The Question:
Is it okay to use the Demonstration Project Identifier segment on an 837I to enter transaction data for a section 1115 waiver project?
The Problem:
As part of a 1115 waiver, California's Substance Use Disorder (SUD) program needs to use an 837I to accept in-patient claims for residential rehabilitation and inpatient withdrawal management (detox). They need to differentiate between the American Society of Addiction Medicine (ASAM) levels of care (3.7 vs 4.0) in order to determine how much SUD will pay on the claim. They don’t have a HCPCS code/modifier, CPT code, or diagnosis code available to do this. Is there a place on the 837I where a provider can indicate that the patient has been assessed as a 3.7 or 4.0?
Potential Solutions:
1. 005010X223|837|2300|REF - DEMONSTRATION PROJECT IDENTIFIER
2. 005010X223|837|2300|NTE – CLAIM NOTE
The 005010X223A2 TR3 supports numerous External Code Sets. If those code sets currently do not support your business needs, the Loop 23000 REF - DEMONSTRATION PROJECT IDENTIFIER segment Situational Rule reads: Required when it is necessary to identify claims which are atypical in ways such as content, purpose, and/or payment, as could be the case for a demonstration or other special project, or a clinical trial. If not required by this implementation guide, do not send. The usage rule would not prevent you from using this segment for your described business need.
If you have a business need not supported in a published TR3, you may submit an ASC X12 change request for consideration in a future version of the TR3. Change requests are submitted at http://changerequest.x12.org/.
Also, if you a have business need not currently addressed by existing codes maintained by the NUBC, those needs should be directed to the NUBC for instructions at: http://www.nubc.org/contactus/index.dhtml