Change Request Detail
No.
1148
Date
2/15/2011
Submitter
Type of Request
Payment of a Health Care Claim
Status
DSMO Process Completed
Business Reason
Many Medicaid Managed Care Organizations receive payments that exceed the allowed number of digits in the Imp Guide.  Work arounds are performed today but these work arounds might be construed as being out of HIPAA compliance. 
Suggestion
A larger payment amount needs to be supported.

The transaction itself supports a payment amount in excess of $99,999,999.99.  However, both the 4010A1 Implementation Guide as well as the 5010 TR3 impose a maximum length that prevents reporting a total payment amount in excess of $99,999,999.99.  A change to the next release of 835 Implementation Guide that would extend the maximum field length to allow for the reporting of a payment of up to $999,999,999.99 is being requested.

This also has an impact on the NACHA EFT transaction in that this transaction has a field length limitation that does not support the initiation of an ACH payment that exceeds $99,999,999.99. 

Also, Section B.1.1.3.1.2 Decimal in the common content would need to be modified:

For implementation of this guide under the rules promulgated under the Health Insurance Portability and Accountability Act (HIPAA), decimal data elements in Data Element 782
(Monetary Amount) will be limited to a maximum length of 10 characters including reported or implied places for cents (implied value of 00 after the decimal point). Note the statement in the preceding paragraph that the decimal point and leading sign, if sent, are not part of the character count.
EXAMPLE
For implementations mandated under HIPAA rules:
• The following transmitted value represents the largest positive dollar amount that can be sent: 99999999.99
• The following transmitted value is the longest string of characters that can be sent representing whole dollars: 99999999
• The following transmitted value is the longest string of characters that can be sent representing negative dollars and cents: -99999999.99
• The following transmitted value is the longest string of characters that can be sent representing negative whole dollars: -99999999

DSMO Category
D
Recommendation
Disapprove. The issue is with the NACHA (The Electronic Payments Association) limitations on EFT payment size. The DeCC further understands that this is outside of ASC X12 control and can’t expand the size until NACHA expands the size of the related ACH (Automated Clearinghouse) format.

Appeal Recommendation