CMS Pub. 100-04, ch. 24, § 50.3.2

Upon receiving an ASC X12 276 claim status request or ASC X12 837 claim

(institutional or professional) current standard transaction adopted under HIPAA, the A/B

MAC will process the file through their Front End EDI solution, composed of at

minimum a COTS translator. The COTS translator creates the appropriate CMS defined

flat file, based on transaction type. The CMS defined flat file will include a skeleton

Control Record, either a Detail Record (CTRD) or a Resubmission Record (CTRR), for

each Interchange Control Header/Interchange Control Trailer (ISA/IEA) present, and the

A/B MAC then loads/places this file into the designated folder for the CCEM to pick up

and process.

The CTRD/CTRR record is placed in the designated transaction outbound folder for the

A/B MAC LDC to move via Network Data Mover (NDM) to the EDC. The EDC will

run a receipt/control/balancing process upon receipt of a file to ensure that what was sent

by the LDC is what the EDC received. Once the EDCs have checked the files, the

“Received” portion of the Control Records will be populated, and a copy of the Control

Record shall be sent back to the LDC and logged in the Control Record database. If the

file balances, the Control Records will be stripped off and the file will be queued up to be

pulled into the next processing cycle. If file does not balance, “Received” portion of the

Control Records will be populated, and a copy of the Control Record shall be sent back to

the LDC and logged in the Control Record database. An alert will be sent to the LDC to

indicate there is a problem with a file, and the bad ISA/IEA will be stripped out of the

file. Once the LDC has identified and fixed the issues, they resubmit the bad ISA/IEA.

The Receipt/Control/Balancing process will also be in place for the outbound ASC X12

835 remittance advice and the ASC X12 277 claim status response. The shared system

maintainers (SSMs) will create the appropriate CMS defined flat file, based on

transaction type. The CMS defined flat file will include the Control Records. The

transactions will be sent to the MAC/CEDI local data center, where they will be passed

through the receipt/control/balancing process to ensure if the CMS defined flat file is

balanced. During the outbound translation process the A/B MACs shall remove the

control records prior to translating the CMS defined flat files to ASC X12 EDI format.