New Mexico OmniCaid System DocumentationMarch 15, 2016
7.4 Prior Authorization Subsystem Interface Functionality
The interfaces supported by this subsystem are:
- TPA to OmniCaid
- TPA to Omnicaid Error File
- TPA to PDCS
- Children’s Medical Services (CMS) to OmniCaid
- Children’s Medical Services (CMS) to PDCS
- PDCS to OmniCaid
- Remaining Units Report
- Remaining Units By Case Manager Report
- PA Waiver Extract File for the Department of Health (DOH)
- TPA Prior Authorization Audit File (OBSOLETE)
Each of these is described in detail on the following pages.
This documentation is managed and provided byInterface7.4 – 1
Xerox for the New Mexico Medicaid contract
New Mexico OmniCaid System DocumentationMarch 15, 2016
NEW MEXICO OMNICAID MMIS PRIOR AUTHORIZATION SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
TPA TO OMNICAID INTERFACE
Description:This module processes the daily Non-Drug Prior Authorization requests input from the TPA interface. This module will process requests for update to existing PA requests and add new PA requests to the OmniCaid PA tables.
Source Files:
The input to this module is theTPA Non-Drug PA requests output of module NMMA8200.
Target Tables:
Prior Authorization Header and Detail Tables. The PA Exception Table will be updated if exceptions are generated.
Target Files
Errors generated from this process will be written to a file to be put on the DMZ for the TPA
Reports:
N/A
Remarks:
TheTPA input contains updates to and new Prior Authorization requests.
NEW MEXICO OMNICAID MMIS PRIOR AUTHORIZATION SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
TPA TO OMNICAID INTERFACE
The following layout of the prior authorization file is received from the TPA and is mapped back to the former Blue Cross Blue Shield format (BCBS-AUTH-RECORD) for internal processing. This mapping was necessitated because of the packed or binary fields defined were not supported by the TPA in earlier transitions. The file contains a header and a trailer record.
01 TPA-HEADER-RECORD.
05 RECORD-INDICTOR PIC X(01) VALUE ‘H’.
05 TPA-SOURCE PIC X(09).
05 DATE-TRANSMITTED PIC X(06).
01 TPA-TRAILER-RECORD.
05 RECORD-INDICTOR PIC X(01) VALUE ‘T’.
05 TPA-SOURCE PIC X(09).
05 RECORD COUNT PIC 9(09).
000010*------*
000020* PRIOR AUTH FILE LAYOUT *
000030* *
000031*****************************************************************
000032* ------CSR CHANGES ------*
000033* *
000035* CSR CHANGE ANALYST *
000036* NBR DATE NAME DESCRIPTION OF CHANGE *
000037* *
000038* 291029 07/09/2009 CUNNINGHAM NEW COPYBOOK DESIGNED TO MAP *
000038* TO COPYBOOK BCBSREC. THIS *
000038* COPYBOOK CONTAINS NO PACKED *
000040* OR BINARY DATA (VS BCBSREC). *
000041*****************************************************************
000050*
000060 01 PAUTH-AUTH-RECORD.
000070 03 PAUTH-RECORD.
000080 05 PAUTH-FIXED-PORTION.
000090 10 PAUTH-KEY.
000100 15 PAUTH-AUTH-NUMBER.
000110 20 PAUTH-CNTL-IND PIC X(001).
000120 20 PAUTH-JUL-DATE PIC X(004).
000130 20 PAUTH-CNTL-NUM PIC X(005).
000140 20 PAUTH-CNTL-NUM-RE REDEFINES PAUTH-CNTL-NUM.
000150 25 PAUTH-NUM PIC 9(005).
000160 15 PAUTH-CMS-AUTH-NUMBER
000160 REDEFINES PAUTH-AUTH-NUMBER.
000170 20 PAUTH-CMS-FILLER PIC X(004).
000180 20 PAUTH-CMS-NUMBER PIC X(006).
000190 10 PAUTH-ALT-KEY.
000200 15 PAUTH-RECIP-ID-NUMBER PIC X(014).
10 PAUTH-A-COE-CD PIC X(003).
10 PAUTH-A-HCBS-LOC-CD PIC X(001).
10 PAUTH-A-TY-CD PIC X(001).
000220 10 PAUTH-RECIP-CNTL PIC 9(009).
