eMedNY Transactions

CHANGE TO ELECTRONIC REMITTANCES

835 and 820 Supplementary Files to Provide Denied Claim Detail

 Effective Monday, February 20 th, 2006 (Cycle 1487):

1. The 835 Supplementary File will provide detailed information for Denied claims, including up to 27 eMedNY edits for each denied claim. CSC will continue to report Pended claims on the 835 Supplementary File, with no change to the current record layout for pended claims.
2. The 820 Supplementary File will continue to provide detailed Denied claim information, however, up to 27 eMedNY edits will now be reported for each denied claim. Pended claims, Retros, State Submitted Adjustment/Voids, certain Stop/Loss, Kick Newborn/Maternal claims, and approved claims where the rate code was changed during adjudication, will continue to be reported on the 820 Supplementary File as well.
3. (NOTE: Unlike the Pend record, the Deny record will not have an error message. This applies to both the 835 Supplementary File and the 820 Supplementary File.)
4. To help providers resolve claim denials, the Edit / Error Knowledge Base has been updated ( http://www.emedny.org/HIPAA/Edit_Error/KnowledgeBase.html ) . This will be a great tool for providers to use for edit analysis, especially with the addition of new eMedNY edits that have been added for Phase 2. A provider needs to simply search for the eMedNY edit that a particular claim has failed, and a detailed explanation will be displayed. Providers can use this to view the possible cause for the edit failure, a solution, and sample segments/loops from the 837 transaction to use in resubmission. (The current version, which is familiar to hundreds of providers, contains all edits prior to the implementation of eMedNY Phase 2.)

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835 Supplementary File – There will be two record layouts for this file: one for Pended claim detail (currently exists), and one for Denied claim detail.

• The current Pend record layout for the 835 Supplementary file will remain the same, and will be identified in your application by recognizing value “PEND” in the claim status field, positions 28 through 31.
• The new Deny record will be identified in your application by recognizing value “DENY” in the claim status field, positions 28 through 31. The Deny record will have the same record length (527 including asterisk delimiters and tilde) as the Pend record, and will for the most part contain the same data fields. However, the data fields that will change are as follows:
• Positions 293 (beginning of Error Reason Code1) through Position 485 (end of field Error Reason Message2) will be redefined to report eMedNY edits for the Deny Record.
• The redefinition will depict 27 allotments for a 5-digit eMedNY edit code. For example: if only 2 edits were failed within the eMedNY claim adjudication system, then only 2 edits will be reported on the Supplementary file. Position 293 will start the first edit, position 298 will contain the asterisk field delimiter, and position 299 would start the next edit, followed by an asterisk and so on. Fields containing no edit will be populated with spaces. The 27 th edit field will be followed by an asterisk (position 454), followed by filler (ending in position 485), which will be delimited by an asterisk (position 486).
• The type of edits that will be reported may include approved and/or pend and/or other deny edits. However, the first edit will always be the deny edit for which the claim failed adjudication.
• The last field of the record remains the same as for a pend: 40 bytes of filler, followed by an end of record delimiter tilde (~).
• Please remember that the end of file delimiter is also a tilde (~).
• Please use the TCN for re-association to the X12 Remittance transaction.

820 Supplementary File – The programming specifications are similar to the 835 (above) with two exceptions:

• Your application already recognizes values: DENY, PEND, VOID, ADJ, and PAID in the claim status field.
• The 40 bytes of filler that appear after the new Deny fields could either be filler or have a field definition for the 820 (in the event of a Retro or State Submitted Adjustment/Void).

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(Please review the modified record layout provided in the 820 and 835 Supplemental Companion Guides carefully and adjust your applications accordingly.)

We strongly urge you to begin modifying your applications immediately in order to be ready for the February implementation. In order to allow time for your programming changes, we have published draft Companion Guides on our website. A summary of changes is provided in each Companion Guide in the Introduction section entitled “CG MODIFICATION TRACKING”. Additionally, we have provided updated sample supplementary files for your testing purposes. Please click here.