837 Professional Health Care Claim Outbound. Section 1 837P Professional Health Care Claim: Basic Instructions

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1 Companion Document 837P 837 Professional Health Care Claim Outbound This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained in this document are supplemental and should be used in conjunction with the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) as published by the Washington Publishing Company. Section 1 837P Professional Health Care Claim: Basic Instructions Section 2 837P Professional Health Care Claim: Enveloping Section 3 837P Professional Health Care Claim: Charts for Situational Rules Any questions? Contact MCS/JAA representatives dl-mcsit@anthem.com Contact E-Solutions LiveChat Page 1 of 10

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted from Anthem Blue Cross (Anthem) for processing pass through compliance edits. In response to the outbound , trading partners must return a 999 in the submitter s trading partner mailbox for acknowledgment. 1.2 HIPAA Compliant Codes HIPAA-compliant codes will be used from current versions of the following: Physician s Current Procedure Terminology (CPT) Health Care Financing Administration Common Procedural Coding System (HCPCS) International Classification of Diseases Clinical Mod (ICD-9-CM) Diseases Provider Taxonomy Codes National Drug Code *ICD-10 Codes will not be accepted any earlier than October 1, Diagnosis Codes According to the 837P TR3, a transaction is not X12 compliant if decimal points are used in diagnosis codes. Therefore, Anthem will not send diagnosis codes containing a decimal point. 1.4 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, spaces, and other special characters. All alpha characters will be submitted in UPPERCASE letters only. To avoid syntax errors, hyphens, parentheses and spaces are not used in values for identifiers. Examples: ZIP Code Medical Record # Anthem will not use the following special characters: asterisk (*), less than/greater than signs (<, >), colon (:), and slash (/). This minimizes the risk for a special character to be recognized as a delimiter. Example: Patient Control Number 12* Although an asterisk (*) is a valid special character, it adversely affects processing since it is also a common delimiter. The value 12* may process incorrectly as two separate values 12 and Decimal R Data Element Types R data element types contain a decimal point; involving monetary amounts, units, visits, weights, and frequency. Anthem will use decimal points for monetary amounts, and whole numbers for other types of R data elements. 1.6 Numeric s, s and Units Anthem pays all claims in US dollars and therefore, accepts monetary amounts in US dollars only. Codes related to foreign currencies will not be used. No negative service line charge or negative units will be used in SVC segment. SV102 - Line Item Charge Amount SV104 Quantity - Service Unit Count Page 2 of 10

3 Section 2 - Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 837 Professional Health Care Claim Envelope Specific from Anthem Blue Cross (TR3, Appendix C) ISA Interchange GS Functional Group GE Functional Group IEA Interchange Control Header Header Trailer Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 10 spaces GS02 PRBCCA GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 PSBCCA ISA04 10 spaces GS03 RECEIVER ID ISA05 ZZ GS04 refer to TR3 ISA06 PRBCCA GS05 refer to TR3 PSBCCA GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 RECEIVER ID GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA ISA13 refer to TR3 ISA14 refer to TR3 *ISA06/GS02=PRBCCA represents JAA ISA15 refer to TR3 *ISA06/GS02=PSBCCA represents PRICE ONLY/FFE ISA16 refer to TR3 Page 3 of 10

4 Section 3 - Charts for Situational Rules TR3 Listed below are loops, segments, and data elements required for proper adjudication by Anthem per the situational rules in the 837P TR3. Segment 837 Professional Health Care Claim Reference P.70 ST ST03 - Health Care Claim, Transaction Set Header Implementation Convention Ref Professional P.71 BHT BHT06 CH CH - Chargeable Beginning of Transaction Type Hierarchical Trx Code Loop ID 1000A Submitter Name P.74 NM1 NM103 WGS20 Represents Anthem Blue Cross as Submitter Name Last Name or submitter. Organization Name NM109 (Submitter Identifies ETIN established by trading Identification Code Identifier) partner agreement. P.76 PER PER03 PROGRAMMER Submitter Contact Name Submitter EDI Name ON CALL Contact Information PER04 TE TE - Telephone Communication Number Qualifier PER Communication Number Communication Number Loop ID 1000B Receiver Name P.79 NM1 NM103 (Receiver Name) Represents Name of MCS Client. Receiver Name Last Name or Organization Name NM Electronic Transmitter Identification ID Code Qualifier Number (ETIN) NM Represents the Receiver Primary Identification Code Identification Number. Loop ID 2000A Billing Provider Hierarchical Level P.81 HL Billing Provider Hierarchical Level - Refer to TR3 P.83 PRV Biling Provider Specialty Information - Refer to TR3 Loop ID 2010AA Billing Provider Name P.87 NM1 Billing Provider Name - Refer to TR3 P.91 N3 N301, N302 (Billing Prov For paper claims, the P.O. Box may be Billing Provider Address Information Address Line) used, if applicable. Address P.92 N4 N403 (Billing Billing Provider Zip Code will be used as the Billing Provider Postal Code Provider's Zip practicing zip code. City, State, ZIP Code) P.94 REF Billing Provider Tax Identification Number - Refer to TR3 P.96 REF Billing Provider UPIN/License Information - Refer to TR3 P.98 PER Billing Provider Contact Information - Refer to TR3 Loop ID 2000B Subscriber Hierarchical Level P.114 HL Subscriber Hierarchical Level - Refer to TR3 P.116 SBR SBR03 Anthem Blue Cross assigned number Subscriber Group Number Format - 10 position alphanumeric Information Page 4 of 10

