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    Jenni Bertels   
503-947-7742   

EDI Medical Bill Reporting:
Frequently asked questions

Filing-Related Questions
Data-Related Questions
Structure-Related Questions
Form-Related Questions
Pharmacy Reporting Questions
 
 
Filing-Related Questions:
Does Oregon accept medical bill filings from multiple reporting partners for a single carrier? [Answer]
   
Which bills are required to be reported to Oregon? [Answer]
   
We recently dropped off some files on your Secure File Transfer Protocol (SFTP) server that have not been picked up yet. What's wrong? [Answer]
   
We received a "TA1" file back from the division; what does that mean? [Answer]
   
How often can medical bill files be submitted during the testing period? Do medical bill files need to be submitted only on the day of the week indicated in our Transmission Profile? [Answer]
   
Is a Trading Partner Agreement required? [Answer]
   
What is Oregon's Receiver ID? [Answer]
   
Please clarify how reconsiderations must be submitted.[Answer]
   
Where is the list of insurers and self-insured employers required to report medical bill data to Oregon? [Answer]
   
When reporting ANSI 837 medical data for Oregon insurers that are not required to report Bulletin 220 data. Should we report their medical bills along with the rest of our ANSI 837 required reporters? [Answer]
   
How frequently must we report ANSI medical bills? [Answer]
   

Who is the division contact to set up a Secure FTP mailbox to report ANSI 837 medical bill data? [Answer]
   

How soon can we expect to receive the 997 and 824 acknowledgments after we submit an 837 file to Oregon? [Answer]
   

Are submissions for multiple parties allowed in a single Interchange (as opposed to having to do a separate run for each)? [Answer]
   

For the 837 Filename, the FEIN is required as part of the name. Our business supports two different lines and we have two different FEINs Do you want separate files for each line of business, or can we just use one of the FEINs for all of our transactions? [Answer]
   
What rules govern EDI filing of medical bills for Oregon? [Answer]
   
Does the division have a File Naming Convention for inbound EDI files? [Answer]
   
   
Data-Related Questions:
When comparing the data elements for the 837 between California and Oregon, there are some data elements that California requires, but Oregon does not. If those California fields are written to the 837, will the division ignore those elements, or should this information be left out completely? [Answer]
   
The structural fields (such as the ISA header fields) are not listed in your data requirements. Are they mandatory? [Answer]
   
Batch Control Number is listed as optional. Is a batch control number required in our submissions? [Answer]
   
Will Oregon perform validation of the provider license prefix? [Answer]
   
Does Oregon require reporting of denied bills? [Answer]
   
   
Structure-Related Questions:
What kinds of structural errors have you seen in submitted files? [Answer]
   
How does the division's translator handle valid but unexpected segments? [Answer]
   
   
Form-Related Questions:
The division has specific data requirements for some form fields, where would that information be located? [Answer]
   
   
Pharmacy Reporting Questions:
What do you expect to receive when a pharmacy benefit manager (PBM) reports pharmacy payments? Which amount and which received date do you want? [Answer]
   
Is there a generic National Drug Code (NDC) code for over-the-counter (OTC) drugs? [Answer]
   
When we report pharmacy bills to Oregon, do you want the National Provider Identifier (NPI) for the pharmacy or the pharmacist? [Answer]
   
For a pharmacy bill, if we do not have the rendering bill provider NPI, then do you want the rendering bill provider's FEIN and license number? [Answer]
   
For pharmacy bills, how should we report DN647, Rendering Bill Provider's NPI, and DN592, Rendering Line Provider's NPI? [Answer]
   
When we receive pharmacy bills, they often contain a different number than the NPI or state license number, e.g. the NCPDP number or DEA number. What number should we use when reporting pharmacy bills? [Answer]
 
 

 
---------------Below are the questions and answers---------------
 

Filing-Related Questions & Answers:
Question Does Oregon accept medical bill filings from multiple reporting partners for a single carrier?
Answer Yes, multiple reporter filings will be accepted.
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Question Which bills are required to be reported to Oregon?
Answer Insurers and self-insured employers are required to report all paid and denied medical bills on accepted claims within 60 days of the date of bill payment or denial. Per OAR 436-010-0005: "Medical Service" means any medical treatment or any medical, surgical, diagnostic, chiropractic, dental, hospital, nursing, ambulances, and other related services, and drugs, medicine, crutches and prosthetic appliances, braces and supports and where necessary, physical restorative services.
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Question We recently dropped off some files on your Secure File Transfer Protocol (SFTP) server that have not been picked up yet. What's wrong?
Answer Please check the file name; that has been the most frequent error to date. See our File Naming Convention below. Files that are misnamed will not be recognized by our file retrieval program, and can't be processed.
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Question We received a "TA1" file back from the division; what does that mean?
Answer A TA1 acknowledgment means there was an Interchange-Level error that prevented us from creating a 997 acknowledgment. There's a structural error with your file that must be corrected before resubmission. The TA1 file name will be formatted just like all our other file names (see below), but ending in "TA1" instead of "997."
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Question How often can medical bill files be submitted during the testing period? Do medical bill files need to be submitted only on the day of the week indicated in our Transmission Profile?
Answer Medical bill files can be submitted daily during testing. Or medical bill files can be submitted on a different day than initially indicated. Once production status has been achieved, the division would like to be able to predict and balance the processing of the submitted data load, so it is better for our submitters to send files on the day of the week that has been agreed to.
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Question Is a Trading Partner Agreement required?
Answer We require a Trading Partner Agreement and Transmission Profile from all data reporters. We do not require an Agreement from each carrier/self-insurer.
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Question What is Oregon's Receiver ID?
Answer ID Code Qualifier = FI (FEIN)
Receiver FEIN = 930952020
Receiver Postal Code = 97301
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Question Please clarify how reconsiderations must be submitted.
Answer

