Companion Guide for the X222A1 Health Care Claim: Professional (837P) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC

Transcription

1 Companion Guide for the X222A1 Health Care Claim: Professional (837P) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC Segment Loop Description TR3 Values Notes Delimiter: Data Element (*) Asterisk Separator Delimiter: Composite Element (:) Colon Separator Delimiter: Segment Terminator (<NL>) New Line Hex Value 0A (line feed) ISA Interchange Control Header One ISA IEA per transmission Interchange ID ZZ = Mutually Defined ISA06 Interchange Sender ID HMSA assigned submitter ID ISA07 Interchange ID 30 US Federal Tax ID ISA08 Interchange Receiver ID Both ISA07 must be equal to 30 and ISA08 must be equal to , otherwise HMSA will reject the file. ISA11 Repetition Separator ({) Left Brace ISA12 Interchange Control Version ISA13 Interchange Control Use a unique number assigned by the sender to identify the interchange data. It is used as an audit trail and in a check for duplicate exchange. A Control should never be reused. ISA14 Acknowledgement Requested 0, 1 0 TA1 will not be created ISA15 Usage Indicator P, T P for production. T for test. HMSA will reject the file received with T in production and viceversa. ISA16 Component Element Separator : (Composite delimeter) GS Functional Group Header HMSA will allow multiple Submitters within a GS GE functional group. HMSA will allow more than one Line of Business in an ISA IEA interchange GS02 Application Sender ACC = Accounting GS03 Application Receiver AH = Away From Home Care BC = Blue Card FE = Federal Employee Program (FEP) QT = QUEST RC = Senior Plans RG = Private Business CLM = more than one line of business included in the Functional Group. The subscriber number will determine which line of business the claim will be processed under. Hawaii Medical Service Association September 2013

2 GS06 Group Control Group Control should be unique for every GS GE functional group transmitted within the same day. A unique value will facilitate reconciliation with 999 functional acknowledgement transaction. GS08 Version Identifier X222A1 ST Transaction Set Header Recommend only one Billing Provider in each ST SE Transaction set. Providers can submit more than one Billing Provider in each ST SE but HMSA rejects will be done at the ST SE transaction set level. ST03 Implementation Convention X222A1 Reference BHT Beginning Of Hierarchical BHT03 Transaction Originator Application Transaction ID Use a unique number in this field. The assigned number must be unique within each file creation date (BHT04). This will be used as a duplicate check for each transaction. The fields for the duplicate check are: BHT03 (submission number), 1000A. NM109 (Submitter ID), BHT04 (create date), GS03 (line of business). BHT06 Claim or Encounter ID List CH = Chargeable 1000A - Submitter Name NM1 1000A Submitter Name NM109 Submitter Identifier HMSA Assigned Submitter ID PER 1000A Submitter EDI Contact 1000B Receiver Name NM1 1000B Receiver Name NM103 Receiver Name HAWAII MEDICAL SERVICE ASSOCIATION NM109 Receiver Primary Identifier = HMSA s Federal Tax ID 2000A Billing Provider Hierarchical Level HL 2000A Billing Provider Hierarchical Level PRV 2000A Billing Provider Specialty This Loop is required when Loop 2310B is not used. CUR 2000A Foreign Currency 2010AA Billing Provider Name NM1 2010AA Billing Provider Name N3 2010AA Billing Provider Address Use the physical address not the mailing address. HMSA is using Hawaii Medical Service Association September 2013

3 this information for processing. N4 2010AA Billing Provider City/State/Zip N403 Postal HMSA requires Zip + 4 digits with no hyphen or spaces. REF 2010AA Billing Provider Tax REF 2010AA Billing Provider UPIN/License PER 2010AA Billing Provider Contact 2010AB Pay To Address Name NM1 2010AB Pay-To Address Name N3 2010AB Pay-To Address N4 2010AB Pay-To Address City/State/Zip N403 Postal When present, this information will be used by HMSA for processing. When submitted, format should be Zip + 4 digits with no hyphen or spaces. 2010AC Pay To Plan Name NM1 2010AC Pay-To Plan Name N3 2010AC Pay-To Plan Address N4 2010AC Pay-To Plan City, State, Zip REF 2010AC Pay-To Plan Secondary REF 2010AC Pay-To Plan Tax 2000B Subscriber Hierarchical Level HL 2000B Subscriber Hierarchical Level SBR 2000B Subscriber SBR B Individual Relationship SBR09 Claims Filing Indicator List 18 = Self HMSA will accept any valid qualifier, but will require usage of these particular qualifiers to denote the following types of claims: BL = Blue Cross/Blue Shield must be used for Blue Card FI = Federal Employees Program MC = Medicaid is required for QUEST claims ; no other value is allowed when EPSDT or Family Planning Indicators = Y PAT 2000B Patient 2010BA- Subscriber Name NM1 2010BA Subscriber Name NM102 Entity Type 1 or 2 1 = Person = Subscriber NM103 Subscriber Last Name Do not use the following special Hawaii Medical Service Association September 2013

