Medical EDI Implementation Guide and Requirements
Version 2.1 - Revision Date: 9/30/2015
Download the Requirements by clicking on the links below.
The Requirements are housed in three tables:
- Event Table
- This table relates EDI information to the circumstances under which they are initiated as well as the timeframes for sending the information. These circumstances and timeframes reflect legislative mandates and specifications relative to reporting requirements based on various criteria. This Medical Event Table is used to convey the level of EDI reporting. This is based on the IAIABC Medical Bill Payment Release 2.0 Implementation Guide for 837 Application Advice (5010).
- Element Requirements
The North Carolina Industrial Commission Medical Element Requirement Table, worksheet labeled "837 Medical Requirements", provides the medical business and technical data element requirements based on Report Type(s) established on the Medical Event Table. Refer to the Medical Edit Matrix for the edits that will be applied based on the data element requirements.
As part of the Medical Element Requirement Table, Medical conditional data elements are included in the worksheet labeled "837 Medical Conditions". These conditional data elements are normally optional but become mandatory or expected under conditions established by the jurisdiction. If the defined condition exists, the data element becomes mandatory, and the corresponding rules apply. For Mandatory/Conditional data elements, the data element must be present and must be a valid format or the transaction will be rejected.
- Edit Matrix
- The Edit Matrix contains worksheets that convey the specific edits, Population Restrictions, Valid Values, Match Data, and Sequencing that will be applied to the Medical data elements/reports.
The changes to the Requirements are logged in the following table:
- Requirement Tables Change Log
- This table presents the changes that are made to the Requirement Tables.