Transactions & Code Sets

General Information

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care. The Mental Health Managed Care Programs at DMH that are impacted by HIPAA as well as the Automated Systems for processing Short-Doyle/Medi-Cal claims.

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SHORT DOYLE MEDI-CAL PHASE II

Short-Doyle Medi-Cal (SD/MC) is group of related local assistance programs and activities associated with Medi-Cal behavioral health claims. The SD/MC system processes health care claims submitted from counties and direct providers to the Department of Mental Health (DMH) and Alcohol and Drug Programs (ADP).  DMH and ADP act as agents of the Medicaid Program, Medi-Cal.  The Department of Health Care Services, Information Technology Services Division (DHCS-ITSD), maintains the SD/MC mainframe-based system, performing application maintenance, daily system operation, batch program execution, and key data entry.  ADP and DMH make the actual payments to counties and direct providers. The SD/MC processes approximately one million claims monthly.

The SD/MC HIPAA Phase II project addresses several gaps between the Phase I project solution and the full set of HIPAA compliance requirements. SD/MC Phase II is intended to be fully HIPAA-compliant; significant business and system changes are expected.

As of November 2007, the SD/MC Phase II design, development, and implementation vendor has started work. It is anticipated they will follow an 18-month project plan. The request for proposal and bidder’s library is available through the link below.

SD/MC Phase II RFP Documents

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Technical / Companion Guides (Mappings & Crosswalks)

A technical guide (companion guide / mapping) is a description of how to translate the proprietary SD/MC claim or EOB information into HIPAA compliant TCS format. There are three guides, each describing one HIPAA compliant transaction mapping. The 837 P guide is for professional service claims, the 837 I guide is for institutional (hospital) service claims, and the 835 guide is for claim payment / advice. The guides are formatted as Excel workbooks. Each workbook contains multiple tabs. The crosswalk for DMH SD/MC service procedures is included in these workbooks.

HIPAA TCS Technical Guides for SD/MC

• DMH Companion Guide for the 837 P, 837 I and 835 Transactions and Code Sets (2.15 MB)
• SDMC 837 P Mapping
• SDMC 837 I Mapping
• SDMC 835 Mapping

Technical Assistance Staff Contact List

DMH staff are available to assist counties with their transition from the current SD/MC claiming system to the new HIPAA compliant SD/MC claiming system. This includes support to understand the technical guides and resolving technical issues regarding HIPAA compliant claim submission and testing procedures. The primary contact person is
HIPAA.TCS@dmh.ca.gov.

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CMS Guidance

On 7/24/03, the United States Department of Health and Human Services released the Guidance on Compliance with HIPAA Transactions and Code Sets after the October 16, 2003, Implementation Deadline.