4 (=), pound sign (#) or caret symbol (^) NM104 Subscriber First Name Do not use the following special (=), pound sign (#) or caret symbol (^) NM108 MI or II MI = HMSA ID NM109 Subscriber Primary Identifier N3 2010BA Subscriber Address N4 2010BA Subscriber City/State/Zip HMSA Subscriber See HMSA Subscriber ID details in the Trading Partner Manual. This element is required for HMSA business needs. When submitted, format should be zip+4 digits with no hyphen or spaces. DMG 2010BA Subscriber Demographic DMG03 Subscriber Gender M, F, U M = Male or F = Female REF 2010BA Subscriber Secondary REF 2010BA Property and Casualty Claim PER 2010BA Property and Casualty Subscriber Contact 2010BB Payer Name NM1 2010BB Payer Name NM103 Payer Name HAWAII MEDICAL SERVICE NM108 PI or XV ASSOCIATION PI = Plan Identifier This element is required for HMSA business needs. NM109 Payer Identifier = HMSA s Federal Tax ID. N3 2010BB Payer Address N4 2010BB Payer City, State, Zip REF 2010BB Payer Secondary REF 2010BB Billing Provider 2000C Patient Hierarchical Level HL 2000C Patient Hierarchical Level PAT 2000C Patient 2010CA Patient Name NM1 2010CA Patient Name N3 2010CA Patient Address N4 2010CA Patient City/State/Zip DMG 2010CA Patient Demographic Hawaii Medical Service Association September 2013

5 DMG03 Patient Sex M, F, U M = Male or F = Female REF 2010CA Property and Casualty Claim PER 2010CA Property and Casualty Patient Contact 2300 Claim CLM 2300 Claim CLM01 CLM05-3 CLM11 Claim Submitter Identifier/Patient Account Claims Frequency Type - Submission Reason Related Causes Patient Account Do not use the following special (=), pound sign (#) or caret symbol (^) Use only 1 = Original; 7 = Resub; or 8 = Void All potential related causes on the claim must be sent within the transaction. Required if accident date is present. DTP 2300 Date Onset of Current Illness or Symptom DTP01 Date/Time 431 = Onset of Current Symptoms or Illness DTP03 Onset of Current Illness or Injury Date Should be the earliest onset date on the claim DTP03 will not be used for processing DTP 2300 Date Initial Treatment Date DTP 2300 Date Last Seen Date DTP 2300 Date Acute Manifestation DTP 2300 Date - Accident DTP01 Date/Time 439 = Accident DTP03 Accident Date Required if CLM11-1, CLM11-2 = AA, EM or OA DTP 2300 Date Last Menstrual Period DTP 2300 Date Last X-Ray Date DTP 2300 Date Hearing and Vision Prescription Date DTP 2300 Date Disability Dates DTP 2300 Date- Last Worked DTP 2300 Date Authorized Return to Work DTP 2300 Date - Admission DTP01 Date/Time 435 = Admission DTP03 Admission Date Required on all ambulance claims when the patient was known to be admitted to the hospital or on an inpatient medical visit claim. DTP 2300 Date Discharge DTP 2300 Date Assumed and Hawaii Medical Service Association September 2013

6 Relinquished Care Dates DTP 2300 Date Property and Casualty Date of First Contact DTP 2300 Date Repricer Received Date PWK 2300 Claim Supplemental CN Contract AMT 2300 Patient Amount Paid REF 2300 Service Authorization Exception REF 2300 Mandatory Medicare (Section 4081)Crossover Indicator REF 2300 Mammography Certification REF 2300 Referral REF01 Reference 9F 9F Referral REF02 Referral Treatment Authorization. Do not use the following special (=), pound sign (#) or caret symbol (^). Do not submit more than 15 characters REF 2300 Prior Authorization REF01 Reference G1 G1 Treatment Authorization REF02 Prior Authorization REF 2300 Payer Claim Control REF 2300 Clinical Laboratory Improvement Amendment (CLIA) REF 2300 Repriced Claim REF 2300 Adjusted Repriced Claim REF 2300 Investigational Device Exemption REF 2300 Claim Identifier For Transmission Intermediaries REF 2300 Medical Record REF 2300 Demonstration Project Identifier REF 2300 Care Plan Oversight K File NTE 2300 Claim Note Treatment Authorization. Do not use the following special (=), pound sign (#) or caret symbol (^). Do not submit more than 15 characters Hawaii Medical Service Association September 2013

