Q.

Where can I find the provider taxonomy codes?

A.

Provider taxonomy codes and other codes are available on the Washington Publishing Company Web site.

Q.            

Are you capable of receiving the 837 version 4010A1 format mandated by HIPAA? If so, what software (name and version) do you use for this?

A.            

At this time, DHS accepts claims for payment in the 837 Professional, Institutional and Dental formats for fee-for-service and encounter. DHS does not accept claims for long-term care or nursing home inpatient facility charges in the 837 format.

DHS does not endorse or recommend any HIPAA software. For more information about how to select an EDI vendor (for software, billing or clearinghouse services), go to our Getting Started page.

Q.            

Does Oregon DHS require an agreement for HIPAA compliance between a health care provider and the state?

A.              

Yes, DHS does require an agreement between a healthcare provider wishing to submit claims electronically and DHS for payment. Please see the FAQ on Trading Partner Agreements and our Registration and Testing page for more  information.

Q.            

If I elect to receive the 835 Remittance Advice (RA) on the Trading Partner Agreement, but my software is not ready to receive and utilize the data I would receive back, can I still receive the paper RA OMAP currently generates?

A.            

DHS will continue to produce the paper RAs after a provider begins receiving the 835 remittance advice.

Q.

As I am not the technical or encounter data person, could you shed some light on the 837 transaction? I am under the impression that the 837 form is the standard claim form for everyone, submitted by the managed care plans to DMAP.

A.

The 837 is the standard transaction for all health care providers wishing to send claims to payers electronically. There are three types: the professional, institutional and dental. The professional most closely relates to the current CMS-1500 or NSF format, the institutional to the UB-04 for inpatient and outpatient and the dental to the ADA form or NSF format. There are additional differences with regard to fee-for-service claims versus managed care encounter claims.

Q.            

What can DHS tell me about locating information on the new HIPAA Transaction and Codes Sets standards for health care claims payment?

A.            

The 837 Dental (D), Institutional (I) and Professional (P) Implementation Guides (IGs) detail the specifics of creating, and/or receiving electronic data interchange of health care claims/encounters information. These are electronic formats and no paper equivalent exists.

While there are no forms specifically formatted for these transactions, they were based on commonly used paper forms such as the ADA Dental claim form for the 837 D, the CMS-1500 for the 837 P, and the 837 I for the UB-04.

However, there is no one–to-one relationship to the data on the paper forms and the data required in the 837 formats. You will need to review the IGs and your current system to determine what changes your current system will require. 

DHS will be using the Final Addenda Version (4010A1) mandated February 2003. The Implementation Guides and Addenda are available for purchase from the Washington Publishing Company Web site. Federal law mandates that all electronic medical claims (dental, institutional and professional) must be transmitted using the HIPAA formats on and after October 16, 2003.

Q.            

I want to become an electronic submitter of claims with DHS. Does DHS have software available?

A.              

DHS does not have software that can be used to submit electronic claims. We recommend contacting your local professional association, checking the Internet, CMS Web site, or review the resources on the Getting Started page of our Web site.

Q.

What is a Trading Partner Agreement?

A.

The Trading Partner Agreement (TPA) is a binding agreement between DHS and a provider (OAR 407-120-0100). DHS requires all of those planning to do electronic business with DHS to sign a Trading Partner Agreement before testing.

Q.

Can we have multiple contact persons on the TPA?

A.

Exhibit B of the TPA allows for seven different contacts: Two provider contacts for contact or authorized signer, another two provider contacts for claims inquiries, and three contacts for the EDI submitter.

Q.

Are pharmacies required to submit a TPA?

A.

The answer is yes and no.

• Yes, if the pharmacy electronically submits durable medical equipment (DME) claims, they must complete a TPA and register for the 837 Professional transaction.
• Yes, if the pharmacy is receiving an electronic RA, they must register to receive the 835 RA transaction.
• Yes, if the pharmacy only submits electronically through point of sale (POS), they must register to receive the 835 RA transaction. 
• No, if the pharmacy submits paper claims only, DHS will only return claims information on the paper RA.

Q.

What happens if a provider submits to one clearinghouse, and the clearinghouse passes the claim along to one or more additional clearinghouses before it is submitted to DHS?

A.

The TPA is designed to identify the two relationships DHS must understand: 1) Who the provider is (the trading partner), and 2) Who will be submitting the compliant transaction to DHS for payment or adjudication (the EDI submitter).

