BACKGROUND

One of the twelve specific HIPAA standard transactions is described as being when a health plan sends premium payment information to another covered entity.  For this business case, HIPAA mandates that the ASC X12 820 transaction be used.

Further assessment was conducted in 2003 that identified the Medi-Cal Managed Care Division (MMCD) as a DHCS organization that originates a premium payment to other covered entities.  Specifically, this process calculates the capitation payment to contracted managed care plans within the Medi-Cal program.  Steps were taken to document this process, analyze the requirements for implementing a compliant process and ultimately to implement a compliant process.  This project was referred to as the 820 Phase 1 project and was conducted by the DHCS Office of HIPAA Compliance (OHC). 

820 Phase 1

The 820 Phase 1 (820 P1) project impacted a number of organizations within DHCS and outside of the department:

·        Medi-Cal Managed Care Division (MMCD)

·        Medi-Cal Dental Services Branch (MDSB)

·        Third Party Liability and Recovery Division (TPLRD)

·        Long Term Care Division (LTCD)

·        Information Technology Services Division (ITSD)

·        Fiscal Management Branch (FMB), Accounting Section

The 820 P1 project was completed in September 2005 with a Post Implementation Evaluation Report (PIER) being completed in March 2006.

The PIER report documented that even though a compliant transaction had been successfully implemented, the transaction produced during 820 P1 had not achieved the member-level detail that the Managed Care Organizations (MCOs) had hoped to receive.  (The “member level detail” as mentioned above is a transaction which contains information for each of the individual enrollees represented by the 820 transaction.)

820 Phase 2

In response to these findings, OHC has initiated the 820 Phase 2 (820 P2) project focused on achieving complete utilization of the 820 transaction by all contracted MCO’s by implementing a version of the 820 transaction that includes member-level detail.

5010 820 Draft Companion Guides

The 5010 820 Companion Guide has been temporarily removed while undergoing maintenance.  Please contact the DHCS 820 team with any questions. 

820 FAQs

5010 820 Sample Files

Following are a number of sample 5010 820 files for initial review by the managed care plans. 

5010 820 Beneficiary Payments

37 beneficiaries_All w 13 month history.txt (Medi-Cal and Medicare Part D capitation with 13 months of net change activity)

GMC Dental Capitation Invoices w 7percent withhold.txt

Negative Rate Adjustments_Primary Capitation.txt

Healthy Families_Hyde_MCal_MCare Invoices.txt

Net Eligibility Changes and Craig vs Bonta Invoices.txt

Positive Rate Adjustment for Supplemental Invoices.txt

Primary Capitation w Advance Payments and Adjustments.txt

5010 820 Plan Based Payments

GMC Dental Withhold Release.txt

Other Plan Based Payment.txt