837 Professional Health Care Claim - Outbound

Transcription

1 Companion Document 837P 837 Professional Health Care Claim - Outbound Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional claims. The tables in this document provide information about 837 Claim segments and data elements that require specific instructions to efficiently process from Anthem Blue Cross (ABC) systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide Health Care Claim: Professional, 837, ASC X12N 837 (004010X098), May 2000, and the subsequent Addenda (004010X098A1), October 2002, published by the Washington Publishing Co. Anthem Blue Cross Page 1 of 15

2 Enveloping EDI envelopes control and track communications between you and Anthem Blue Cross. One envelope may contain many transaction sets grouped into functional groups. The envelope consists of: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Page 2 of 15

3 837 Envelope Control Segments Outbound Health Care Claim Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. Containing authorization and security information, it also clearly identifies the sender, receiver, date, time, and interchange control number. Segment ISA Interchange Control Header ISA01 Auth Info No Authorization Information Present ISA02 (10 Spaces) 10 positions populated Authorization Info ISA No Security Information Present Security Info ISA04 (10 Spaces) 10 positions populated Security Information ISA05 ZZ ZZ - Mutually Defined Interchange ID ISA06 PRBCCA PRBCCA - JAA Interchange Sender PSBCCA PSBCCA - Price Only/FFE ID ISA07 Interchange ID ISA08 Interchange Rec ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version ISA13 Interchange Cntrl No. ISA14 Ack Requested ISA15 Usage Indicator ISA16 Component Element Separator 837 Professional Health Care Claim Interchange Control Header (ISA) ZZ (Receiver ID) (YYMMDD) (HHMM) U ZZ - Mutually Defined Represents Receiver ID of MCS Client Valid date in YYMMDD format. Valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Anthem) 0 1 P T (:) Colon Fixed length 9 positions, numeric. Identical to IEA No Acknowledgment Requested 1 - Interchange Acknowledgment Requested P - Production Data T - Test Data Page 3 of 15

4 2 837 Health Care Claim Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Segment GS Functional Group Header GS01 Functional Identifier GS02 Application Sender's GS03 Application Receiver's GS04 Date GS05 Time GS06 Group Control GS07 Responsible Agency GS08 Version / Release / Industry Identifier 837 Professional Health Care Claim Functional Group Header (GS) HC HC - Health Care Claim (837) PRBCCA PSBCCA (Receiver ID) (CCYYMMDD) (HHMM) (Assigned by Anthem) X X098A1 PRBCCA - JAA PSBCCA - Price Only/FFE Represents Receiver ID of MCS Client Valid date in CCYYMMDD format. Valid time in HHMM format. Format positions, numeric. Identical to GE02. X - Accredited Standards Committee X12 Operationally used to identify the transaction: X098A1-837 Professional Claim Page 4 of 15

5 3 837 Health Care Claim Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Segment 837 Professional Health Care Claim Functional Group Trailer (GE) GE Functional Group Trailer GE01 of Transaction Sets Included GE02 Group Control (Total of Transaction Sets in Functional Group or Transmission) (Control ) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format positions, numeric. Left-justified with no trailing zeroes or spaces. Identical to GS Health Care Claim Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). Segment 837 Professional Health Care Claim Interchange Control Trailer (IEA) IEA Interchange Control Trailer IEA01 of Included Functional Groups IEA02 Interchange Control ( of Functional Groups GS/GE Pairs in Interchange) (Control ) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format - Fixed length 9 positions, numeric. Unique value greater than zero. Identical to ISA13. Page 5 of 15