000230 10 PAUTH-PROV-ID-9 PIC X(009).
000240 10 FILLER REDEFINES PAUTH-PROV-ID-9.
000250 15 FILLER PIC X(001).
000260 15 PAUTH-PROV-ID-NUMBER PIC X(008).
000270 10 FILLER REDEFINES PAUTH-PROV-ID-9.
000280 15 PAUTH-NABP-NUM-2 PIC X(002).
000290 15 PAUTH-NABP-NUM-7 PIC X(007).
000300 10 PAUTH-REQUEST-DATE PIC 9(006).
000310 10 PAUTH-APPROVED-DATE PIC 9(006).
000320 10 PAUTH-LAST-ACTIV-DATE PIC 9(006).
000330 10 PAUTH-LAST-ACTIV-CODE PIC X(001).
000340 10 PAUTH-NO-PROCEDURES PIC 9(002).
000350 10 PAUTH-AUTH-FROM-DATE PIC 9(006).
000360 10 FILLER REDEFINES PAUTH-AUTH-FROM-DATE.
000370 15 PAUTH-AUTH-FR-DT-YY PIC 99.
000380 15 PAUTH-AUTH-FR-DT-MM PIC 99.
000390 15 PAUTH-AUTH-FR-DT-DD PIC 99.
000400 10 PAUTH-AUTH-THRU-DATE PIC 9(006).
000410 10 FILLER REDEFINES PAUTH-AUTH-THRU-DATE.
000420 15 PAUTH-AUTH-TH-DT-YY PIC 99.
000430 15 PAUTH-AUTH-TH-DT-MM PIC 99.
000440 15 PAUTH-AUTH-TH-DT-DD PIC 99.
000450 10 PAUTH-RETRO-IND PIC X(001).
000460 10 PAUTH-CMS-CASE-LIM-IND PIC X(001).
000470 10 PAUTH-REVIEW-DATA.
000480 15 PAUTH-REVIEW-AREA OCCURS 3.
000490 20 PAUTH-REVIEW-CODE PIC X(003).
000500 10 PAUTH-HDR-STAT-CD PIC X(001).
000510 10 PAUTH-RECORD-TYPE PIC X(003).
000520 10 PAUTH-ENTRY-DATE PIC 9(008).
000530 10 FILLER REDEFINES PAUTH-ENTRY-DATE.
000540 15 PAUTH-ENTRY-CCYY PIC 9(004).
000550 15 PAUTH-ENTRY-MM PIC 9(002).
000560 15 PAUTH-ENTRY-DD PIC 9(002).
000561 10 PAUTH-PROV-NPI-ID PIC X(010).
000562 10 PAUTH-PROV-NPI-TXNMY-CD PIC X(010).
000563 10 PAUTH-PROV-ZIP5-CD PIC X(005).
000564 10 FILLER PIC X(055).
000570
000580 05 PAUTH-AUTH-PROCEDURES OCCURS 21 TIMES.
000590 10 PAUTH-VARIABLE-PORTION.
000600 15 PAUTH-SEG-MAINT-ID PIC X(005).
000610 15 PAUTH-INVOICE-TYP PIC X(002).
000620 15 FILLER REDEFINES PAUTH-INVOICE-TYP.
000630 20 FILLER PIC X(001).
000640 20 PAUTH-INVOICE-TYP1 PIC X(001).
000650 15 PAUTH-PROC-REV-THER-CL PIC X(005).
000660 15 FILLER1 REDEFINES PAUTH-PROC-REV-THER-CL.
000670 20 PAUTH-PROC-CODE PIC X(005).
000680 15 FILLER2 REDEFINES FILLER1.
000700 20 PAUTH-REV-CODE PIC X(004).
000720 20 PAUTH-REV-FILLER PIC X(001).
000730 15 FILLER3 REDEFINES FILLER2.
000740 20 PAUTH-THERP-CLASS PIC X(003).
000750 20 PAUTH-THERP-FILLER PIC X(002).
000760 15 PAUTH-TOS PIC X(002).
000770 15 PAUTH-TOOTH PIC X(002).
000780 15 PAUTH-SURFACE PIC X(005).
000790 15 PAUTH-AUTH-UNITS PIC 9(005)V99.
