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820 Transaction - Premium Payment

Background

The 820 transaction is a federally mandated ASC X12 standard when a health plan sends premium payment information to another covered entity. The CAPMAN project was completed in July 2011, and replaced the manual process used to calculate and make payments to managed care health plans. The project was implemented in the following two phases.

820 Phase 1

An assessment was conducted in 2003 that identified the Manage Care Operations Division (MCOD) as a DHCS division that originates a premium payment to other covered entities. Specifically, this process calculates the capitation payment to contracted managed care health 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 (820 P1) project and was conducted by DHCS’s OHC.

 

The project impacted a number of organizations within DHCS and outside of the department:

  • Managed Care Operations Division (MCOD)
  • Medi-Cal Dental Services Division (MDSD)
  • Third Party Liability and Recovery Division (TPLRD)
  • Long Term Care Division (LTCD)
  • Enterprise Innovation Technology Services (EITS)
  • 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 initiated the 820 Phase 2 (820 P2) project focused on achieving complete utilization of the 820 transaction by all contracted MCOs by implementing a version of the 820 transaction that includes member-level detail. The 820 P2 project was completed in July 2011.

820 Companion Guides

For managed care health plans, please submit questions to: DHCS-820-834-Support@dhcs.ca.gov

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Last modified on: 6/21/2017 4:17 PM