In this scenario, we are only interested in the clearinghouse that ultimately submits the claim to DHS. If the relationship between the trading partner and their identified EDI submitter changes, the trading partner must notify DHS using Exhibit C– EDI Registration Change Form available on our Web site.

Q.

Can I list all providers on the first page of the TPA, or do I need to list each separately?

A.

If each provider receives their own check, they each have to fill out a TPA. If a clinic or group of providers receives the payment, then only one TPA is required. Instructions on how to complete registration for multiple individuals are available in the EDI Registration Packet at this link.

Q.

Can I fax my TPA once it is completed?

A.

Because DHS requires original inked signatures, we must have the original TPA on file. As with any legal document, do not use correction fluid.

Q.

I am a provider. Do I need to submit a TPA for my EDI submitter(s) as well as for myself?

A.

If you submit on your own behalf but also use an EDI submitter for some of your work, then yes. One TPA will indicate the transactions you will submit; a separate TPA will indicate which transactions your EDI submitter will send on your behalf. The second scenario requires the TPA to go to the submitter for their information and signature.

Q.

Who should sign the TPA?

A.

The authorized signer is the person of authority in the provider's office. This does not include a billing service. The authorized signer can delegate another person to have signing authority such as an office manager to make changes to the TPA. If you choose to have a deleted signer in addition to the authorized signer, make sure to clearly identify the delegate on the TPA.

Q.

Will there be any enrollment data changes (e.g., provider IDs, data elements changing)? When will these changes take place?

A.

DHS does not anticipate any significant changes to the TPA registration process. However, HIPAA is a federally mandated requirement and DHS must comply as the requirements change.

Q.

Will re-enrollment be required and what are the terms and deadlines?

A.

If the HIPAA X12 formats change, the TPA will need to be revised and trading partners will need to complete new TPAs to register for the updated formats.

Q.

Where can I find the EDI Registration Packet containing the TPA?

A.

You can download the information on our Registration and Testing page. If you have additional questions call 503-947-5347, 888-690-9888, or email DHS.EDIsupport@state.or.us.

Q.

My company name changed, but not my tax identification number. Must I complete a new TPA?

A.

No.  You can update this information using Exhibit C (EDI Registration Change Form).

Q.

I realized I checked a transaction that I am not going to be submitting. Do I need to make any changes to the TPA?

A.

Yes. DHS tracks and uses this information when setting up profiles for submission of transactions. To update your list of authorized transactions, complete Exhibit C.

Q.

If I submit the 837 transaction, must I receive the 835 Remittance Advice or can I continue to receive the paper RA by not selecting the 835 on the trading partner agreement (TPA)?

A.

If you submit claims to DMAP electronically in the 837 transaction, you have the option at this time to receive the electronic 835 RA response or the paper RA.

Q.

I sent an email to the DHS.EDIsupport@state.or.us yesterday and have not received a response. What is the turn around time on questions?

A.

DHS has committed to responding to email questions within 2-5 business days. Questions are answered in the order they are received based on how technical the question.

Q.

I sent a question to the business to business email address and have not received a response. Why?

A.

The DHS business-to-business email address is not used for questions and answers. Please use the DHS.EDIsupport@state.or.us address.

Q.

What is DHS' expectation for passing business-to-business testing?

A.

DHS expects a test file to contain at least 25 claims, but no more than 100 live claims. DHS strongly encourages providers to test the coordination of benefit segments. DHS will run the file through Edifecs and Claredi edits before setting the file up to process in our test environment.

If the file passes the structural and data requirements of Edifecs and Claredi, DHS will process the file in our test environment and generate an error report. If the file has not exceeded the threshold of any more than 10% error rate, DHS will notify you of a provisional pass status for production. If the file exceeds the 10% error rate, review the error report for possible modifications.

Q.

I am in business-to-business testing and have a question related to the Implementation Guide (IG). Who can I ask at DHS?

A.

DHS is a health care provider and is under the same federal requirements as set forth by HIPAA. The Implementation Guide (IG) is a document maintained and published by the Washington Publishing Company. We can not advise any health care provider, software vendor or clearinghouse on how to interpret the IG.

Q.

What type of claims do I test with? Can I use sample/dummy data? How many claims should I put in a test data file?

A.

DHS requires you to use real, live claims for testing purposes. Test data must not have dates more than 365 days from the original date of service, and you must include 25-100 claims per data file tested.

Q.

I am in production for the 837 professional transaction fee-for-service and continue to receive the paper RA. On the RA, I receive an error for type of service (TOS). There is no TOS in the HIPAA transaction, so why am I receiving this information on the RA?