7 CR Ambulance Transport CR Spinal Manipulation Service CRC 2300 Ambulance Certification CRC 2300 Patient Condition : Vision CRC 2300 Homebound Indicator CRC 2300 EPSDT Referral HI 2300 Health Care Diagnosis HI 2300 Anesthesia Related Procedure HI 2300 Condition HCP 2300 Claim Pricing/Repricing 2310A Referring Provider Name NM1 2310A Referring Provider Name NM101 Entity Identifier DN or P3 DN = Referring Provider REF 2310A Referring Provider 2310B Rendering Provider Name NM1 Rendering Provider Name PRV 2310B Rendering Provider Specialty REF 2310B Rendering Provider 2310C Service Facility Location NM1 2310C Service Facility Location Name N3 2310C Service Facility Location Address N4 2310C Service Facility Location City/State/Zip N403 Postal Required for processing. Format should be Zip + 4 positions with no hyphen or spaces. REF 2310C Service Facility Location PER 2310C Service Facility Contact 2310D Supervising Provider Name NM1 2310D Supervising Provider Name REF 2310D Supervising Provider 2310E Ambulance Pick-Up Location NM1 2310E Ambulance Pick-Up Location N3 2310E Ambulance Pick-Up Location Address Hawaii Medical Service Association September 2013

8 N4 2310E Ambulance Pick-Up Location City, State, Zip 2310F - Ambulance Drop-Off Location NM1 2310F Ambulance Drop-Off Location N3 2310F Ambulance Drop-Off Location Address N4 2310F Ambulance Drop-Off Location City, State, Zip 2320 Other Subscriber Other Sub/ Other Payer loops repeated once for each Payer SBR 2320 Other Subscriber SBR01 Payer Responsibility Sequence Commonly reported values: P = Primary S = Secondary T = Tertiary SBR09 Claim Filing Indicator Commonly reported values: 16= Health Maintenance Organization (HMO) Medicare Risk BL=Blue Cross/Blue Shield CI=Commercial Insurance Co. MA=Medicare Part A MB=Medicare Part B When submitted, format should be zip+4 digits with no hyphen or spaces. When submitted, format should be zip+4 digits with no hyphen or spaces. Describes the responsibility for Payer in 2330B Other Payer Name Loop Use BL (Blue Cross/Blue Shield) when HMSA is Other Payer. A valid Claim Filing Indicator is required prior to the mandated use of Plan ID. Not used after Plan ID is mandated. MA, MB or 16 must be used to identify prior payer = Medicare Although separate claim submission is not normally required for dual membership situations, use BL when HMSA is Other Payer in 2330B. This would typically be used when submitting for Tertiary benefits. CAS 2320 Claim Level Adjustments The CAS segment in the 2320 loop is used to report prior payers claim level adjustments that caused the amount paid to differ from the amount originally charged. This segment is used if the payer in this loop has reported claim level adjustment information on the primary payer s remittance advice. This line can be repeated if there are multiple adjustment groups. If primary payer EOB provides line level adjustments, do not include any amounts reported at the line level in the claim level. Hawaii Medical Service Association September 2013

9 CAS01 CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 CAS03 CAS06 CAS09 CAS12 CAS15 CAS18 CAS04 CAS07 CAS10 CAS13 CAS16 Claim Adjustment Group Claim Adjustment Reason Monetary Adjustment Amount Service Lind Adjusted Units CAS19 AMT 2320 Coordination of Benefits (COB) Payer Paid Amount CO=Contractual Obligation CR = Corrections and Reversals OA = Other Adjustments PI = Payer Initiated PR = Patient Responsibility This code tells HMSA who (the patient or the provider) is responsible for any adjustments made Identifies the reason for the claim being adjusted. For example: 1 = deductible 2 = coinsurance 3 = copayment Note: Your paper remittance may already contain standard code values. If so, please use the codes furnished by the primary payer. If primary payer uses proprietary reasons explaining reductions, those values will need to be mapped to standard codes for submission. Represents the dollar amount being adjusted Represents the units of service being adjusted This segment is required when the claim has been adjudicated by the payer identified in the 2330B loop. AMT01 Amount D= Payer Amount Paid AMT02 Monetary Amount Dollar amount that correlates to AMT01 identifier. This amount should equal total charges minus claim level and line level adjustments. AMT 2320 Coordination of Benefits Note: It is acceptable to show 0 (zero) as an amount paid, provided the CAS segment(s) properly explains why no payment was made. Hawaii Medical Service Association September 2013