000800 15 PAUTH-AUTH-UNITS-RE REDEFINES PAUTH-AUTH-UNITS
000810 PIC X(007).
000820 15 PAUTH-UNITS-USED PIC 9(005)V99.
000830 15 PAUTH-UNITS-USED-RE REDEFINES PAUTH-UNITS-USED
000840 PIC X(007).
000850 15 PAUTH-AUTH-AMOUNT PIC 9(007)V99.
000860 15 PAUTH-AUTH-AMOUNT-RE REDEFINES PAUTH-AUTH-AMOUNT
000870 PIC X(009).
000880 15 PAUTH-AMOUNT-PAID PIC 9(007)V99.
000890 15 PAUTH-AMOUNT-PAID-RE REDEFINES PAUTH-AMOUNT-PAID
000900 PIC X(009).
000910 15 PAUTH-DIAG-CODE PIC X(005).
000920 15 PAUTH-CLM-UPDT-DATE PIC 9(006).
000930 15 PAUTH-CLM-UPDT-DATE-RE REDEFINES
000940 PAUTH-CLM-UPDT-DATE
000950 PIC X(006).
000960 15 PAUTH-ICN-LAST-UPDT PIC X(013).
000970 15 PAUTH-HCPC-MODIFIER PIC X(002).
000980 15 PAUTH-DENY-IND PIC X(001).
001000 15 PAUTH-PROC-ORAL-CAV-CD PIC X(002).
001010 15 FILLER PIC X(004).
001020 15 PAUTH-LI-STAT-CD PIC X(001).
001030 15 PAUTH-HCPC-MODIFIER-2 PIC X(002).
001040 15 PAUTH-HCPC-MODIFIER-3 PIC X(002).
001050 15 PAUTH-HCPC-MODIFIER-4 PIC X(002).
001070
The following is the former BCBS layout used internally by the batch processes:
