5010/D.0 Compliance (X12/NCPDP Submitters)

Point of sale
Point of sale or D.0 pharmacy submitters must refer to the NCPDP Implementation Guide for basic instructions for D.0 requirements. NCPDP members access the guide through the NCPDP website.

Payer sheet
Review the Minnesota Medicaid Version D.0 NCPDP Payer Sheet (DHS-7616) (PDF) for more detailed information about Medicaid D.0 NCPDP transaction requirements.

MN–ITS Interactive or DDE is HIPAA-compliant and follows standards outlined in the Minnesota Uniform Companion Guides.

Testing is not required for MN–ITS DDE.

The MN–ITS DDE application and related user guides comply with 5010 requirements.

You may copy, replace and void claims regardless of the date of submission. You must include 5010 required values and diagnosis codes when copying or replacing claims. Validate the claim to confirm all necessary fields are completed.

Claim transactions (837P, 837I, 837D)
MHCP follows the AUC guidelines and best practices established for professional, institutional and dental health care claims to comply with requirements.

MHCP remittance advice (RA) (835)
Refer to Minnesota Uniform Companion Guide for Health Care Claim Payment/Advice (835) (PDF) for 5010/NCPDP requirements. MHCP will:

• Place all RAs and 835s into the MN–ITS mailbox folders by Friday following each payment cycle
• Provide billing intermediaries, clearinghouses and health plans separate 835s, 835Es and 835Cs for each pay-to provider and display both the submitter and pay-to provider NPIs in the file name (example:A0000000X0_835_1234567890_20111102121915234.TXT)

Eligibility inquiry and response (270/271)
MHCP follows the AUC guidelines for Health Care Eligibility Benefit Inquiry and Response (PDF) (270/271) and best practices to comply with implementation requirements.

Acknowledgements (TA1, 999)
Refer to the Minnesota Uniform Companion Guides for the following acknowledgment guidelines: 

• TA1 Interchange Acknowledgement Segment
• 999 Functional Transaction Set

Unless rejected for one of the following, MHCP will return an additional HTML report with X12 data for rejected TA1s and 999s:

Rejected TA1

Rejected 999

Authorization request (278)
MHCP developed an implementation guide for submitting 5010 X12 authorization request (278) transactions.

Request status (276/277)
MHCP developed an implementation guide for submitting 5010 request status (276) transactions.

If you submit X12 or NCPDP batch files using proprietary software, follow these steps:

1. Use the HIPAA electronic data interchange (EDI) standards as outlined in the X12 Standards or NCPDP Implementation Guides.
2. Use the Minnesota Uniform Companion Guides.
3. Review the FTP (File Transfer Protocol) Software Instructions for MN–ITS Batch Use for submitting and receiving batch transactions to and from MHCP.
4. Conduct 5010 syntax testing with MHCP for each transaction type before submitting batch X12 to production.

Batch file size
MHCP requests you submit no more than the number specified within a batch file for the following transaction sets. Files greater than the following numbers may require manual intervention and result in delays in processing and payment.

• NCPDP Pharmacy Claims – 5,000 claims per file
• 837 claims – 5,000 claims per file
• 270 eligibility – 99 patient inquiries per transaction set
• 276 claim status – 100 claim requests per file

Use the following file structure guidelines to submit NCPDP Pharmacy/5010 X12 Batch HIPAA-compliant transactions through MN–ITS (references to real-time apply only to production submissions, not to syntax testing).

ISA/IEA per file
For batch or real-time applications, MHCP processes only one Interchange ISA/IEA loop per file. If you send more than one Interchange ISA/IEA loop, MHCP will reject with a TA1:TA104-022 (Invalid Control Structure).

GS/GE per ISA/IEA
MHCP accepts:

• One real-time GS/GE
• Multiple batch GS/GE; however, each must contain the same Function Group Identifier (GS08). If they do not, MHCP will reject TA1 with TA104-024 (Invalid Interchange Content)

ST/SE per GS/GE
MHCP accepts:

• One real-time ST/SE 
• Multiple batch ST/SE
• Upper case and case sensitive qualifier values; MHCP will otherwise reject with 999
• One byte segment delimiters; MHCP will otherwise reject with TA104-004

Refer to Appendix B.1.1 Interchange and Application Control Structures of the Implementation Guides for additional information. 

MHCP requires:

• For 837 I/P/D: 5000 claims per ST/SE
• For 270 batch: 99 inquiries per ST/SE and up to 5000 inquiries per file

Use the following formats when naming files and submitting X12 Batch or NCPDP HIPAA-compliant transactions to MHCP.

