Statewide Health Information Policy Manual (SHIPM) 4.3.1 Transactions and Code Sets (TCS)

Checklist of Requirements for: List of Transmitted and Received Standard Transactions and Code Sets (TCS); Trading Partner Agreement/Trading Partner Companion Guide (TPA/TPA-CG)

Statewide Health Information Policy Manual (SHIPM) 4.3.1 – Transactions and Code Sets (TCS) Compliance Review Tool Question #88 Artifact Must Haves Covered Item # Topic (Y or N) Comment Was documentation (artifact) submitted to demonstrate compliance with 1 requirements for Transactions and Code Y N Sets (if applicable)? Does the documentation demonstrate 2 compliance with the current format and content of the following transactions:  NCPDP D.0 COB Coordination of 2a Benefits Y N 2b  NCPDP D.0 Eligibility for a Health Plan Y N  NCPDP 5.1 and NCPDP D.0 Retail 2c Pharmacy Drug Claims Y N  NCPDP 3.0 Medicaid Pharmacy 2d Subrogation Y N  ASC X12 270/271 Eligibility Benefit 2e Inquiry and Response Y N  ASC X12 276/277 Claim Status Inquiry 2f and Response Y N  ASC X12 278 Referral Certification 2g and Authorization Y N 2h  ASC X12 820 Premium Payment Y N 2i  ASC X12 834 Enrollment/Maintenance Y N 2j  ASC X12 835 Remittance Advice Y N 2k  ASC X12 837 D, P, I Electronic Claims Y N 2l  ASC X12 837 COB Y N Does the documentation demonstrate that 3 the organization complies with transaction Y N formats and content without exceptions? Does the documentation demonstrate that the organization complies with code set 4 formats and content without exceptions, for the following: 4a  ICD-10-CM codes? Y N 4b  HCPCS codes? Y N 4c  CPT-IV codes? Y N 4d  NDC codes? Y N

1 | P a g e Publication Date: 09/01/2016 CalOHII – Version FINAL Checklist of Requirements for: List of Transmitted and Received Standard Transactions and Code Sets (TCS); Trading Partner Agreement/Trading Partner Companion Guide (TPA/TPA-CG) Covered Item # Topic (Y or N) Comment 4e  CDT codes? Y N Does the artifact(s) have official 5 review/acceptance? 5a  Effective Date Y N 5b  Revision Date Y N  Authorizing Sr./Executive Y N 5c Management Signature

Title(s) of Submitted Policy/Document/Artifact(s) Reviewed: ______

Stored Location of, or link to Artifact(s) Reviewed: ______

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Overall CalOHII Reviewer Comments: ______Name of CalOHII Reviewer: ______Date Reviewed: ______

Title of or link to Other Source(s) used (e.g., sources not in checklist, templates) – optional:

2 | P a g e Publication Date: 09/01/2016 CalOHII – Version FINAL