01 BCBS-AUTH-RECORD.
03 BCBS-RECORD.
05 BCBS-FIXED-PORTION.
10 BCBS-KEY.
15 BCBS-AUTH-NUMBER.
20 BCBS-CNTL-IND PIC X(001).
20 BCBS-JUL-DATE PIC X(004).
20 BCBS-CNTL-NUM PIC X(005).
20 BCBS-CNTL-NUM-RE REDEFINES BCBS-CNTL-NUM.
25 BCBS-NUM PIC 9(005).
15 BCBS-CMS-AUTH-NUMBER REDEFINES BCBS-AUTH-NUMBER.
20 BCBS-CMS-FILLER PIC X(004).
20 BCBS-CMS-NUMBER PIC X(006).
10 BCBS-ALT-KEY.
15 BCBS-RECIP-ID-NUMBER PIC X(014).
10 BCBS-A-COE-CD PIC X(003).
10 BCBS-A-HCBS-LOC-CD PIC X(001).
10 BCBS-A-TY-CD PIC X(001).
10 BCBS-RECIP-CNTL PIC 9(014).
10 BCBS-PROV-ID-NUMBER PIC X(009).
10 BCBS-REQUEST-DATE PIC 9(006).
10 BCBS-APPROVED-DATE PIC 9(006).
10 BCBS-LAST-ACTIV-DATE PIC 9(006).
10 BCBS-LAST-ACTIV-CODE PIC X(001).
10 BCBS-NO-PROCEDURES PIC 9(002).
10 BCBS-AUTH-FROM-DATE PIC 9(006).
10 BCBS-AUTH-THRU-DATE PIC 9(006).
10 BCBS-RETRO-IND PIC X(001).
10 BCBS-CMS-CASE-LIM-IND PIC X(001).
10 BCBS-REVIEW-DATA.
15 BCBS-REVIEW-AREA OCCURS 3.
20 BCBS-REVIEW-CODE PIC X(003).
10 BCBS-HDR-STAT-CD PIC X(001).
10 FILLER PIC X(003).
10 BCBS-ENTRY-DATE PIC 9(008).
10 FILLER REDEFINES BCBS-ENTRY-DATE.
15 BCBS-ENTRY-CCYY PIC 9(004).
15 BCBS-ENTRY-MM PIC 9(002).
15 BCBS-ENTRY-DD PIC 9(002).
10 BCBS-PROV-NPI-ID PIC X(010).
10 BCBS-PROV-NPI-TXNMY-CD PIC X(010).
10 BCBS-PROV-ZIP5-CD PIC X(005).
10 FILLER PIC X(055).
05 BCBS-AUTH-PROCEDURES OCCURS 21 TIMES.
10 BCBS-VARIABLE-PORTION.
15 BCBS-SEG-MAINT-ID PIC X(005).
15 BCBS-INVOICE-TYP PIC X(002).
15 BCBS-PROC-REV-THER-CL PIC X(005).
15 FILLER1 REDEFINES BCBS-PROC-REV-THER-CL.
20 BCBS-PROC-CODE PIC X(005).
15 FILLER2 REDEFINES FILLER1.
20 BCBS-REV-CODE PIC X(004).
20 FILLER PIC X(001).
15 FILLER3 REDEFINES FILLER2.
20 BCBS-THERP-CLASS PIC X(003).
20 FILLER PIC X(002).
15 BCBS-TOS PIC X(002).
15 BCBS-TOOTH PIC X(002).
15 BCBS-SURFACE PIC X(005).
15 BCBS-AUTH-UNITS PIC 9(005)V99 COMP-3.
15 BCBS-AUTH-UNITS-RE REDEFINES BCBS-AUTH-UNITS
PIC X(004).
15 BCBS-UNITS-USED PIC 9(005)V99 COMP-3.
15 BCBS-UNITS-USED-RE REDEFINES BCBS-UNITS-USED
PIC X(004).
15 BCBS-AUTH-AMOUNT PIC S9(007)V99 COMP-3.
15 BCBS-AUTH-AMOUNT-RE REDEFINES BCBS-AUTH-AMOUNT
PIC X(005).
15 BCBS-AMOUNT-PAID PIC S9(007)V99 COMP-3.
15 BCBS-AMOUNT-PAID-RE REDEFINES BCBS-AMOUNT-PAID
PIC X(005).
15 BCBS-DIAG-CODE PIC X(005).
15 BCBS-CLM-UPDT-DATE PIC 9(006) COMP-3.
15 BCBS-CLM-UPDT-DATE-RE REDEFINES
BCBS-CLM-UPDT-DATE
PIC X(004).
15 BCBS-ICN-LAST-UPDT PIC X(013).
15 BCBS-HCPC-MODIFIER PIC X(002).
15 BCBS-DENY-IND PIC X(001).
15 BCBS-PROC-ORAL-CAV-CD PIC X(002).
15 FILLER PIC X(004).
15 BCBS-LI-STAT-CD PIC X(001).
15 BCBS-HCPC-MODIFIER-2 PIC X(002).
15 BCBS-HCPC-MODIFIER-3 PIC X(002).
15 BCBS-HCPC-MODIFIER-4 PIC X(002).
NEW MEXICO OMNICAID MMIS PRIOR AUTHORIZATION SUBSYSTEM
INTERFACE SPECIFICATION
INPUT FILE LAYOUT
TPA TO OMNICAID INTERFACE
TPA TO OMNICAID INTERFACE RECORD
SourceField / Target
Table / Target
Column / Std
Edit / Req / Def / Specifications / Note Ref
TPA HEADER RECORD / This field is required to be present on every input file. It identifies the TPA and date of transmission.
RECORD INDICATOR / N/A / N/A / N/A / A / N / Should be “H” for header
TPA SOURCE / N/A / N/A / N/A / A / N / Indicates the TPA that sent the file.
DATE TRANSMITTED / N/A / N/A / N/A / A / N / The date the file was transmitted in YYMMDD format.
Source
Field / Target
Table / Target
Column / Std
Edit / Req / Def / Specifications / Note Ref
TPA TRAILER RECORD / This field is required to be present on every input file. It identifies the record count transmitted. If this doesn’t match the number of records sent, the job will abend.
RECORD INDICATOR / N/A / N/A / N/A / A / N / Should be “T” for trailer
TPA SOURCE / N/A / N/A / N/A / A / N / Indicates the TPA that sent the file.