5 837 Professional Health Care Claim Loop ID 2010BA Subscriber Name P.121 NM1 Subscriber Name NM109 Identification Code Subscriber ID bytes Recommended to have software support 20 bytes. P.124 N3 Subscriber Address - Refer to TR3 P.125 N4 Subscriber City, State, ZIP Code - Refer to TR3 P.129 REF REF01 SY SY - Social Security Number Subscriber Ref ID Qualifier Secondary REF02 (Subscriber Subscriber's Social Security Number Identification Reference Supplemental Identification Identifier) Loop ID 2010BB Payer Name P.133 NM1 NM103 WGS20 Represents Anthem Blue Cross as payer Payer Name Payer Name NM108 PI PI - Payer Identification ID Code Qualifier NM109 (Payer Primary represents Anthem Blue Cross Identification Code Identifier) Loop ID 2000C Patient Hierarchical Level P.142 HL Patient Hierarchical Level - Refer to TR3 Loop ID 2300 Claim Information P.157 CLM CLM01 (Patient Maximum of 20 alphanumeric characters. Claim Information Claim Submitter's Account Identifier Number) CLM02 (Total Claim Charge Amt) P.176 DTP Date - Admission - Refer to TR3 P.182 PWK Claim Supplemental Information - Refer to TR3 P.194 REF REF02 (Prior Auth or Prior Authorization Reference Referral Identification Number) P.196 REF REF01 F8 Payer Claim Ref ID Qualifier Control Number REF02 (Claim Original Reference Reference Identification Number) P.202 REF REF01 D9 Claim ID for Ref ID Qualifier Transmission REF02 (VAN Trace Intermediaries Reference Number) Identification equals the total amount of submitted charges for service lines in Loop 2400 SV102. For Entertainment Guilds, this represents the HIN Network Referral Number F8 - Original Reference Number Represents the claim number assigned by Anthem Blue Cross. D9 - Claim Number Represents Anthem's Document Claim Number (DCN). P.204 REF Medical Record Number - Refer to TR3 NTE Segment applies to BlueCard MCS/JAA ONLY P.209 NTE NTE01 PMT PMT - Payment Claim Note Note Reference Code NTE02 Provides the Secondary Payer Pricing Qualifier (SPPQ), Claim Note Text Medicare Payer Pricing Qualifier Code (MPPQ), HOST/HOME status (TPA), Claim Receipt Date, and 835 File Response Page 5 of 10

