Medicare Medicaid (FAI)
This page provides valuable CMS guidance, materials and information for the successful electronic submission of Medicare-Medicaid data.
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If rejecting the last Medicare encounter for the subscriber, would all loops/segments pertaining to the encounter be rejected and therefore deleted from the file sent to the State, starting with 2300:CLM up to the next HL (next subscriber or billing provider)?Is CMS expecting the value that was provided in Field 896 in the NCPDP PAH 4.2 pharmacy encounter file to be used for credit/debit transactions after the claim has been processed?If multiple encounters for a subscriber exists and rejecting a Medicaid claim, would all loops/segments pertaining to the encounter be rejected and therefore deleted from the file being sent to the State, starting with 2300:CLM up to the next 2300:CLM?When you say “unique plan id”, you are referring to the MMPs 5 position H contract number, correct?If rejecting a single encounter for a single subscriber and a single billing provider, would all loops/segments pertaining to the Medicaid encounter be rejected and therefore deleted from the file being sent to the State, starting with ST and up to SE?If rejecting a single encounter for a subscriber, would all loops/segments pertaining to the Medicaid encounter be rejected and therefore deleted from the file being sent to the State, starting with the subscriber HL and up to the next HL (next subscriber or billing provider)?In those cases where no NPI is submitted for a specific encounter, will Medicare leave this alone or provide a default value?Will Medicare require State agencies to respond to Medicare with an audit file? If so, in what format. Is this still necessary or required?For transaction identification purposes, State agencies will need a complete list of Submitter-IDs as referenced in the above document for ISA06, GS02, and 1000A NM109. In order for State agencies to identify which MMP submitted which data State agencies would need to know which plan codes belong to which MMPs, hence our request for a complete list of plan codes (submitter ids) and their associated owners.Will MMP use Addendum to Encounter Data System Companion Guide and State Assigned Medicaid Companion Guides Version Number 2.0, dated November 15, 2013 (CSSCOperations.com) – specifically sections 4.0 and 5.0?MMP Edits Update Effective February 29, 2016 - ClarificationWhat file naming conventions will be in place for data sent to the State agencies?What is the naming convention that MMPs use for these Medicaid data submissions?Will Palmetto group encounters from the same MMP together?Will CMS send back rejects on the NCPDP file for compounds under the DE or will we see the CD identifier starting in position 47?Will data rejected by Medicare be omitted from the data sent to State agencies?With the exception of those fields referenced in sections 4.0 and 5.0, will the MMP use the State agencies provided companion guide for all remaining data elements?Will Medicare make any changes to the data submitted by an MMP prior to State agencies receiving it?Will data sent to State agencies, be separated by submitting plan? Either they will send a consolidated file or will send separate files per submitter. Presuming they will send a consolidate single file per day, where the data is identified at a high level loop per submitter. Please confirm if this is the case and where the iteration will be based (loop-wise).Will data sent to State agencies consist of data submitted by multiple MMPs in a single consolidated file?When will a test file be available to show State agencies the exact implementation of the interface between Medicare and State agencies?If rejecting only the non-compliant portion of the Medicaid file, is the rejection at the transaction (ST – SE), or claim level?If rejecting the last encounter for the subscriber, would all loops/segments pertaining to the Medicaid encounter be rejected and therefore deleted from the file being sent to the State, starting with 2300:CLM up to the next HL (next subscriber or billing provider)?How will MMPs test with Medicare and State agencies on an end-to-end integration test?How long will it take from Medicare receipt of the submitted MMP encounter data to when this data is posted to State agencies?Will the NCPDP file be part of the audit tracking?In the event of a compliance failure on the Medicaid file does CMS/Palmetto reject the non-compliant portion of the file or the entire file?If rejecting a single Medicare encounter for a single subscriber, would all loops/segments pertaining to the encounter be rejected and therefore deleted from the file sent to the State, starting with the billing provider HL and up to the next HL (next subscriber or billing provider)?If rejecting a single Medicare encounter for a single subscriber and a single billing provider, would all loops/segments pertaining to the encounter be rejected, starting with ST and up to SE?If a single Medicare encounter is rejected will the HLs be renumbered to be in sequence?If a single Medicare encounter is rejected will the ST/SE count be recalculated to reflect the new count for the transaction?Will more than 1 response line be sent per claim on the NCPDP file if there are both detail and compound rejects?If multiple Medicare encounters for a subscriber exists and there is a encounter being rejected, would all loops/segments pertaining to the encounter be rejected and therefore deleted from the file sent to the State, starting with 2300:CLM up to the next 2300:CLM?If rejecting a single encounter for a single subscriber, would all loops/segments pertaining to the Medicaid encounter be rejected and therefore deleted from the file being sent to the State, starting with the billing provider HL and up to the next HL (next subscriber or billing provider)?In what position on the NCPDP file will CMS populate the CMS assigned number for each claim?Will encounters from the same billing provider be grouped together?NCPDP Response Report LayoutMMP Webinar Training - January 22, 2015MMP NCPDP Companion GuideX12 Version 5010 StandardsInformation and Guidance for PlansDental Error Code ListingMMP Dental Companion Guide AddendumState Data Resource CenterWashington Publishing CompanyNCPDP Error Code ListingDoes CMS/Palmetto perform compliance validation on 837 files received from ICOs for Medicaid services?If rejecting a single Medicare encounter for a subscriber, would all loops/segments pertaining to the encounter be rejected and therefore deleted from the file sent to the State, starting with the subscriber HL and up to the next HL (next subscriber or billing provider)?Will ISA08 equal GS03 (80892 for Medicaid)?If rejecting at the claim level for the Medicaid file, is the compliant portion reformatted to a compliant 837 transaction?MMP Inst Addendum to Encounter Data Submission and Processing Guide and State assigned Medicaid Companion GuidesMMP Prof Addendum to Encounter Data Submission and Processing Guide and State assigned Medicaid Companion GuidesMMP DME Addendum to Encounter Data Submission and Processing Guide and State assigned Medicaid Companion GuidesEncounter Data Processing System Maintenance Dental Validation Report Layout2024 PDE Monthly Report Distribution StatusUpdate to the PDE Outbound File Layout2024 PDE Monthly Report Distribution Status