RECORD COUNT / N/A / N/A / N/A / A / N / The number of records sent (not counting header or trailer)
Detail Record
SourceField / Target
Table / Target
Column / Std
Edit / Req / Def / Specifications / Note Ref
BCBS-AUTH-NUMBER / A_PA_HEADER_TB
A_PA_DETAIL_TB / A_ID / S / A / 2
BCBS-ALT-KEY (BCBS-RECIP-ID-NUMBER) / A_PA_HEADER_TB / B_SYS_ID
B_ALT_ID / If received, it should be the client id. It is cross walked to the internal client system id that Omnicaid uses. It can default to zeroes, but will result in an exception if not found.
For the PDCS interface if not present error message “CLIENT ID MISSING ON TPL TXT” is generated. If it is not numeric, error “CLIENT ID NOT NUMERIC” is generated. If not found on the Client Alternate ID table, error “CLIENT ID NOT ON FILE” is generated.
BCBS-A-COE-CD / A_PA_HEADER_TB / A_COE_CD / V / C / “Z” / Default is “Z” (none). This value is only used for waiver PA types. If provided must edit to valid value number 8174 or error “INVALID VALID VALUE FOR A-COE-CD” will be generated.
BCBS-A-HCBS-LOC-CD / A_PA_HEADER_TB / A_HCBS_LOC_CD / V / C / “Z” / Default is “Z” (none). This value is only used for waiver PA types. If provided must edit to valid value number 235 or error “INVALID VALID VALUE FOR A-HCBS-LOC-CD” will be generated.
BCBS-A-TY-CD / A_PA_HEADER_TB / A_TY_CD / V / C / “F” / Default is “F” (FFS). This value is only used for waiver PA types. If provided must edit to valid value number 150 or error “INVALID VALID VALUE FOR A-TY-CD” will be generated.
BCBS-RECIP-CNTL / A_PA_HEADER_TB / N/A / S / C / Zeros / The interface program uses BCBS-RECIP-CNTL as an internal hold field for the B-SYS-ID. It can be set to zeroes by the TPA.
BCBS-PROV-ID-NUMBER / A_PA_HEADER_TB
A_PA_DETAIL_TB / C_BLNG_PROV_ID
A_LI_RNDR_PROV_ID / S / A / 3
BCBS-REQUEST-DATE / A_PA_HEADER_TB / A_SUBM_DT / D / A / Input format: YYMMDD
Must be a valid date.
BCBS-APPROVED-DATE / N/A / N/A / Not used
BCBS-LAST-ACTIV-DATE / N/A / N/A / The interface program uses it as an internal field for logging, and populates it internally. It can be set to zeroes by the TPA.
BCBS-LAST-ACTIV-CD / N/A / N/A / The interface program uses it as an internal field for logging, and populates it internally. It can be set to spaces by the TPA.
BCBS-NO-PROCEDURES / A / This field needs to be populated with the number of rows in the BCBS-AUTH-PROCEDURES. If this is not populated correctly, it could cause an issue with the interface program.
BCBS-AUTH-FROM-DATE / A_PA_HEADER_TB
A_PA_DETAIL_TB / A_EFF_DT
A_LI_STRT_DT / D / A / Input format: YYMMDD
If not numeric an exception will be created. . If numeric, it must be a valid date. If zeroes, a dummy date is utilized (01/01/01). Thru date must be greater than from date.
In the PDCS interface, if this field is missing, error “FROM DATE MISSING” issued. If the date is invalid, error “FROM DATE INVALID” is issued. If the from date is greater than the thru date, error “FROM DATE GREATER THAN THRU DATE” is issued. If its not numeric “FROM DATE NOT NUMERIC” is issued.
BCBS-AUTH-THRU-DATE / A_PA_HEADER_TB
A_PA_DETAIL_TB / A_EXPIR_DT
A_LI_END_DT / D / A / Input format: YYMMDD
If not numeric an exception will be created. . If numeric, it must be a valid date.
In the PDCS interface, if this field is missing, error “THRU DATE MISSING” issued. If the date is invalid, error “THRU DATE INVALID” is issued. If its not numeric “THRU DATE NOT NUMERIC” is issued.
BCBS-RETRO-IND / A_PA_HEADER_TB / A_RETRO_AUTH_CD / N/A / A / “Z” / If input = spaces, it defaults to “N” otherwise it uses the input value..When the PA is added online the field defaults to “Z” (none), It can be changed on an update but is added in the batch interface as “Z” The Retro Authorization Code is used to show whether or not a Prior Authorization is for services already performed and a description for the retro authorization. Refer to valid values for the field A-RETRO-AUTH-CD.