Reconsiderations must be sent one of two ways. For example, if the original provider bill was for $100, and you paid $50 and then reconsidered and paid an additional $25, you could:

1. Send a replacement (05) transaction, to replace it with the total reconsidered amount ($75); or
2. Send a cancellation (01) transaction, to remove the original payment ($50) and send another original (00) transaction with the total reconsidered amount ($75).

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Question Where is the list of insurers and self-insured employers that are required to report medical bill data to Oregon located?
Answer Here is the list of insurers and self-insured employers (Bulletin 359) required to report medical bill data in Oregon.[Top]
 
Question When reporting ANSI 837 medical data for Oregon insurers and self-insured employers that are not required reporters, should we report their medical bills along with the rest of our ANSI 837 required reporters?
Answer Yes. The division accepts all Oregon medical bill data, including those submitted voluntarily. In order to encourage reporting for non-required insurers, we will send an additional error message: "DN0006 Insurer FEIN: Error Code 039, No Match on Database" for any bill transactions from non-required insurers that reject for other data errors. That way, the submitter can segregate those errors if they do not wish to correct and resubmit them. [Top]
 
Question How frequently must we report ANSI medical bill data?
Answer ANSI medical bills must be reported and accepted within 60 days of the date of bill payment or denial. Files can be submitted to the division on a weekly or monthly basis, depending on volume, but enough time should be allowed for timely correction and resubmission of rejected transactions. If your expected volume is high, we'd prefer you report on a weekly basis. This will allow us to give quicker feedback on submissions, and reduce the size of any error reports that may need to be processed after each submission. [Top]
 

Question

Who is the division contact for assistance to set up a Secure File Transfer (SFTP) mailbox to report ANSI 837 medical bill data?
Answer Please contact the division EDI coordinator at 503-947-7742 to provide your company's technical contact for setting up SFTP filing. The EDI coordinator will then e-mail or call your technical contact person to get the process started. [Top]
 

Question

How soon can we expect to receive the 997 and 824 acknowledgments after submitting an 837 file to Oregon?
Answer Files are processed seven days a week, after 5:00 p.m. Pacific time. Any files that are submitted before the 5:00 cut-off time will be processed that evening, and both 997 and 824 acknowledgments will be dropped off to your SFTP mailbox overnight. Files submitted after 5:00 pm will be processed on the next business day and the acknowledgments will be returned overnight. [Top]
 

Question

Are submissions for multiple parties allowed in a single interchange (as opposed to having to do a separate run for each)?
Answer Yes, sending information for multiple carriers in a single file is acceptable. For the 837 Filename, the FEIN is required as part of the name. Some businesses support two different lines and have two different FEINs.[Top]
 

Question

Does the division want separate files for each line of business, or can we just use one of the FEINs for all of our transactions?
Answer You can pick one of your FEINs and use it for all your reporting. Just make sure to let us know that (as part of the Reporter Profile information we're working on) so that we can set up our Reporter FEIN table for matching purposes. [Top]
 
Question What rules govern EDI filing of medical bills for Oregon?
Answer EDI filing of medical bills in Oregon is governed by the Division 160 Rules and can be found on our main Rules Web page. [Top]
 
Question Does the division have a File Naming Convention for inbound EDI files?
Answer Yes, the division is using the suggested IAIABC format, which is:

• The State of Jurisdiction (2 Alpha)
• The Trading Partner/Sender FEIN (9 numeric)
• Test/Production Indicator (1 Alpha)
• Date Stamp of 837 File (8 Date CCYYMMDD)
• Time Stamp of 837 File (6 Time HHMMSS)
• File Sequential Counter (3 Numeric)
• File Layout (837, TA1, 997, or 824) (3 Numeric)

An example of the 837 File name is as follows:
OR_123456789_T_20080101_120100_001_837

The corresponding acknowledgement files would be named:
OR_123456789_T_20080101_120100_001_TA1
OR_123456789_T_20080101_120100_001_997
OR_123456789_T_20080101_120100_001_824

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Data-Related Questions & Answers:
Question When comparing the data elements for the 837 between California and Oregon, there are some data elements that California requires, but Oregon does not. If those California fields are written to the 837, will you ignore those elements, or should this information be left out completely?
Answer If the division does not require it, then we will skip it. An optional field will not cause a transaction to reject.[Top]
 
