Change Request Detail
No.
1045
Date
7/29/2006
Submitter
Type of Request
Dental Claim
Status
DSMO Process Completed
Business Reason
X12 Insurance Subcommittee (N), the Health Care Task Group (TG2), and the Health Care Claims and Encounter Work Group (WG2) are submitting the following Technical Report Type 3 (TR3) as a version upgrade / replacement for the 837 HIPAA transaction, which is currently adopted and implemented using version 004010A1.

The new X12 version is 005010 with Implementation GUide (TR3) designated 005010X224 837 Health Care Claim: Dental.
Suggestion
Recommend to NCVHS that the 005010 version of the X12 837 transaction together with its X12 005010 TR3 (Implemenation Guide) 005010X224 for Health Care Claims: Dental Claims be named to replace the current HIPAA mandated transaction version 004010 and its Implementation Guide designated as 004010X097A1 .
DSMO Category
I
Recommendation
Approve. Recommend to NCVHS that the 005010 version of the X12 837 transaction together with its X12 005010 TR3 (Implementation Guide) 005010X224 for Health Care Claims: Dental Claims be named to replace the current HIPAA mandated transaction version 004010 and its Implementation Guide designated as 004010X097A1. The DSMO recognizes that concerns have been raised by the dental industry related to HCPCS modifiers, provider accept assignment codes, and diagnostic codes.  The following three issues in the 5010 version of the 837D TR3:
• HCPCS Procedure Modifiers – The following statement currently appears in the 837D – A modifier must be a HCPCS modifier or from code source 135 (American Dental Association) found in the “Code on Dental Procedures and Nomenclature.”  However, HCPCS modifiers cannot be used with the CDT codes because the HCPCS codes/modifiers were not approved for use for dental claims and are not mentioned as part of the HIPAA regulations as a recognized code set for dental claims.  In addition, HCPCS is not included as an external code set in the 5010 837D TR3.
• Provider Accept Assignment Codes – Currently, CLM07 segment includes a reference to the following REQUIRED codes:
A – Assigned (Required when the provider accepts assignment and/or has a participation agreement with the destination payer.  Or, required when the provider does not accept assignment and/or have a participation agreement but is advising the payer to adjudicate the specific claim under participating provider benefits as allowed under certain plans.
C – Not Assigned
The term “assignment” in version 5010 refers to the agreement between the provider and the payer, whereby the provider agrees to accept the payer’s reimbursement as payment-in-full.  In dentistry, however, the term “assignment” usually means the agreement between the patient and the provider to allow the benefits of the third-party payer to be assigned to the provider.  The DeCC believes that applying the version 5010 definition of “assignment” to dentistry will cause unnecessary complication and confusion that should be resolved prior to the adoption of version 5010.
• Diagnostic Codes – The DeCC discussed how this issue had been brought to the DSMO process several times and was denied.  However, a request was submitted directly to X12 and it was approved to include in the 5010 version of the 837D TR3.
The DeCC recognizes the difficulty faced by providers in reporting oral and maxillofacial and dental anesthesia services.  However, it believes that the situational use of diagnostic codes does not address this problem.  Other solutions that have been proposed, such as adding tooth codes to the 837 professional TR3, have not been adopted.  Currently, when reporting claims it is clear to providers when diagnostic codes should be used but in the 5010 837D it is not clear when diagnostic codes should be used.
The DSMO understands that these concerns can be addressed by DeCC, CMS, and X12 through education and outreach, as they have already expressed the willingness to do so.  Despite these concerns, the DSMO recognizes the benefits that are contained in the TR3, such as extensive COB instructions, addition of service office address, and improved front matter instructions.  In addition, the DSMO encourages quick adoption of the TR3, which could occur if the streamlined process, as identified by the standards development organizations and WEDI, for modifications to standards is adopted and followed.The DSMO acknowledges that the maintenance of administrative transaction standards is an evolving process and looks forward to continuing to work on improving the standards and the business processes they support.
Appeal Recommendation