10 (COB) Total Non-Covered Amount AMT 2320 Remaining Patient Liability OI 2320 Other Insurance Coverage MOA 2320 Outpatient Adjudication Submit if returned by prior payer on remittance advice (835) 2330A Other Subscriber Name NM1 2330A Other Subscriber Name NM108 NM109 /Other Insured Identifier/Subscriber Primary Identifier MI or II Note: When Medicare is primary payer and MOA03 or MOA05 or MOA20 or MOA21 or MOA22 contain values MA18 or N89, this indicates that Medicare crossover occurred and claim should not be submitted to HMSA until more than 30 days have passed from Medicare remittance date. When HMSA is Other Payer, use MI Subscriber This is the membership id number used by the prior payer. (When Medicare is prior payer, this should contain HIC number.) N3 2330A Other Subscriber Address N4 2330A Other Subscriber City, State, Zip REF 2330A Other Subscriber 2330B Other Payer Name NM1 2330B Other Payer Name This is the Insurance Plan Name or Program Name from the previous payer. NM103 NM108 NM109 Last Name or Organization Name Other Payer Primary Identifier N3 2330B Other Payer Address PI or XV Required when Loop 2320 Other Subscriber is used. Do not use the following special (=), pound sign (#), or caret symbol (^). PI = Payer ID Use Complementary Insurer Identifiers. Located in HMSA Trading Partner Manual Appendix C Hawaii Medical Service Association September 2013

11 N4 2330B Other Payer City, State, Zip DTP 2330B Claim Check or Remittance Date Required when payer identified in 2330B/NM1 has previously adjudicated the claim. Do not report Loop 2330B if remittance date is being reported at the line level (Loop 2430). When prior payer is Medicare, do not submit claim until at least 31 days have passed since Medicare remittance date and HMSA has not processed the claim for secondary. This allows ample time for the Medicare crossover claim to be received and processed. DTP B Date/Time 573 Date Claim Paid DTP B Date Time Period Adjudication or Payment Date REF 2330B Other Payer Secondary Identifier REF 2330B Other Payer Prior Authorization REF01 Reference G1 G1 = Treatment Authorization REF02 Prior Authorization Treatment Authorization - Don t use the following special (=), pound sign (#), or caret symbol (^). REF 2330B Other Payer Referral REF01 Reference 9F 9F = Treatment Authorization REF02 Referral Treatment Authorization - Don t use the following special (=), pound sign (#), or caret symbol (^). REF 2400 Other Payer Claim Adjustment Indicator REF 2400 Other Payer Claim Control 2330C Other Payer Referring Provider NM1 2330C Other Payer Referring Provider REF 2330C Other Payer Referring Provider Secondary 2330D Other Payer Rendering Provider NM1 2330D Other Payer Rendering Provider REF 2330D Other Payer Rendering Hawaii Medical Service Association September 2013

12 Provider Secondary 2330E Other Payer Service Facility NM1 2330E Other Payer Service Facility Location REF 2330E Other Payer Service Facility Location 2330F Other Payer Supervising Provider NM1 2330F Other Payer Supervising Provider REF 2330F Other Payer Supervising Provider Secondary 2330G Other Payer Billing Provider NM1 2330G Other Payer Billing Provider REF 2330G Other Payer Billing Provider Secondary 2400 Service Line LX 2400 Service Line SV Professional Service SV111 EPSDT Indicator QUEST Claims: When submitting an EPSDT claim, the EPSDT Indicator (Loop 2400, SV111) must = Y and the Claim Filing Indicator (2000B, SBR09) must = MC. SV112 Family Planning Indicator QUEST Claims: If the Family Planning Indicator is used, the Claim Filing Indicator (SBR09) must = MC SV Durable Medical Equipment Service PWK 2400 Line Supplemental PWK 2400 Durable Medical Equipment Certification of Medical Necessity Indicator CR Ambulance Transport CR Durable Medical Equipment Certification CRC 2400 Ambulance Certification CRC 2400 Hospice Employee Indicator CRC 2400 Condition Indicator/ Durable Medical Equipment DTP 2400 Date- Service Date DTP 2400 Date- Prescription Date Hawaii Medical Service Association September 2013

