Submissions
How should partially denied claims (paid claims containing denied lines) be submitted?
Last Updated: August 11, 2017Partially denied claims should be submitted in their entirety.
Will gender codes be standardized across all three files?
Last Updated: August 11, 2017Yes. M, F and U should be used as the code set for ME013, MC012 and PC012.
Does CIVHC expect that the data fields to be submitted in field number order, or, in the logical order given in the Submission Guide?
Last Updated: August 11, 2017The order the columns appear in the DSG are the order the columns should appear in the files.
What is the threshold guidance for column MC107?
Last Updated: August 11, 2017Column MC107 (Member Street Address) is a threshold column.
What value should appear in the Payer Code columns?
Last Updated: August 11, 2017The codes for Payer Code columns (HD002, TR002, ME001, MC001, PC001, MP001) will be assigned by CIVHC.
Do Version Numbers ( MC005A) need to be consecutive?
Last Updated: August 11, 2017No. However, the maximum Version Number needs to represent the last known state of the medical claim.
Should only paid and discharged claims be included?
Last Updated: August 11, 2017This addresses interim bill submission. Interim bills are defined by the last digit of the bill type. Interim bills should be sent as they are paid. Treo Solutions will consolidate interim bills as subsequent bills are received.
What is the guidance for MC055 (Procedure Code) for institutional claims?
Last Updated: August 11, 2017MC055 is required for outpatient claims. Inpatient procedure codes should be supplied in column MC058.
What is the guidance for columns MC065 (Co-pay Amount) and MC066 (Coinsurance Amount)?
Last Updated: August 11, 2017Claims that do not have co-pay or coinsurance amounts, a value of 0 should be supplied.
What is the guidance for columns marked as O (Optional)?
Last Updated: August 11, 2017Data for optional columns should be supplied when the source data contains a value.
Should all detail lined be supplied for a paid claim?
Last Updated: August 11, 2017Yes. If a claim has been paid, all detail lines must be included.
What column names should be supplied in the first row?
Last Updated: August 11, 2017Use the Data Element # as the first row after the header row.
What are the definitions for MP003 (Provider Entity)?
Last Updated: August 11, 2017Institutional facilities should be coded as F. Individual Providers (Physicians, Physician Assistants, etc.) should be codes as I. Physician Groups should be coded as G.
Values for column MC054 (Revenue Code), a required column, are not available for professional claims. Should we apply for a variance for this deficiency?
Last Updated: August 11, 2017No. Revenue Codes are only required for institutional claims.
What is the guidance for column MC055 (Procedure Code) where payments are made based on Revenue Code?
Last Updated: August 11, 2017Procedure Codes should be supplied where available.
What is the guidance for MC058 ( ICD-9-CM Procedure Code)?
Last Updated: August 11, 2017For surgical inpatient stays, supply as many procedure codes as available. Medical cases will not have procedure codes and are, therefore, not required.
What is the column delimiter?
Last Updated: August 11, 2017All columns should be delimited by a pipe character (|).
Do Colorado license numbers need to be prefixed with the state code?
Last Updated: August 11, 2017Yes. All license numbers should be prefixed with the issuing state code.
What is the proper coding for dependents over age 18?
Last Updated: August 11, 2017Dependents over age 18 should be coded as 76 (Dependent).