BCBS-CMS-CASE-LIM-IND / A_PA_HEADER_TB / A_CMS_CS_LMT_IND / N/A / A / “N” / If input = “Y” or “N” then set to input value else set to “N”. It is used for CMS. If this is a “Y” during claims processing, the claim will post exception 0714 - Auth CMS Case Limit Ind Is Y. If set to "Y", then case limit processing is in effect for claims PA processing.
Previous TPAs have set this field to spaces.
BCBS-REVIEW-CODE-1 / A_PA_HEADER_TB / A_REVW_CD / N/A / A / The Reviewers Code is validated against hard-coded values - 'DA ' 'LG ' 'MEL' 'EM ' 'RM ' 'CR '
'ER ' 'RA '
'XXX' 'YYY' 'ZZZ' “MPA” and “QUA”
The interface contains 3 review codes, all of which are validated by the input program, but only the first one is used to update the Omnicaid PA header table - A_REVW_CD
BCBS-REVIEW-CODE (2) / N/A / NA
BCBS-REVIEW-CODE (3) / N/A / N/A
BCBS-HDR-STAT-CD / N/A / N/A / This field is not used for the TPA interface, however for CMS processing this field is used to pass a status code to the PDCS Interface.
BCBS-RECORD-TYPE / N/A / N/A / N/A / Not used
BCBS-ENTRY-DATE / Can be spaces – if so zeroes are put in the field. If numeric and not zeroes must be a valid date. This is used when checking for a matching detail record.
BCBS-PROV-NPI-ID / National Provider Identifier – used to verify provider’s NPI number (when provider id is spaces)
BBS-PROV-NPI-TXNMY-CD / Provider Taxonomy Code - – used to verify provider
BCBS-PROV-ZIP5-CD / Provider Location 5 digit zip code - – used to verify provider
BCBS-AUTH-PROCEDURES OCCURS 21 TIMES / One A_PA_DETAIL_TB row per occurrence
For Personal Care authorizationsthat come in from the TPA (review code YYY) where the Procedure Code on the PA is 3241W or 3244W or WC241or WC244 or T1019 or 99509, the system will create multiple lines for the PA for each month authorized; creating a separate line equal to the full amount of the authorization.
Duplicate procedures will result in an error.
BCBS-SEQ-MAINT-ID / Not used, the TPA should set it to spaces.
n/a / A_PA_HEADER_TB / A_PR_PLCMT_CD / N/A / N/A / Space / Program generated
n/a / A_PA_HEADER_TB / A_HCBS_LOC_CD / N/A / N/A / Space / Program generated
n/a / A_PA_HEADER_TB / A_TY_CD / N/A / N/A / “F” / Program generated
n/a / A_PA_HEADER_TB / A_PAT_ACCT_CD / N/A / N/A / Space / Program generated
n/a / A_PA_HEADER_TB / A_PLN_LMT_AMT / N/A / N/A / Zeroes / Program generated
n/a / A_PA_HEADER_TB / A_HDR_ORIG_AUTH_ID / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_HEADER_TB / A_HDR_ORIG_AUTH-DT / N/A / N/A / Current Date / Program generated
n/a / A_PA_HEADER_TB / A_COE_CD / N/A / N/A / “Z “ / Program generated
n/a / A_PA_HEADER_TB / R_TXT_LOCN_CD / N/A / N/A / Space / Program generated
n/a / A_PA_HEADER_TB / A_NF_RES_IND / N/A / N/A / “Z“ / Program generated
n/a / A_PA_HEADER_TB / A_HDR_STAT_CD / N/A / N/A / N/A / Program generated . Set to ‘A’ - Approved or ‘S’ - Suspended. If there are no edit errors it is set to approved, otherwise it is set to suspended.