Inbound files (837, 270, 278, 276, N12, NCPDP)
To send inbound files:

• Limit the name size to 60 characters
• Use the following preferred file naming format “NPI_TransactionID_CCYYMMDD_TPinfo.dat”

“Transaction ID” may be any of the following:

• 837I, 837P, 837D, 270, 278, 276, for fee-for-service and encounter submissions

“TPinfo” may:

• Be anything the trading partner chooses to add to further identify the data
• Be alphanumeric
• Use the underscore special character (_) to separate each name element

Example of a file name using the suggested naming format:
0123456789_837P_20110930_mynewtransaction_newclient.dat

X12 RA (835s, 835Es and 835Cs)
MHCP uses the following file name formats:

• SubmitterNPI_TransactionID_CCYYMMDD_IDSequenceNum.txt
• SubmitterNPI_TransactionID_PaytoProviderNPI_CCYYMMDD_IDSequenceNum.txt (to identify both the billing organization and each pay-to provider in the transaction)

(Example: A0000000X0_835_1234567890_20111102_121915234.TXT)

File-to-file (271)
The eligibility response is file-to-file transaction. MHCP uses the following file name format:
“NPI_TransactionID_CCYYMMDD_INfilename.dat”

“INfilename” = the incoming file name in the 270 requests without an extension (.txt, .dat, .dat01, and so on)

Acknowledgements (TA1, 999, N12R)
MHCP uses the following file name format for TA1, 999 and N12R acknowledgments:
“NPI_TransactionID_InTransactionID_CCYYMMDD_INfilename.dat”

“INfilename” = the incoming file name without extension (.txt, .dat, .dat01, and so on)
“InTransactionID” = the “TransactionID” from the inbound file for which the Acknowledgements are generated

MHCP requires all trading partner batch submitters, including managed care organizations (MCOs), to test for syntax errors before submitting 5010 batch transactions. Upload all syntax test transactions manually using the Submit Transactions application in MN–ITS. MHCP will not respond to test files submitted through SFTP.

A billing organization that submits batch transactions on your behalf must initiate the 5010 syntax testing for your batch files.

The MN–ITS test region allows batch submitters to test transactions for syntax errors in an environment similar to MN–ITS production. MHCP created one username and one password for all MN–ITS test account users.

Log in to the MN–ITS test region
To access the test region:

1. Log in to your MN–ITS account.
2. Select MN–ITS Home at the top of the screen.
3. Select Test Region in the right column under “Related Pages.”
4. Follow the directions on the test region page.

MHCP sends a response to your test region mailbox within 48 hours. After you receive an AcceptTestMsg.txt per transaction type, wait 48 hours before submitting in production.

Current X12/NCPDP batch submitters: MHCP created a test account for your NPI/UMPI. Follow the directions on the MN–ITS Test Region home page to log in to your test account (NCPDP testing is only for MCOs).

New batch submitters: You must first create your test account within the test region before logging in to submit test transactions. Follow the steps on the Test Region home page in MN–ITS to create your test account.

Avoid these common syntax testing errors:

• The ISA15 field must be "P".
• The ISA11 field must contain a valid character – MHCP recommends a left bracket ([).
• Currently, MHCP cannot accept a pipe symbol (|) in either the ISA or body of the file – your file will not receive a 999 or TA1.
• The same segment terminator at the end of ISA16 must be at the end of your file, no extra characters; otherwise the file will not receive a 999 or TA1.
• Use an underscore (_) to separate file names.
• Use a period (.) only to indicate the extension of your file.

After submitting your 5010 test transactions, check the 999, TA1 or Production Failed folders within the test region for results.

Review MCO Encounter Submissions from the Managed Care Organization provider home page for additional information about submitting 5010 transactions to MHCP. The following explains how to submit 5010 and NCPDP test transactions to MHCP.

MCO encounter claim test transactions
MCOs must complete the following steps to submit test transactions to MHCP:

1. Log in to your MN–ITS test account to submit test transactions.
2. Send test files through MN–ITS/Submit Transactions option.
3. Test each transaction separately
   • Send NPIs/UMPIs in ISA06 and GS02 (in ISA06, include 5 trailing spaces, as ISA06 must contain 15 bytes)
   • Continue to send “ZZ” in ISA05, “30” in ISA08 and “41-1674742” (with the dash) in ISA08
4. Retrieve your transaction responses within 24 hours from your MN–ITS mailbox Transactions Responses folder.

Continue to review MCO Encounter Submissions for additional instructions and announcements.

• MDH AUC home page
• ASCX12 (Accredited Standards Committee X12)
• National Council for Prescription Drug Programs (NCPDP)