835 Health Care Claim Payment/Advice LA Medicaid

Transcription

1 835 Health Care Claim Payment/Advice LA edicaid HIPAA/V5010X221A1/835: 835 Health Care Claim Payment/Advice Version: 1. 1 Created 10/21/2011 Revision 9/23/2013 Author: Publication: EDI Department LA edicaid Companion Guide The purpose of this guide is to clarify the usage of the X X221A1 835 Health Care Claim Payment/Advice HIPAA Implementation Guide for electronic submitters participating in the LA edicaid program. This guide does not replace the published HIPAA Implementation Guide, nor does it change the meaning of the published Guide. Submitters must use the format mandated by HIPAA as of January 1, One 835 transaction reflects a single payment (check or EFT), or one 835 per pay -to provider. The 835 must balance, meaning the total check or EFT amount reported must be supported by detail data in both Table 2 and Table 3. Both paid and denied claims will be reported in the 835. Pended claims will be reported in the ASC X12 Health Care Claim Status Notification Transaction Set U277 (unsolicited 277) transaction and will be transmitted in the same envelope as the 835. The 835 transaction will replace the existing electronic remittance. The 835 method ERA with Payment by Separate EFT (described in the 835 Implementation Guide) corresponds to the current method used to report claims and EFT transmissions separately. Service line data is required when reporting professional claims or when payment adjustments (reduction to billed charges or denial) are related to specific claim lines. Since Louisiana edicaid is a claim line processor, all adjustments are line specific, except for institutional claims when the per-diem is the only service line adjustment. Each claim line will be reported in the 835 as a claim. One CLP segment (Claim Payment Information) represents a single claim document. Data not supplied at the claim level must be supplied at the line level (SVC Service Payment Information). NOTE: National Provider entification Numbers are returned in all 835 transactions. Atypical providers who have not registered an NPI with Louisiana edicaid will continue to receive their legacy edicaid Provider in the 835 as the only provider identifier X221A1-835v1.ecs 1

2 Document Title Louisiana edicaid anagement Information System (LIS) X221A1 Companion Guide Author Technical Communications Group, olina edicaid Solutions LIS QA Revision History Date Description of Change LIFT By 10/21/11 Initial document release 6729 T. Tate 9/23/2013 Changes to BPR and TRN segments T. Tate 2

3 835 Health Care Claim Pa y ment/advice Functional Group=HP Heading: POS Segment Name ax Use Repeat Notes 020 BPR Financial Information TRN Reassociation Trace Number O 1 N1/040 LOOP 1000A 1 N1/080L 080 N1 Payer entification O 1 N1/ N3 Payer Address O N4 Payer City, State, ZIP Code O 1 LOOP LOOP 1000B 1000B Payer entification 1 1 N1/080L N1/080L N1/ N1 Payer Payee entification Additional Information O 1 N1/ REF Payee Additional Information O 1 Detail: POS Segment Name ax Use Repeat Notes LOOP N2/003L LOOP CLP 020 CAS 030 N1 040 REF Claim Payment Information Claim Adjustment Patient Name Other Claim Related entification 1 O 99 N2/020 1 O 5 2/040 LOOP SVC 090 CAS Service Payment Information Service Adjustment O 1 O 99 Summary: POS Segment Name ax Use Repeat Notes 010 PLB Provider Adjustment O 1 C3/ X221A1-835v1.ecs 2 3

4 9/23/2013 Health Care Claim Payment/Advice ISA Interchange Control Header Pos: ax: 1 Not Defined - andatory Loop: N/A Elements: 16 ISA01 I01 Authorization Information Qualifier LA edicaid: Value will be 00 for this element 2/2 ISA02 I02 Authorization Information LA edicaid: Value will be spaces for this element AN 10/10 ISA03 I03 Security Information Qualifier LA edicaid: Value will be 00 for this element 2/2 ISA04 I04 Security Information LA edicaid: Value will be spaces for this element AN 10/10 ISA05 I05 Interchange Qualifier LA edicaid: Value will be ZZ for this element 2/2 ISA06 I06 Interchange Sender LA edicaid: Value will be LA-DHH-EDICA for this element AN 15/15 ISA07 I05 Interchange Qualifier LA edicaid: Value will be ZZ for this element 2/2 ISA08 I07 Interchange Receiver AN 15/15 LA edicaid: Value will be the 7 digit olina assigned submitter (i.e. 450XXXX) followed by spaces ISA09 I08 Interchange Date LA edicaid: The date format is YYDD DT 6/6 ISA10 I09 Interchange Time LA edicaid: The time format is HH T 4/4 ISA11 I10 Interchange Control Standards entifier LA edicaid: Value will be U for this element 1/1 ISA12 I11 Interchange Control Version Number LA edicaid: Value will be for this element 5/5 ISA13 I12 Interchange Control Number N0 9/9 LA edicaid: Value will be identical to the interchange trailer IEA02. ust be unique for every transmission submitted. ISA14 I13 Acknowledgment uested 1/1 LA edicaid: Value will be 0 for this element. An acknowledgement is not expected from the receiver. ISA15 I14 Usage Indicator 1/1 LA edicaid: T = Test Data P = Production Data ISA16 I15 Component Element Separator 1/1 LA edicaid: ust be a colon : - ASCII x3a X221A1-835v1.ecs 3 4

5 GS Functional Group Header Pos: ax: 1 Not Defined andatory Loop: N/A Elements: 8 GS Functional entifier Code LA edicaid: Value will be HP for this element 2/2 GS Application Sender's Code LA edicaid: Value will be identical to the value in ISA06 AN 2/15 GS Application Receiver's Code AN 2/15 LA edicaid: Value will be 7 digit olina assigned submitter (i.e. 450XXXX) followed by spaces GS Date LA edicaid: The date format is CCYYDD DT 8/8 GS Time LA edicaid: The time format is HH T 4/8 GS06 28 Group Control Number LA edicaid: Uniquely assigned and maintained by LA edicaid N0 1/9 GS Responsible Agency Code LA edicaid: Value will be X for this element 1/2 GS Version / Release / Industry entifier Code LA edicaid: Value will be X221A1 for this element AN 1/12 BPR Financial Information BPR Transaction Handling Code 1/2 LA edicaid: Value will always be I Remittance Information only or H Notification only BPR Credit/Debit Flag Code LA edicaid: Value will always be "C Credit 1/1 BPR Payment ethod Code LA edicaid: Value will be either ACH or CHK or NON 3/3 BPR Payment Format Code LA edicaid: Value will be CCP when BPR04 equals ACH O 1/10 BPR (DFI) Number Qualifier LA edicaid: Value will be 01 when BPR04 equals ACH C 2/2 BPR (DFI) Number Qualifier LA edicaid: Value will be 01 when BPR04 equals ACH C 2/2 BPR Date 01 DT 8/8 LA edicaid: Value will be the EFT date when BPR04 equals ACH or Check Issue date when BPR04 equals CHK or RA Date when BPR04 equals NON Pos: 020 ax: 1 Heading - andatory Loop: N/A Elements: X221A1-835v1.ecs 4 5

6 TRN Reassociation Trace Number Pos: 040 ax: 1 Loop: N/A Elements: 1 TRN erence Notification AN 1/30 LA edicaid: A 15 digit number assigned by sender when payment made via EFT consisting of the routing # of the ODFI and the Entry Detail Sequence number. This value equals the Trace Number in the CCD+Addenda record and can be used for reassociation of the 835 and the EFT payment. Value will be check number if payment by check or remittance number if no payment made. TRN Originating Company entifier 01 A/N 1/50 LA edicaid: This is the payer s TIN preceded by a 1. N1 N3 Payer entification Payer Address Pos: 080 ax: 1 Loop: 1000A Elements: 2 N entification Code Qualifier C 1/2 LA edicaid: This segment will not be used until National Plan is mandated for use N entification Code C AN 2/80 LA edicaid: This segment will not be used until National Plan is mandated for use Pos: 100 ax: 1 Loop: 1000A Elements: 2 N Address Information AN 1/55 LA edicaid: Value will be 628 N. 4 th Street for this element N Address Information O AN 1/55 LA edicaid: Value will be PO Box for this element N4 Payer City, State, ZIP Code Pos: 110 ax: 1 Loop: 1000A Elements: X221A1-835v1.ecs 5 6

7 N City Name LA edicaid: Baton Rouge O AN 2/30 N State or Province Code LA edicaid: LA O 2/2 N Postal Code LA edicaid: O 3/15 N1 Payee entification Pos: 080 ax: 1 Loop: 1000B Elements: 2 N entification Code Qualifier C 1/2 LA edicaid: Value will be XX for this element if NPI is registered with LA edicaid. Value will be FI if provider is atypical and has not registered an NPI with LA edicaid. N entification Code C AN 2/80 LA edicaid: If value is XX, this element will contain the NPI registered with LA edicaid. If value is FI, this element will contain the federal taxpayer s number X221A1-835v1.ecs 6 7

8 REF Payee Additional Information Pos: 120 ax: 1 Loop: 1000B Elements: 2 REF erence entification Qualifier LA edicaid: Value will be PQ Payee entification for this element 2/3 REF erence entification C AN 1/30 LA edicaid: LA edicaid will enter the 7 digit Louisiana edicaid provider number of the payee when the Provider is atypical and has not registered an NPI with LA edicaid. REF Payee Additional Information Pos: 120 ax: 1 Loop: 1000B Elements: 2. If the value in N103 is XX, this loop is not sent. REF erence entification Qualifier 2/3 LA edicaid: Value will be TJ for this element REF erence entification C AN 1/30 LA edicaid: LA edicaid will enter the Taxpayer Number (EIN or SSN) of the payee. CLP Claim Payment Information Pos: 010 ax: 1 Detail andatory Loop: 2100 Elements: 2 CLP Claim Status Code 1/2 LA edicaid: LA edicaid will report back status codes of 1 and 2. Pended claims will be reported in the unsolicited 277 transaction (U277) CLP Claim Filing Indicator Code LA edicaid: Value will be C for this element O 1/2 CAS Claim Adjustment Pos: 020 ax: 99 Detail - Optional Loop: 2100 Elements: 1 CAS onetary Amount R 1/18 LA edicaid: Inpatient claim level adjustments to per diem rates will be reported in this element X221A1-835v1.ecs 7 8

9 N1 Patient Name Pos: 030 ax: 1 Detail andatory Loop: 2100 Elements: 2 N entification Code Qualifier LA edicaid: Value will be R for this element C 1/2 N entification Code C AN 2/80 LA edicaid: The thirteen digit Louisiana edicaid recipient identification number will be reported in this element N1 Service Provider Name Pos: 030 ax: 9 Detail andatory Loop: 2100 Elements: 2 N entification Code Qualifier C 1/2 LA edicaid: Value will be XX for this element if the NPI is submitted in the claim. Value will be FI for this element if the Federal Taxpayer s entification number is submitted in the claim. Value will be C for this element if the NPI is not present in the claim. N entification Code C AN 2/80 LA edicaid: If value is XX, this element will contain the NPI submitted in the claim. If value is FI, this element will contain the Federal Taxpayer s entification number. If value is C, this element will contain the 7-digit edicaid provider number assigned by olina and will only be sent when the provider is atypical and has not registered an NPI with LA edicaid. REF Other Claim Related entification Pos: 040 ax: 5 Detail Optional Loop: 2100 Elements: 2 REF erence entification Qualifier LA edicaid: Value will be EA, F8, or G1 for this element 2/3 REF erence entification C AN 1/30 LA edicaid: The former claim ICN will be reported here if the claim submitted was an adjustment or void. The prior authorization number and/or edical Record Number will be reported if received on original claim X221A1-835v1.ecs 8 9

10 REF Rendering Provider entification Pos: 040 ax: 5 Detail Optional Loop: 2100 Elements: 2 REF erence entification Qualifier LA edicaid: Value will be 1D for this element 2/3 REF erence entification C AN 1/30 LA edicaid: Value will be the seven-digit edicaid number issued by LA edicaid of the Attending/Rendering edicaid provider as submitted on the claim or as processed using the NPI/edicaid number crosswalk.. SVC Service Information Pos: 070 ax: 90 Detail Optional Loop: 2110 Elements: 7 SVC Procedure Code AN 1/48 LA edicaid: LA edicaid will report the new bundled procedure code here if as a result of ckesson ClaimCheck editing, two or more procedures are going to be paid under one procedure code. SVC Line Item Charge Amount R 1/18 LA edicaid: LA edicaid will report the total billed charge(s) of the originally billed claim lines when claim lines are bundled as a result of ckesson ClaimCheck editing or report the originally submitted Claim line billed charge amount if bundling is not involved. SVC Procedure Code AN 1/48 LA edicaid: LA edicaid will report the original submitted procedure code here if as a result of ckesson ClaimCheck editing the claim line was bundled and the procedure code is different from the adjudicated claim procedure code shown in SVC01-2. CAS Service Adjustment Pos: 090 ax: 99 Detail Optional Loop: 2110 Elements: 3 CAS Claim Adjustment Group Code 1/2 LA edicaid: Claims that have been bundled as a result of ckesson ClaimCheck editing will have CO for the Claim Adjustment Group Code. CAS Claim Adjustment Reason Code 1/5 LA edicaid: LA edicaid will use Claim Adjustment Reason Code 97 to report adjustment of the original submitted code when bundling occurs as a result of ckesson ClaimCheck editing. CAS Adjustment Amount R 1/18 LA edicaid: The billed amount of the original submitted code will be reported for claims that are bundled as a result of the ckesson ClaimCheck editing. The amount for the new created claim line will be the difference between the total billed charge in SVC02 and the paid amount in SVC X221A1-835v1.ecs 9 10

11 PLB Provider Adjustment Pos: 010 ax: 1 Summary Optional Loop: N/A Elements: 2 PLB Date LA edicaid: Date expressed as CCYYDD DT 8/8 PLB03 C042 Adjustment entifier Comp 426 Adjustment Reason Code LA edicaid: Value will be FB, CS, IR or LE for this element. See Segment Comments and PLB03-C04202 (below) 2/2 127 erence entification O AN 1/30 LA edicaid: If PLB03-1 is F B, this value will be either Negative balance applied or Negative balance forwarded. If PLB03-1 is CS and for CommunityCARE Fee Payments, this value will be the first 13 digits of the Recipient number, followed by month and year of service date in YY format followed by the 13 digit assigned ICN. If PLB03-1 is CS and for a financial adjustment, this value will be FCN in first 10 bytes, followed by transaction type description. If PLB03-1 is CS and Lien/Levy, this value will be State of Louisiana, edical Trust Fund or Deferred Compensation. If PLB03-1 is L E, this value will be Internal Revenue Service levy If PLB03-1 is I R, this value will be Internal Revenue Service withholding amount. Comments: There a Four s of Adjustments: 1. Financial adjustments - Financial adjustments, such as check cancellations or return monies for Third Party payments, will be reported in the PLB segment using Adjustment reason code (PLB03-1) "CS". Any claims associated with these financial transactions will be reported in Table 2. PLB03-2 Adjustment entifier will carry the 10 digit Financial Control Number (FCN) assigned, followed by a description of the type of transaction. 2. Lien/Levy - Lien/Levy withholdings will be reported in the PLB segment using Adjustment reason code LE for Lien/Levy account type A, IR for account type C and CS for account types B, E, and F. The PLB03-2 will carry the following descriptions: (A) Internal Revenue Service (B) State of Louisiana (C) Internal Revenue Service (E) Deferred Compensatio n (F) edical Assistant Trust Fund. 3. Negative Balances - Negative balances will be reported in the PLB segment using Adjustment Reason code of "FB". PLB03-2 Adjustment entifier will indicate Negative balance applied or Negative balance forwarded. 4. Community Care Fee payments -; These payments will be reported in the PLB loop and not in Table 2 Claims Data. One PLB loop will occur per Recipient per payment. The PLB03-1 Reason Code will contain "CS". PLB03-2 Adjustment entifier will carry the 13 digit Recipient edicaid, followed by 4 digit date of service (YY), followed by the 13 digit assigned Internal Control Number (ICN). GE Functional Group Trailer Pos: ax: 1 Not Defined andatory Loop: N/A Elements: 2 GE01 97 Number of Transaction Sets Included LA edicaid: Number of transaction sets included N0 1/6 GE02 28 Group Control Number LA edicaid: Value will be identical to the value in GS06 N0 1/ X221A1-835v1.ecs 10 11

12 IEA Interchange Control Trailer Pos: ax: 1 Not Defined andatory Loop: N/A Elements: 2 IEA01 I16 Number of Included Functional Groups LA edicaid: Number of included functional groups N0 1/5 IEA02 I12 Interchange Control Number LA edicaid: Value will be identical to the value in ISA13 N0 9/ X221A1-835v1.ecs 1 12