6 837 Professional Health Care Claim Loop ID 2300 Claim Information (cont'd) NTE Segment applies to BlueCard MCS/JAA ONLY P.209 NTE Claim Note Bytes 1-19: SPPQ information, if applicable DISCOUNT VALID NTE ADD DISCOUNT VALID ITS-HOST-PAYS-PRVDR PRVDR 835=Y~ DISCOUNT NOT VALID ITS-HOST-PAYS-PRVDR 835=Y~ DISCNT CONDITIOINAL ITS-HOST-PAYS-PRVDR 835=Y~ Byte 20: MPPQ information MEDICARE PAYER PRICING QUALIFIER CODE - ASSIGNED 1-Lines w/ Med Allowed Amt, Prov accepts Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts Host Allowed Amt 2-Lines w/ Med Allowed Amt, Prov accepts Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts the Charge Amt 3-Lines w/ Med Allowed Amt, Prov accepts lesser of Host or Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts Host Allowed Amt 4-Lines w/ Med Allowed Amt, Prov accepts lesser of Host or Med Allowed Amt Lines w/o Med Allowed Amt, Prov accepts the Charge Amt ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=Y~ Bytes 21-28: Date Claim Received ITS-HOST-PAYS-PRVDR 835=Y~ Bytes 29-46: Pay to Subscriber/Provider, HOME represents you, the client ITS-HOST-PAYS-SUB 835=N~ ITS-HOST-PAYS-PRVDR 835=N~ ITS-HOME-PAYS-SUB 835=N~ ITS-HOME-PAYS-PRVDR 835=N~ For claims that require payment to the subscriber, ABC will price the claim and forward to the client to handle direct. Payment must be handled by the client to the Bytes 50-54: Yes/No indicator if 835 response required for PAR and ECRP ITS-HOST-PAYS-PRVDR 835=Y~ ITS-HOST-PAYS-PRVDR 835=N~ For CO, NV, and CA claims under Bluecard or JAA process, all the claims must be paid by Anthem. This means that all par and non-par providers will require an 835 back to ABC to issue payment to providers directly. Bytes 56-57: CA Indicator for CA claim under JAA Process ONLY ITS-HOST-PAYS-PRVDR 835=Y CA~ P.226 HI Health Care Diagnosis Code - Refer to TR3 Loop ID 2310B Rendering Provider Name P.262 NM1 P.265 PRV P.267 REF Rendering Provider Name - Refer to TR3 Rendering Provider Specialty Information - Refer to TR3 Rendering Provider Secondary Identification - Refer to TR3 Anthem will forward COB information (excluding Other Payer Address Information) whenever received from submitting provider/source. If data received is incomplete, dummy membership information will be populated solely for the purpose of passing COB amounts to the client. Loop ID 2320 Other Subscriber Information SBR segment created in support of SVD codes due to clinical editing or pricing even when no COB is present. P.295 SBR Other Subscriber Information SBR01 Payer Responsibility Sequence No. P S T P - Primary; S - Secondary; T - Tertiary In support of SVD codes due to clinical i l editing or pricing, the value will match the payer resp seq code in Loop 2000B SBR01. Page 6 of 10

7 837 Professional Health Care Claim Anthem will forward COB information (excluding Other Payer Address Information) whenever received from submitting provider/source. If data received is incomplete, dummy membership information will be populated solely for the purpose of passing COB amounts to the client. Loop ID 2320 Other Subscriber Information (cont'd) SBR segment created in support of SVD codes due to clinical editing or pricing even when no COB is present. P.295 SBR SBR02 21 In support of SVC and CAS segments due to Other Subscriber Individual clinical editing or pricing, 21 will be used Information Relationship Code 21 - Unknown SBR09 CI In support of SVC and CAS segments due to Claim Filing Indicator clinical editing or pricing, CI will be used Code CI - Commercial Insurance Co. P.299 CAS Claim Level Adjustments - Refer to TR3 P.305 AMT COB Payer Paid Amount - Refer to TR3 P.306 AMT COB Total Non-Covered Amount - Refer to TR3 P.307 AMT Remaining Patient Liability - Refer to TR3 P.308 OI Other Insurance Coverage OI03 Yes/No Condition or Response Code Information OI04 Patient Signature Source Code OI06 Release of Information Code Loop ID 2330A Other Subscriber Name P.313 NM1 Other Subscriber Name NM103 Name Last or Organization Name NM108 ID Code Qualifier NM109 Identification Code N Y B Y (Other Insured Last Name) MI ZZ (Oth Insured Identifier) P.316 N3 Other Subscriber Address - Refer to TR3 P.317 N4 Other Subscriber City, State, ZIP Code - Refer to TR3 P.319 REF Other Subscriber Secondary Identification - Refer to TR3 Loop 2400 and 2430 will only be provided on DETAIL PROCESSED CLAIMS Loop ID 2400 Service Line P.350 LX Service Line Number - Refer to TR3 Represents assignment of benefits indicator. N - No; Y - Yes In support of SVC and CAS segments due to clinical editing or pricing, B will be used. B - Signed signature authorization form or forms for both HCFA-1500 Claim Form block 12 and block 13 are on file In support of SVC and CAS segments due to clinical editing or pricing, Y will be used. Y - Yes, Provider has signed statement permitting release of medical billing data related to a claim Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, REQ FOR ANTHEM SVD will be used) MI - Member Identification No.; ZZ - Mutually Defined Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, MI will be used) Information from other carrier will be passed (exception: in support of SVC & CAS segments due to clinical editing or pricing, 00 will be used) Page 7 of 10