Question The structural fields (such as the ISA header fields) are not listed in your data requirements. Are they mandatory?
Answer Yes, these structural fields are required to build the file, and are mandatory. We did not list them on our business data requirements because we assumed that all reporters building the ANSI 837 file would automatically include them. Your file cannot be processed without all structural components present and in the correct order. [Top]
 
Question Batch Control Number is listed as optional. Is a batch control number required in our submissions?
Answer Although this is listed as optional, the division strongly suggests that reporters include a unique batch control number to help them match acknowledgments to submissions. We will return the reported batch control number in our 824 acknowledgement, even if it is all zeroes. [Top]
 
Question Will Oregon perform validation of the provider license prefix?
Answer No, the division will not be validating provider license prefixes. You only need to report the provider license number when the provider does not have an NPI. You are encouraged to collect and report the NPI for all providers. [Top]
 
Question Does Oregon require reporting of denied bills?
Answer The division requires reporting of denied bills on accepted claims. A denied bill is defined as any bill in which there is a non-zero charge and a zero payment. [Top]
 
   
Structure-Related Questions & Answers:
Question What kinds of structural errors have you seen in submitted files?
Answer The division has found quite a few loop segment problems. Even if the division has not specified required data fields in segments which begin the loop containing the required data, the (loop-starting) segment itself must be present, or else a structural error will be triggered. For example, NM1 indicates that a new loop is starting and should be used, with asterisks showing the presence of the fields/absence of data, before the group of REF segments indicating a provider's license number, NPI, etc.
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Question How does the division's translator handle valid but unexpected segments?
Answer The division does not consider it a structural error if a segment that we do not utilize is reported. However, those unutilized segments must be structurally correct--including proper codes--as defined in the IAIABC manual.[Top]
 
   
Form-Related Questions & Answers:
Question The division has specific data requirements for some form fields, where would that information be located?
Answer The division has a Data Elements by Source Table. This table gives information on the various source field(s) for our required data elements. [Top]
 
   
Pharmacy Reporting Questions:
Question What do you expect to receive when a pharmacy benefit manager (PBM) reports pharmacy payments? Which amount and which received date do you want?
Answer There may be two scenarios: 1) PBM pays the pharmacy and then submits that bill payment to us. Carrier pays PBM and that bill is also submitted to us (2 bills); or 2) PBM pays the pharmacy and does not submit that bill payment to us. Carrier pays PBM and that bill is submitted to us (1 bill).

In the first case, PBM will send us a Replacement Bill (same unique bill identification as the one they originally submitted to us) when the carrier/self-insured pays them. Each bill will have its own received and paid dates.

In the second case, PBM sends us an original bill telling us how much the carrier paid them, along with the received and paid date. We will not know how much the PBM paid the pharmacy, or when that payment was made.
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Question Is there a generic National Drug Code (NDC) code for over-the-counter (OTC) drugs?
Answer No, there is no generic NDC code. All OTC drugs have their own NDC code associated with them. If you pay for OTC drugs, please indicate their correct NDC code on the line.
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Question When we report pharmacy bills to Oregon, do you want the NPI for the pharmacy or the pharmacist?
Answer We want the pharmacy's information (NPI), not the individual pharmacist's NPI or license number. All pharmacies in Oregon have license numbers, and most, if not all, should have NPIs. If a pharmacy does not have an NPI, you must report their state license number. [Top]
 
Question For a pharmacy bill, if we do not have the rendering bill provider NPI, then do you want the rendering bill provider's FEIN and license number?
Answer Yes, we expect the "billing" provider's FEIN, the one who is being paid. In some cases, the "billing" provider does not have a state license number, i.e., billing companies that bill on behalf of the pharmacy. [Top]
 
Question For pharmacy bills, how should we report DN647, Rendering Bill Provider's NPI, and DN592, Rendering Line Provider's NPI?
Answer For pharmacy bills, we expect only the rendering provider's NPI, i.e., the pharmacy's NPI. There is no rendering line provider for pharmacy bills.

The one exception to this is for physician-billed drugs on the CMS 1500 form. In this case only, if the rendering bill provider is different from the rendering line provider, then provide the rendering line provider's NPI on the correct line in box 243. The rendering bill provider's NPI goes in box 33a. [top]
 
Question When we receive pharmacy bills, they often contain a different number than the NPI or state license number, e.g. the NCPDP number or DEA number. What number should we do when reporting pharmacy bills?
Answer Oregon requires the pharmacy's NPI., or if the pharmacy does not have an NPI, the state license number must be reported. If one of these numbers is not available, then you must use the default of 99999.

All pharmacies in Oregon must be licensed, so even in those rare instances when the pharmacy may not have an NPI, the pharmacy will always have a state license number. We highly recommend you contract those entities who report pharmacy bills to you and alert them that the NPI or state license number should be collected and reported for all pharmacy bills reported to Oregon.

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If you have questions about this webpage, please contact Jenni Bertels, 503-947-7742.