n/a / A_PA_HEADER_TB / A_HDR_STAT_DT / N/A / N/A / “F” / Program generated
n/a / A_PA_HEADER_TB / A_HDR_AUTH_ID / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_HEADER_TB / G_AUD_USER_ID / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_HEADER_TB / G_AUD_DT / N/A / N/A / System date / Program generated
n/a / A_PA_HEADER_TB / G_AUD_TM / N/A / N/A / System time / Program generated
n/a / A_PA_HEADER_TB / B_ALT_ID / N/A / N/A / Space / Program generated
n/a / A_PA_HEADER_TB / G_AUD_ADD_DT / N/A / N/A / System date / Program generated
n/a / A_PA_HEADER_TB / G_AUD_ADD_TM / N/A / N/A / System time / Program generated
n/a / A_PA_HEADER_TB / G_AUD_ADD_USER_ID / N/A / N/A / “NMA8100” / Program generated
BCBS-INVOICE-TYP / A_PA_DETAIL_TB / A_LI_SVC_TY_CD / V / A / 4
BCBS-PROC-REV-THER-CL (BCBS-PROC-CD / BCBS-REV-CODE) / A_PA_DETAIL_TB / A_LI_SVC_TY_DESC / N/A / C / 5
BCBS-TOS / A_PA_DETAIL_TB / A_LI_INVC_TYP_CD
C_PROC_MOD_1ST_CD / V / A / The field is used to override the HCPCS modifier values inserted on the PA detail table. If it is ‘H’, then ‘RR’ is moved to C_PROC_MOD_1ST_CD_
The first character of this two byte field is validated against hard coded values of '0' THRU '9' 'A'
'F' 'H' 'J' 'L' 'M' 'N' 'T' 'U' 'V' 'Y' 'Z'.
BCBS-TOOTH / A_PA_DETAIL_TB / R_PROC_TOOTH_CD / V / C / 6
BCBS-SURFACE / A_PA_DETAIL_TB / C_DENT_1ST_SURF_CD
C_DENT_2ND_SURF_CD
C_DENT_3RD_SURF_CD
C_DENT_4TH_SURF_CD
C_DENT_5TH_SURF_CD / V / C / If BCBS-INVOICE-TYP =
“DENT”.
The field is currently not being edited in the update program although there is a valid value list of “0 – 3” in copybook WVR2188C. If received, we will update the 5 surface code fields on the database. Used in claims processing in edit 0609 Auth/Tooth Surf Cnfl
BCBS-AUTH-UNITS / A_PA_DETAIL_TB / A_LI_REQ_UNT_AMT / N / A / Received value must be numeric
For a CMS reviewer the value must be > 0. If not a CMS reviewer and it’s a drug invoice or drug procedures (‘DISP’,’ENUTR’,’NUTRI’, OXYG’) the auth amount is set to zero otherwise the value must be > 0.
BCBS-UNITS-USED / A_PA_DETAIL_TB / A_LI_USED_UNT_AMT / N / A / Defaults to zeroes
BCBS-AUTH-UNITS / A_PA_DETAIL_TB / A_LI_APP_UNT_AMT / N / A
BCBS-AUTH-AMOUNT / A_PA_DETAIL_TB / A_LI_APP_AMT
A_LI_REQ_AMT / N / A / If field greater than zeroes. If we did and the procedure was ‘DISP’,‘ENUTR’,
‘NUTRI' or 'OXYG’ we would move zeroes to the field. Otherwise it would get updated on the PA detail table.
In the PDCS interface, if this field is not numeric, error “PRIOR AUTH AMOUNT NOT NUMERIC” is issued. If its greater than $1 million, error “PRIOR AUTH AMOUNT GT ONE $MILLION” is issued.
Previous TPAs have set this field to zeroes.
BCBS-AMOUNT-PAID / A_PA_DETAIL_TB / A_LI_USED_AMT / N / A / Defaults to zeroes. Currently not receiving anything in this field.
BCBS-DIAG-CODE / A_PA_DETAIL_TB / R_DIAG_CD / N / A / Spaces / Edited against the Omnicaid diagnosis table. Previous TPAs have set this field to spaces.
BCBS-CLM-UPDT-DATE / A_PA_DETAIL_TB / A_CLM_UPDT_DT / C / D / 0001-01-01 / May be equal to zeros, spaces or CCYYMMDD
If we receive zeroes in this field, we will use the low date (‘0001-01-01’) default in populating the A_CLM_UPD_DT on the PA detail table.Previous TPAs have set this field to zeroes.