8 837 Professional Health Care Claim Loop 2400 and 2430 will only be provided on DETAIL PROCESSED CLAIMS Loop ID 2400 Service Line (cont'd) P.351 SV1 Professional SV102 (Line Item Charge Sum of service line charges must equal the Total Claim Charge Amount in Loop 2300 CLM02. Service Amount) SV (Diagnosis Pointer must reference diagnosis due to responsibility of Diagnosis Code Code provider to send "minimum necessary" data to represent Pointer Pointer) claim. P.380 DTP Date - Service Date - Refer to TR3 P.413 NTE NTE01 TPO TPO - Third Party Organization Third Party Note Reference Organization Code NTE02 Claims Xten Supporting Information, use in addition to CAS Description Codes Bytes 1-7: CXT RSN Code CXT Rule Code Byte 8: (Space) Bytes 9-19: HIST DCN 1 History Database DCN 1 Byte 20: (Space) Byte 21: ELIG IND 1 System from where history lines are pulled; W = WGS Byte 22: (Space) Bytes 23-33: HIST DCN 2 History Database DCN 2 Byte 34: (Space) Byte 35: ELIG IND 2 System from where history lines are pulled; W = WGS Byte 36: (Space) Byte 37: Supporting Claim Status DDC DB for open claims History DB for finalized O = Claim is in DDC DB S = Claim is in History DB X = Claim is in DDC and History DB H = Claim is a Supporting History Line P.416 HCP Service lines with HCP segment are required in order to be returned on 835. Claim Pricing/ Repricing Information HCP01 Pricing Methodology HCP03 HCP12 Quantity 00 - NON-PAR providers 01 - PAR provider with No allowable-full Discount 10 - Other Pricing (PAR Provider priced) 14 - Adjustment Pricing (except BlueCard and JAA/IntraPlan) Represents savings amount to consider on a claim level. Represents the approved service units or inpatient days. HCP13 Reject Reason Code T1 T1 - Cannot identify Provider as TPO (Third Party Organization) Participant Loop ID 2410 Drug Identification P.423 LIN P.426 CTP P.428 REF Drug Identification - Refer to TR3 Drug Quantity - Refer to TR3 Prescription of Compound Drug Association Number - Refer to TR3 Loop ID 2420A Rendering Provider Name P.430 NM1 Rendering Provider Name - Refer to TR3 P.433 PRV P.434 REF Rendering Provider Specialty Information - Refer to TR3 Rendering Provider Secondary Identification - Refer to TR3 Page 8 of 10

9 837 Professional Health Care Claim Outbound Loop ID 2400 Service Line (cont'd) P.416 HCP Service lines with HCP segment are required in order to be returned on 835. Claim Pricing/ Repricing Information HCP01 Pricing Methodology 00 - NON-PAR providers 01 - PAR provider with No allowable-full Discount 10 - Other Pricing (PAR Provider priced) HCP02 HCP03 HCP13 Reject Reason Code Loop ID 2410 Drug Identification P.423 LIN P.426 CTP P.428 REF 14 - Adjustment Pricing (except BlueCard and JAA/IntraPlan) (Allowed Represents allowed amount to consider on a Amount) claim level (Savings Represents savings amount to consider on a Amount) detail line T1 T1 - Cannot identify Provider as TPO (Third Party Organization) Participant Drug Identification - Refer to TR3 Drug Quantity - Refer to TR3 Prescription of Compound Drug Association Number - Refer to TR3 Loop ID 2420A Rendering Provider Name P.430 NM1 P.433 PRV P.434 REF Rendering Provider Name - Refer to TR3 Rendering Provider Specialty Information - Refer to TR3 Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2430 Line Adjudication Information Multiple Adjustments will be sent as they apply on COB and Medicare claims. It will also be used to notify the receiver of denials or limitations found by our editing or pricing P.480 SVD Line Adjudication Information SVD01 Indentification Code (Other Payer Primary Identifier) Matches Loop 2330B NM109 identifying Other Payer. SVD02 (Service Line Paid Amount) Amount paid for this service line by COB/Medicare prior payer. SVD06 Assigned Number (Line Number) Bundled Line Number (will Be used ONLY for Claims Xten) CAS Segment Codes (refer to TR3) received on electronic transactions will be passed as received. CAS Segment Codes listed below will be applied to paper claims. P.484 CAS Line Adjustment CAS01 Adj Group Code CAS02 Adj Reason Code Anthem Adjustments made by Anthem COB DEDUCTIBLE AMOUNT PI PR 1 COINSURANCE AMOUNT PR 2 COPAYMENT AMOUNT PR 3 CO 96 CO 45 OA 96 NON-ELIGIBLE AMOUNT DISCOUNT AMOUNT CONTRACT EXCLUSION + CONTRACT LIMITATION Medicare DEDUCTIBLE AMOUNT Part A/B COINSURANCE AMOUNT COPAYMENT AMOUNT NON-ELIGIBLE AMOUNT CONTRACT EXCLUSION CAS03 Represents the amount being adjusted. P.491 AMT Remaining Patient Liability - Refer to TR3 PR 1 PR 2 PR 3 CO 45 OA 96 Page 9 of 10

10 837 Professional Health Care Claim Outbound Loop ID 2440 Form Identification Code P.492 LQ P.494 FRM Form Identification Code - Refer to TR3 Supporting Documentation - Refer to TR3 P.496 SE Transaction Set Trailer - Refer to TR3 Page 10 of 10