A.

The paper RA is from DHS' current Medicaid Management Information System (MMIS), which still requires a TOS code to be present. To process claims in the existing system, DHS created a workaround where TOS is automatically entered for each claim based on provider type, modifier usage and procedure code.

If the TOS entered based on this information is incorrect, the claim does not pay. The RA will show non-payment due to a TOS error, which is based on the combination of data elements used to determine the TOS.

When the replacement MMIS goes live, this RA report will go away. The HIPAA-compliant adjustment reason codes are the ones that you should become familiar with to prepare for the change.

Q.

I did not receive a response 997 or TA1. Should I re-submit my transactions?

A.

No, contact DHS through the DHS.EDIsupport@state.or.us email address, or call 888-690-9888.

Q.

As a clearinghouse in production, what is the process when a provider has been newly enrolled for our service?

A.

The provider must submit a new or revised Trading Partner Agreement (TPA) to DHS. If the provider/trading partner has a TPA on file indicating a different submission process (e.g., different clearinghouse), then the provider can submit Exhibit C (Registration Change Form). .

Q.

Does my password to the mailbox ever expire?

A.

You will need to change your password every 60 days. This time starts from the time you are assigned a password and you change it for the first time. The SFTP mailbox does not offer any reminders to warn you that your password is ready to expire.

Q.

How does Oregon DHS handle scripts that run to submit transactions and/or pick up response transactions?

A.

Oregon DHS does not have a business decision or policy against running scripts, but we strongly advise against it. Scripts do not typically address password requirements, resulting in calls to reset the password. If you do not disable the script, we cannot easily reset the password.

Q.

What is a National Provider Identifier (NPI)?

A.

An NPI is the standard, 10-digit unique health identifier for health care providers mandated by the Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Q.

Why do I need a National Provider Identifier (NPI)?

A.

All covered entities under HIPAA must use NPIs to identify health care providers in standard HIPAA transactions. NPI is meant to replace all other identification numbers assigned to covered entities by various payers, such as the six-digit provider number assigned by DHS. Use of NPI is meant to improve the efficiency and effectiveness of the electronic transmission of health information. More information is available on the CMS Web site at this link. 

Q.

Where do I get an NPI?

A.

You may apply online by following the directions on the National Plan and Provider Enumeration System (NPPES) Web site. Once you receive an NPI, notify EDI Support Services using this fax form. Include your DHS provider number, NPI and the taxonomy code(s) you selected.

Q.

What are taxonomy code(s)?

A.

The taxonomy code allows a single provider (individual, group, or institution) to identify their specialty category, similar to your DHS provider type. Providers may choose more than one taxonomy code.

Q.

What taxonomy code(s) should I use?

A.

Use the code that most accurately describes your business. A provider can change taxonomy code(s) with the NPPES at any time. DHS may recommend which taxonomy code you need to use for continuous, uninterrupted payments in our MMIS system. See Washington Publishing's recommended taxonomy codes.

Q.

Will DHS require taxonomy codes on claim submissions?

A.

If you registered your NPI with DHS with a taxonomy code(s), use that taxonomy code(s) whenever submitting an electronic claim to DHS. This allows DHS to make a positive one-to-one match between your 6-digit DHS provider number and your NPI.

Whenever there is a discrepancy between the identifiers you registered with DHS and the identifiers used on your claim submission, DHS will try to make a match using the provider name, address, and other identifying information. Make sure to use the same provider name on every claims transaction you submit so that DHS can match the claim to the correct provider.

If DHS staff cannot make a positive match, you need work with DHS to ensure a resolution for future claims. Contact EDI Support Services at 888-690-9888 or DHS.EDIsupport@state.or.us. For more information about taxonomy codes and claims, read this Q and A (pdf).

Q.

Will taxonomy codes be required for the referring provider if another entity is billing?

A.

An individual provider should only have one NPI, so the NPI in this case should be sufficient for DHS to gain a one-to-one match; however, it is always safer to include a taxonomy code where one has been identified in the NPI enumeration process.

If the claim is denied for a referring provider reason, the provider should work with DMAP’s Provider Services Unit to determine the cause of the denial, as it may be unrelated to the NPI.  Contact DMAP Provider Services at 800-336-6016 or DMAP.providerservices@state.or.us.

Q.

What if I’ve forgotten which codes I chose?

A.

Call the NPPES at 1-800-465-3203.