6 837 Professional Claim Header The 837 Claim Header identifies the start of a transaction, the specific transaction set, and its business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure ) relates the type of business data expected within each level. The following table indicates the specific values of the required header segments and data elements for Anthem Blue Cross processing. IG Segment Beginning of Hierarchical Transaction P.63 BHT BHT06 Beginning of Transaction Type Hierarchical Transaction P.66 REF REF02 Transmission Transmission Type Type Loop ID 1000A Submitter Name P.67 NM1 Submitter Name 837 Professional Health Care Claim Header NM103 Last Name or Organization Name NM108 ID NM109 P.71 PER Administrative PER03 Name Communications PER04 Contact Communication PER05 Communication Loop ID 1000B Receiver Name P.74 NM1 NM103 Receiver Name Last Name or Organization Name NM108 ID NM109 CH X098A1 WGS20 CH - Chargeable; required to indicate the batch contains all chargeable claims. Will not be used to distinguish between test and production. Represents Anthem Blue Cross as submitter Electronic Transmitter (ETIN) (Submitter Primary Identifies ETIN established by trading partner agreement ) PROGRAMMER ON Submitter Contact Name CALL TE TE - Telephone Communication (Receiver Name) Represents Name of MCS Client Electronic Transmitter (ETIN) Represents the Receiver Primary Page 6 of 15

7 837 Professional Claim Detail The 837 Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant levels include: 1) Information Source (Billing/Pay-to Provider) 2) Subscriber (Can be the Patient when the Patient is the Subscriber) 3) Dependent (Patient when the Patient is not the Subscriber) Page 7 of 15

8 1 837 Claim Detail: Billing/Pay-to Provider Hierarchical Level The first hierarchical level (HL) of the 837 Claim Detail, Billing/Pay-to Provider HL, identifies the original entity who submitted the electronic claim/encounter to the destination payer. IG Segment Loop ID 2000A Billing/Pay-to Provider Hierarchical Level P.79 PRV PRV01 BI BI - Billing Billing/Pay-to Provider Provider PRV03 (Provider Taxonomy code that applies to the service Specialty Taxonomy ) Information Loop ID 2010AA Billing Provider Name P.84 NM1 NM108 XX XX - National Provider Identifier Billing ID Employer's Provider Name NM109 (Billing Provider NPI ('XX') for Non-Exempt providers Primary ID No.) Tax ID ('24') for Exempt providers P.89 N4 N403 (Billing Billing Provider Zip will be used as the Billing Provider Postal Provider's Zip practicing zip code City/State/Zip ) P.91 REF Billing Provider Secondary P.96 PER Administrative Communications Contact Billing/Pay-to Provider Hierarchical Level REF01 ID REF02 PER02 Name PER03 Communication PER04 Communication 0B EI SY (Billing Provider Additional Identifier) (Billing Provider Contact Name) TE (Communication ) 0B - Provider State License EI - Employer's SY - Social Security Assigned Prov No. ('0B') Provider's Tax ID ('EI') Provider's Social Security ('SY') Contact Name for Billing Provider TE - Telephone Phone number for Billing Provider contact Page 8 of 15

9 2 837 Health Care Claim Detail: Subscriber Hierarchical Level The second hierarchical level (HL) of the 837 Health Care Claim Detail is the Subscriber HL. IG Segment Loop ID 2000B Subscriber Hierarchical Level P.108 SBR Subscriber Information SBR01 Payer Responsibility Sequence P, S, T Usage of 'S' or 'T' accompanies information populated in Loop 2320 and 2330 for COB adjudication information. SBR03 Group Loop ID 2010BA Subscriber Name P.117 NM1 NM101 Subscriber Entity Type Name NM102 ID NM109 P.126 REF Subscriber Secondary REF01 ID REF02 Loop ID 2010BB Payer Name P.130 NM1 NM103 Payer Name Payer Name NM108 ID NM109 Subscriber Hierarchical Level (Group ) Individual MI (Subscriber Primary Identifier) SY (Subscriber Supplemental Identifier) WGS20 PI (Payer Primary Identifier) Anthem Blue Cross assigned number Format - 10 position alphanumeric MI - Member Identifcation Subscriber ID bytes. It is strongly recommended to have software support 20 bytes. SY - Social Security Subscriber's Social Security Represents Anthem Blue Cross as payer PI - Payer represents Anthem Blue Cross Page 9 of 15