13 DTP 2400 Date-Certification Revision/ Recertification Date DTP 2400 Date- Begin Therapy Date DTP 2400 Date- Last Certification Date DTP 2400 Date- Last Seen Date DTP 2400 Date- Test Date DTP 2400 Date- Shipped Date DTP 2400 Date- Last X-Ray Date DTP 2400 Date- Initial Treatment Date QTY 2400 Ambulance Patient Count QTY 2400 Obstetric Anesthesia Additional Units MEA 2400 Test Result CN Contract REF 2400 Repriced Line Item Reference REF 2400 Adjusted Repriced Line Item Reference REF 2400 Prior Authorization REF 2400 Line Item Control REF02 Reference Do not use the following special (=), pound sign (#), or caret symbol (^). REF 2400 Mammography Certification REF 2400 Clinical Laboratory Improvement Amendment (CLIA) REF 2400 Referring Clinical Laboratory Improvement Amendment (CLIA) Facility REF 2400 Immunization Batch REF 2400 Referral AMT 2400 Sales Tax Amount AMT 2400 Postage Claimed Amount K File NTE 2400 Line Note NTE 2400 Third Party Organization Notes PSI 2400 Purchased Service HCP Line Pricing/Repricing 2410 Drug LIN 2410 Drug CTP 2410 Drug Quantity Hawaii Medical Service Association September 2013

14 REF 2410 Prescription or Compound Drug Association REF02 Reference Do not use the following special (=), pound sign (#), or caret symbol (^). 2420A Rendering Provider Name NM1 2420A Rendering Provider Name PRV 2420A Rendering Provider Specialty REF 2420A Rendering Provider 2420B Purchased Service Provider Name NM1 2420B Purchased Service Provider Name REF 2420B Purchased Service Provider Secondary 2420C Service Facility Location Name NM1 2420C Service Facility Location Name N3 2420C Service Facility Location Address N4 2420C Service Facility Location City, State, Zip REF 2420C Service Facility Location 2420D Supervising Provider Name NM1 2420D Supervising Provider Name REF 2420D Supervising Provider 2420E Ordering Provider Name NM1 2420E Ordering Provider Name N3 2420E Ordering Provider Address N4 2420E Ordering Provider City, State, Zip REF 2420E Ordering Provider PER 2420E Ordering Provider Contact 2420F Referring Provider Name NM1 2420F Referring Provider Name REF 2420F Referring Provider 2420G Ambulance Pick-Up Location NM1 2420G Ambulance Pick-Up Location N3 2420G Ambulance Pick-Up Hawaii Medical Service Association September 2013

15 Location Address N4 2420G Ambulance Pick-Up Location City, State, Zip 2420H Ambulance Drop-Off Location NM1 2420H Ambulance Drop-Off Location N3 2420H Ambulance Drop-Off Location Address N4 2420H Ambulance Drop-Off Location City, State, Zip 2430 Line Adjudication SVD 2430 Line Adjudication This segment is required when the claim has been previously adjudicated by the payer identified in the 2330B loop and the payer has reported line level payment and/or applied line level adjustments that cause the amount considered by the payer to differ from the amount originally charged. Other Payer Primary Identifier (Loop 2330B, NM109) SVD Other Payer Primary Identifier SVD Service Line Amount Paid Dollar Amount Report line adjudication information if provided by primary payer. SVD Product/Service ID Indicates type of code being reported SVD Procedure Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD Procedure Modifier 1 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD Procedure Modifier 2 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD Procedure Modifier 3 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD Procedure Modifier 4 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD Quantity (Units of Service) Represents paid units of service CAS 2430 Line Adjustment Segment is required when the claim has been adjudicated by the payer identified in the 2330B loop and the payer applied line level Hawaii Medical Service Association September 2013

16 CAS Claim Adjustment Group CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 CAS03 CAS06 CAS09 CAS12 CAS15 CAS18 CAS04 CAS07 CAS10 CAS13 CAS16 CAS Claim Adjustment Reason 2430 Monetary Adjustment Amount 2430 Service Line Adjusted Units DTP 2430 Line Check or Remittance Date AMT 2430 Remaining Patient Liability 2440 Form LQ 2440 Form FRM 2440 Supporting SE GE IEA Documentation Transaction Set Trailer Function Group Trailer Interchange Control Trailer CO=Contractual Obligations CR = Corrections and Reversals OA = Other Adjustments PI = Payer Initiated PR = Patient Responsibility adjustments that caused the amount considered by the payer to differ from the amount originally charged. This explains why the other payer paid less (or more) than billed. most commonly required is deductible, coinsurance and/or copay amounts, negotiated/contractual rate reduction and/or explanation for non-payment. Do not enter at claim level any amounts included at line level. This code tells HMSA who (the patient or the provider) is responsible for any adjustments made Identifies the reason for claim being adjusted. Represents the dollar amount being adjusted Represents the units of service being adjusted Hawaii Medical Service Association September 2013

17 *Updates 09/11/13 Added COB details Hawaii Medical Service Association September 2013