPAA terminology, an 837P (described here at a high level) would contain a CLM segment, and four SV1 segments. This equates to four fee-based claim lines that would be processed as one Document, and would be assigned a single TCN during the adjudication process. (This assignment has variations as stated below.)
- ADJUDICATION RESULTING IN ONE PAID LINE AND ONE OR MORE PENDS: Using the above example:
- When processed internally, if one of the four lines is approved , and one or more of the other lines pend , then all four lines would pend . Each line would be reported on the Remittance Advice Document with THE SAME TCN (which is the TCN of the Document).
- NOTE: Only the claim line(s) that “pended” will appear on the Remittance Advice Document with an error code and message. The other claim lines will appear as well but will not contain error codes and messages.
- Next, once all pended lines of a document are internally adjudicated (paid or denied), then they will appear on an 835 as a paid or denied claim, and their associated lines will appear as paid also.
- ADJUDICATION RESULTING IN ONE PAID LINE AND ONE OR MORE DENIES: Again, using the example of four fee-based lines submitted:
- If one of the four lines is approved , and one or more of the other lines denies , then all four lines would be reported on a Remittance Advice with the same TCN, and the adjudication would be: one paid line, and three denied lines.
- ADJUDICATION RESULTING IN A FOUR PAID LINES, FOUR DENIES, OR FOUR PENDS: Again, using the example of four fee-based lines submitted:
- The only item of note here is that each line would have the same TCN reported on a Remittance Advice.
PROCESSING OF ADJUSTMENTS AND VOIDS OF DOCUMENTS PAID IN PHASE II :
(Note: For a pre-Phase II Document, Providers would need to refer to the 15-digit CRN as received on a Remittance Advice.)
- ADJUSTMENT OF ONE LINE OF A FOUR LINE DOCUMENT
- In order to adjust one line of a four line Document, in addition to supplying the Document TCN in order to reference the previously paid claim (i.e., CLM05-3 = 7, and DOCUMENT TCN in 2300 REF segment – Original Reference Number (ICN/DCN), you would always include all four “lines” in the 2400 Loop, SV1 Professional Service segment (or comparable Service Line segment of another 837). The “unchanged” lines would be entered exactly as they were when first submitted, while the line you wish to adjust would contain the appropriate information to be modified. The result of this submission would be: the Document TCN would be Reversed (Voided), and the appropriate line would be adjudicated (Replaced) and assigned a new TCN. The other lines would not be modified, but would be “re-adjudicated” and assigned the same TCN as the line that was modified.
- If you do not include all four lines, then (a) the DOCUMENT TCN would be VOIDED, and only the one “line” submitted will be adjudicated. The three lines that you did not include will have been voided (as part of the DOCUMENT), however, that would be their last “status”. For those three lines you would subsequently have to resubmit these three as original lines for adjudication. This means that you would submit them as if they were new claims.
ADJUSTMENT OF ALL LINES IN A DOCUMENT USING ABOVE SCENARIO:
- The adjustment process here is the same as the above, however, for each “line” to be adjusted, you must include the necessary X12 transaction requirements for the Document (i.e., CLM05-3 = 7, DOCUMENT TCN in 2300 REF segment – Original Reference Number (ICN/DCN)). Remember to enter all lines in the 2400 Service Line segment separately with appropriate modifications (reason for adjustment). The result will be that the Document will be Reversed (Voided), and each line will then be “modified” (Replaced), and assigned a new TCN and will be reported appropriately on a Remittance Advice. The new TCN for each of the four lines will be the same. The same caution applies here: You must always include all lines when adjusting a Document.
VOID OF ONE LINE OF A FOUR LINE DOCUMENT USING ABOVE SCENARIO :
- In order to void one line of a four line Document, you must submit an ADJUSTMENT instead of a VOID. (See ADJUSTMENT OF ONE LINE OF A FOUR-LINE DOCUMENT. )
- If voiding a Pre-Phase II line, simply do an adjustment referencing a CRN that is NOT the line you want to void, and then in the SERVICE LINE segment (i.e., SV1), omit the line you actually want to void.
- If voiding a Phase II line, simply do an adjustment referencing the TCN, and then in the SERVICE LINE segment (i.e., SV1), omit the line you actually want to void.
VOID OF DOCUMENT USING ABOVE SCENARIO :
- In order to void the Document (all lines), submit a void (CLM05-3 = 8), referencing the TCN, or any of the former Legacy CRNs (if applicable). Remember to add at least one of the associated lines in the SERVICE LINE segment (i.e., SV1).
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