10 3 837 Health Care Claim Detail: Patient Hierarchical Level The third hierarchical level (HL) of the 837 Health Care Claim Detail is the Patient HL. IG Segment Loop ID 2300 Claim Information P.170 CLM CLM01 Claim Claim Information Submitter's Identifier CLM02 Monetary Amount P.208 DTP Date-Admission P.214 PWK Claim Supplemental Information P.227 REF Prior Referral or Authorization P.229 REF Original (ICN/DCN) P.238 REF Claim ID No. for Clearing houses and Other Transmission Intermediaries P.241 REF Medical Record Patient Hierarchical Level DTP01 Date/Time PWK01 Report Type PWK02 Report Transmission REF01 ID REF02 REF01 ID REF02 REF01 ID REF02 REF01 ID REF02 (Patient Account ) (Total Claim Charge Amount) Maximum of 20 alphanumeric characters. equals the total amount of submitted charges for service lines in Loop 2400 SV Admission EB AA G1 (Prior Authorization or Referral ) F8 (Claim Original ) D9 ( Added Network Trace No.) EA (Medical Record ) EB - Explanation of Benefits (Coordination of Benefits or Medicare Secondary Payer) AA - Available on Request at Provider Site G1 - Prior Authorization For Entertainment Guilds, this represents the HIN Network Referral F8 - Original Represents the claim number assigned by Anthem Blue Cross D9 - Claim EA - Medical Record Page 10 of 15

11 Patient Hierarchical Level IG Segment Loop ID 2300 Claim Information (cont'd) NTE Segment applies to BlueCard MCS/JAA ONLY P.246 NTE NTE01 PMT Claim Note Note PMT - Payment NTE02 Provides the Secondary Payer Pricing (SPPQ), Medicare Claim Note Text Payer Pricing (MPPQ), HOST/HOME status (TPA), Bytes 1-19: SPPQ information, if applicable DISCOUNT VALID ITS-HOST-PAYS-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 subscriber 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~ Page 11 of 15

12 IG Segment Loop ID 2310B Rendering Provider Name P.290 NM1 NM108 XX Rendering ID 24 Provider Name P.293 PRV Referring Provider Specialty Information NM109 PRV03 Loop ID 2310D Service Facility Location P.303 NM1 Service NM108 ID XX 24 Facility NM109 Location Name P.310 REF REF01 0B Service Ref ID TJ Facility REF02 Secondary P.318 SBR Other Subscriber Information Patient Hierarchical Level SBR01 Payer Responsibility Sequence No. (Rendering Primary Identifier) (Provider Taxonomy ) (Service Facility Loc Primary ID) (Service Facility Location Additional ID) P S T SBR02 See 837P IG Individual Relationship 21 SBR05 Insurance Type SBR09 Claim Filing Indicator See 837P IG C1 See 837P IG CI (ABC) XX - National Provider Identifier 24 - Employer's NPI ('XX') for Non-Exempt providers Tax ID ('24') for Exempt providers Taxonomy code that applies to the service XX - National Provider Identifier 24 - Employer's NPI ('XX') for Non-Exempt providers Tax ID ('24') for Exempt providers 0B - Provider State License TJ - Tax ID Assigned Prov No. ('0B') - for Exempt Providers Provider's Tax ID ('TJ') ABC 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 - Primary; S - Secondary; T - Tertiary In support of SVD codes due to clinical editing or pricing, the value will match the payer resp seq code in Loop 2000B SBR01. In support of SVC and CAS segments due to clinical editing or pricing, 21 will be used 21 - Unknown In support of SVC and CAS segments due to clinical editing or pricing, C1 will be used C1 - Commercial In support of SVC and CAS segments due to clinical editing or pricing, CI will be used CI - Commercial Insurance Co. Page 12 of 15

13 IG Segment (ABC) ABC 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) P.323 CAS Claim Level Populated with quantity, monetary amounts, and appropriate adjustment reason codes where 1 = deductible, 2 = coinsurance Adjustments CAS02,5,8,11,14,17 (Adjustment Identifies the reason for claim being adjusted. Claim Adjustment Reason Reason ) CAS03,6,9,12,15,18 (Adjustment Represents the amount being adjusted. Monetary Amount Amount) CAS04,7,10,13,16,19 Quantity (Adjustment Quantity) Represents the units of service being adjusted. P.332 AMT AMT01 D D - Payor Amount Paid COB Payer Amount Paid Amount AMT02 (Payer Paid Represents total amount paid by Other Payer Monetary Amount Amount) P.332 AMT AMT01 AAE AAE - Approved Amount COB Payer Amount Approved Amount AMT02 Monetary Amount (Approved Amount) Represents total amount approved by Other Payer P.334 AMT AMT01 B6 B6 - Allowed-Actual COB Allowed Amount Amount AMT02 Monetary Amount (Allowed Amount) Represents total amount allowed by Other Payer P.337 AMT AMT01 D8 D8 - Discount Amount COB Discount Amount P.344 OI Other Insurance Coverage Information Patient Hierarchical Level Amount AMT02 Monetary Amount OI03 Yes/No Condition or Response OI04 Patient Signature Source OI06 Release of Information (Other Payer Discount Amount) N Y See 837P IG B See 837P IG Y Represents Other Payer discount amount 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 Page 13 of 15

14 IG Segment Loop ID 2330A Other Subscriber Name P.350 NM1 NM103 (Other Other Name Last or Insured Last Subscriber Organization Name Name) Name NM108 ID NM109 Loop ID 2330B Other Payer Name P.366 DTP DTP03 Claim Date Time Period Adjudication Date Loop ID 2400 Service Line P.400 SV1 Professional Service P.435 DTP Date - Service Date P.472 REF Line Item Control P.495 HCP Claim Pricing/ Repricing Information Patient Hierarchical Level SV102 Monetary Amount SV Diagnosis Pointer DTP03 Date Time Period REF02 MI ZZ (Oth Insured Identifier) (Other Payer Adjudication or Payment Date) (Line Item Charge Amount) (Diagnosis Pointer) (Service Date) (Line Item Control ) 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 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) Represents date the primary payer adjudicated the claim Sum of service line charges will equal the Total Claim Charge Amount in Loop 2300 CLM02. Pointer will reference diagnosis due to responsibility of provider to send "minimum necessary" data to represent claim. Represents date of service 6R - Provider Control Service lines with HCP segment are required to be returned on 835. HCP01 Pricing Methodology 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) HCP02 Monetary Amount (Allowed Amount) Represents allowed amount to consider on a claim level HCP13 Reject Reason T1 T1 - Cannot identify Provider as TPO (Third Party Organization) Participant Page 14 of 15

15 Patient Hierarchical Level IG Segment Loop ID 2430 Line Adjudication Information P.554 SVD SVD01 (Other Payer Service Line Adjudication ) SVD06 Assigned (Bundled/ Unbundled Line ) Matches Loop 2330B NM109 identifying Other Payer. Identifies the line number to which this line was bundled from or into Multiple Adjustments will be sent as they apply on COB claims. It will also be used to notify the receiver of denials or limitations found by our editing or pricing. P.558 CAS Populated with quantity, monetary amounts, and appropriate adjustment reason Claim Level codes where 1 = deductible, 2 = coinsurance Adjustments CAS01 Claim Adjustment Group See 837P IG Adjustments made by ABC will be identified with group code PI. PI - Payor Initiated Reductions CAS02,5,8,11,14,17 Claim Adjustment Reason CAS03,6,9,12,15,18 Monetary Amount CAS04,7,10,13,16,19 Quantity (Adjustment Reason ) (Adjustment Amount) (Adjustment Quantity) Identifies the reason for claim being adjusted. Represents the amount being adjusted. Represents the units of service being adjusted. Page 15 of 15