BCBS-ICN-LAST-UPDT / A_PA_DETAIL_TB / C_TCN_NUM / N / N / Zeros / May be equal to zeros or spaces.
If received, this is used to populate the tcn number field (C_TCN_NUM) on the PA detail table. Previous TPAs have set this field to zeroes.
BCBS-HCPC-MODIFIER / A_PA_DETAIL_TB / C_PROC_MOD_1st_CD / N/A / N / Space / IF the first character of the BCBS-TOS is “H”, we move “RR” to the
BCBS-HCPC-MODIFIER (OCC-SUB) field (otherwise the modifier is validated against valid value number 0139.
BCBS-DENY-IND / A_PA_DETAIL_TB / A_LI_STAT_CD / N / N / “A” / If the input BCBS-DENY-IND is equal to “Y” then set the line status code to “D”
In the PDCS interface, if this field is invalid (not = spaces, ‘Y’, or ‘N’) error “DENY INDICATOR INVALID” is issued. If the deny indicator is = spaces, the BCBS-INVOICE-TYP field is set to “N’.
BCBS-PROC-ORAL-CAV-CD / A_PA_DETAIL_TB / R_PROC_ORAL_CAV_CD / V / N / Space / If BCBS-INVOICE-TYP =
“DENT” Edit to valid value number 2553
BCBS-LI-STAT-CD / N/A / N/A / This field is not used for the TPA interface, however for CMS processing this field is used to pass a status code to the PDCS Interface.
BCBS-HCPC-MODIFIER-2 / A_PA_DETAIL_TB / C_PROC_MOD_2ND_CD / N/A / N / Space / If BCBS-HCPS-MODIFIER-1 is spaces and BCBS-HCPS-MODIFIER-2 is not an exception is created otherwise validate against valid value number 0139.
BCBS-HCPC-MODIFER-3 / A_PA_DETAIL_TB / C_PROC_MOD_3RD_CD / N/A / N / Space / If BCBS-HCPS-MODIFIER-1 is spaces and BCBS-HCPS-MODIFIER-3 is not or if BCBS-HCPS-MODIFIER-2 is spaces and BCBS-HCPS-MODIFIER-3 is not an exception is created otherwise validate against valid value number 0139.
BCBS-HCPC-MODIFIER-4 / A_PA_DETAIL_TB / C_PROC_MOD_4TH_CD / N/A / N / Space / If BCBS-HCPS-MODIFIER-1 is spaces and BCBS-HCPS-MODIFIER-4 is not or if BCBS-HCPS-MODIFIER-3 is spaces and BCBS-HCPS-MODIFIER-4 is not an exception is created otherwise validate against valid value number 0139.
n/a / A_PA_DETAIL_TB / A_LI_NUM / N/A / N/A / N/A / Program generated. Incremented by 1 for each procedure.
n/a / A_PA_DETAIL_TB / A_LI_AUTH_ID / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_DETAIL_TB / A_LI_DESC_SVC_CD / N/A / N/A / Space / Program generated
n/a / A_PA_DETAIL_TB / A_LI_STRT_DT / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_DETAIL_TB / A_LI_END_DT / N/A / N/A / System date / Program generated
n/a / A_PA_DETAIL_TB / A_LI_ORIG_AUTH_ID / N/A / N/A / ‘TPA’ / Program generated
BCBS-APPROVED-DATE / A_PA_DETAIL_TB / A_LI_ORIG_APP_DT / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_DETAIL_TB / A_LI_APL_STAT_CD / N/A / N/A / “ZZ” / Program generated
n/a / A_PA_DETAIL_TB / A_LI_APL_STAT_DT / N/A / N/A / “0001-01-01” / Program generated
n/a / A_PA_DETAIL_TB / G_AUD_ADD_USER_ID / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_DETAIL_TB / G_AUD_ADD_DT / N/A / N/A / System date / Program generated
n/a / A_PA_DETAIL_TB / G_AUD_ADD_TM / N/A / N/A / System time / Program generated
n/a / A_PA_DETAIL_TB / G_AUD_USER_ID / N/A / N/A / “NMA8100” / Program generated
n/a / A_PA_DETAIL_TB / G_AUD_DT / N/A / N/A / System date / Program generated
n/a / A_PA_DETAIL_TB / G_AUD_TM / N/A / N/A / System time / Program generated
Notes: