Indiana Health Coverage Programs

Transcription

1 Indiana Health Coverage Programs Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version Health Care Claim: Institutional (837) Companion Guide Version Number: 2.1 Library Reference Number: CLEL10014 Revision Date: January 2014 Jan

2 This template is Copyright 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12. Express permission to use ASC X12 copyright materials has been granted. Companion Guide copyright 2012 by Indiana Health Coverage Programs Jan

3 Preface The Health Insurance Portability and Accountability Act (HIPAA) adopted standard transaction sets for Electronic Data Interchange (EDI) of health care data. Covered entities must adhere to the content and format requirements as defined in the ASC X12N Implementation Guides. The Indiana Health Coverage Programs (IHCP) has developed this document to serve as a companion document to provide guidance and clarification as it applies to the IHCP. It is not intended to modify, contradict or reinterpret the rules established by the ASC X12N Implementation Guides. Jan

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5 Table of Contents 1 TI Introduction Background Overview of HIPAA Legislation Compliance according to HIPAA Compliance according to ASC X Intended Use Included ASC X12 Implementation Guides Instruction Table TI Additional Information Business Scenarios Payer Specific Business Rules and Limitations NPI/LPI Crosswalk Submission Summary Report (SSR) Processing Guidelines Interchange Control Header Functional Group Header Fee-for-service Claims Encounter Claims Coordination of Benefits (COB) Assumptions Frequently Asked Questions Other Resources TI Change Summary Jan

6 Transaction Instruction (TI) 1 TI Introduction 1.1 Background Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs Compliance according to HIPAA The HIPAA regulations at 45 CFR require that covered entities not enter into a trading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in a standard. Add any data elements or segments to the maximum defined data set. Use any code or data elements that are marked not used in the standard s implementation specifications or are not in the standard s implementation specification(s). Change the meaning or intent of the standard s implementation specification(s) Compliance according to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory, or clarifying content contained in the implementation guide. Jan

7 Modifying any requirement contained in the implementation guide. 1.2 Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12 s Fair Use and Copyright statements. Jan

8 2 Included ASC X12 Implementation Guides This table lists the X12N Implementation Guides for which specific transaction Instructions apply and which are included in Section 3 of this document. The associated ASC X12 TR3 s are available at Unique ID Name X223 Health Care Claim: Institutional (837) X223A2 Health Care Claim: Institutional (837) Errata Jan

9 3 Instruction Table This table contains one or more rows for each segment where supplemental instruction is needed. Legend SHADED rows represent segments in the X12N implementation guide. NON-SHADED rows represent data elements in the X12N implementation guide X223A2 Health Care Claim: Institutional (837) Page # Loop ID Reference Name s Length Notes/Comments 68 BHT Beginning of Hierarchical Transaction 69 BHT06 Transaction Type A NM1 Submitter Name CH RP Indiana Health Coverage Programs (IHCP) uses CH for fee-for-service (FFS) claims and RP for encounter claims A NM109 Identification IHCP assigned sender ID; the first character is alphabetic followed by three numeric characters A PRV Billing Provider Specialty Information A PRV03 Reference Identification IHCP may need the taxonomy code for a successful NPI to Legacy Provider Identifier (LPI) crosswalk. The crosswalk must successfully identify a unique billing provider for the claim to be accepted. Refer to NPI/LPI Crosswalk in Section AA N4 Billing Provider City, State, ZIP AA N403 Postal Refer to NPI/LPI Crosswalk in Section B SBR Subscriber Information B SBR09 Claim Filing Indicator BA NM1 Subscriber Name MC IHCP uses MC - Medicaid BA NM108 Identification Qualifier MI II IHCP Medicaid claims are coded with MI. IHCP Medical review team (MRT)/pre-admission screening resident review (PASRR) claims are Jan

10 coded with II BA NM109 Identification 12 IHCP member ID for Medicaid claims is 12 digits. The member ID for MRT/PASRR claims is 12 digits BB NM1 Payer Name BB NM103 Name Last or Organization Name BB NM109 Identification BB REF Billing Provider Secondary Identification BB REF01 Reference Identification Qualifier BB REF02 Reference Identification HP HP G2 LU IHCP uses HP for IHCP claims IHCP uses HP for IHCP claims IHCP atypical providers use this segment to send their Legacy Provider Identifier (LPI). Managed care entities (MCEs) submitting encounter claims must include their MCE ID and location code in a repeat of this segment. IHCP expects G2 to be used by atypical providers and LU to be used only by MCEs. 10 IHCP atypical provider identifiers are 10- characters long; nine-numeric and one alpha location code. MCE identifiers are 10-characters long; nine-numeric plus one alpha region code CLM Claim information The IHCP processes a maximum of 5000 CLM segments per ST-SE transaction set CLM01 Claim Submitter's Identifier CLM05-01 Facility Value CLM05-03 Claim Frequency Type CL1 Institutional Claim CL101 Admission Type CL103 Patient Status IHCP supports patient account numbers of up to 20-characters. Encounter claims must send the billing provider's patient account number in this element. IHCP uses 1 Original 7 Replacement 8 Void IHCP uses Admission Type s 1 Emergency 2 Urgent 3 Elective 4 Newborn 5 - Trauma 9 - Unspecified IHCP valid values and definitions are located in the IHCP PWK Claim IHCP ignores this segment if BHT06 = RP or if the Jan

11 Supplemental Information PWK02 Report Transmission PWK06 Identification CN1 Contract Information BM claim is a Medicare submitted crossover claim. IHCP only accepts required attachments by mail IHCP supports attachment control numbers of up to 30-characters IHCP uses this segment to identify an encounter claim from a network provider who has a capitated payment arrangement with an MCE. The IHCP expects to receive capitation indicator information at the claim level, not the service line level CN101 Contract Type 05 IHCP uses code 05 to indicate the provider has a capitated payment arrangement REF Medical Record Number REF02 Reference Identification IHCP recognizes the first 30 characters HI Diagnosis Related Group (DRG) Information HI01-02 Industry IHCP recognizes the first 4 characters HI Occurrence Span Information IHCP recognizes the first two characters of the occurrence code HI01-02 Industry IHCP recognizes the first two characters of the HI02-02 Industry IHCP recognizes the first two characters of the HI03-02 Industry IHCP recognizes the first two characters of the HI04-02 Industry IHCP recognizes the first two characters of the HI05-02 Industry IHCP recognizes the first two characters of the HI06-02 Industry IHCP recognizes the first two characters of the Jan

12 HI07-02 Industry IHCP recognizes the first two characters of the HI08-02 Industry IHCP recognizes the first two characters of the HI09-02 Industry IHCP recognizes the first two characters of the HI10-02 Industry IHCP recognizes the first two characters of the HI11-02 Industry IHCP recognizes the first two characters of the HI12-02 Industry IHCP recognizes the first two characters of the HI Occurrence Information IHCP recognizes the first eight occurrence codes HI01-02 Industry IHCP recognizes the first eight occurrence codes HI02-02 Industry IHCP recognizes the first eight occurrence codes HI03-02 Industry IHCP recognizes the first eight occurrence codes HI04-02 Industry IHCP recognizes the first eight occurrence codes HI05-02 Industry IHCP recognizes the first eight occurrence codes HI06-02 Industry IHCP recognizes the first eight occurrence codes HI07-02 Industry IHCP recognizes the first eight occurrence codes. Jan

13 HI08-02 Industry IHCP recognizes the first eight occurrence codes HI Value Information HI01-02 Industry HI02-02 Industry HI03-02 Industry HI04-02 Industry HI05-02 Industry HI06-02 Industry HI07-02 Industry HI08-02 Industry HI09-02 Industry HI10-02 Industry HI11-02 Industry HI12-02 Industry HI Condition Information IHCP maximum number of condition codes used for processing is seven HI01-02 Industry IHCP maximum number of condition codes used for processing is seven HI02-02 Industry IHCP maximum number of condition codes used for processing is seven HI03-02 Industry IHCP maximum number of condition codes used for processing is seven. Jan

14 HI04-02 Industry IHCP maximum number of condition codes used for processing is seven HI05-02 Industry IHCP maximum number of condition codes used for processing is seven HI06-02 Industry IHCP maximum number of condition codes used for processing is seven HI07-02 Industry IHCP maximum number of condition codes used for processing is seven SBR Other Subscriber Information SBR09 Claim Filing Indicator IHCP uses the Claim Filing Indicator to identify Medicare crossover claims. If the claim is a crossover, the Claim Filing Indicator must be set to MA -Medicare Part A CAS Claim Level Adjustments CAS04 Quantity IHCP maximum quantity processed is CAS07 Quantity IHCP maximum quantity processed is CAS10 Quantity IHCP maximum quantity processed is CAS13 Quantity IHCP maximum quantity processed is CAS16 Quantity IHCP maximum quantity processed is CAS19 Quantity IHCP maximum quantity processed is B NM1 Other Payer Name B NM109 Identification Claims submitted to Medicare that are expected to crossover to the IHCP, must include this segment and contain the payer ID assigned to the IHCP by Medicare. IHCP Medicare claims submitted by the provider must contain a valid Medicare Payer ID from the list found at provider-services/electronic-data-interchange- (edi)-solutions.aspx Jan

15 Claims submitted to Medicare, that are expected to crossover to the IHCP, must use the payer ID assigned to the IHCP by Medicare For HHW encounter claims, the payer identifier should be from this list: Managed Health Services (MHS) MDwise Anthem For HIP encounter claims, the payer identifier should be from this list: MDwise Anthem MHS ESP ACS Any other payers are identified as TPL B REF Other Payer Claim Control Number LX Service Line Number IHCP uses this segment for MCEs to send their ICN for encounter claims. IHCP processes a maximum of 450 LX segments for each claim SV2 Institutional Service Line SV Product/Service ID Qualifier HC IHCP processes claims with HC in this element SV205 Quantity IHCP maximum quantity processed is PWK Line Supplemental Information PWK02 Report Transmission PWK06 Identification CTP Drug Quantity BM IHCP only accepts required attachments by mail IHCP supports attachment control numbers of up to 30-characters CTP04 Quantity IHCP maximum quantity processed is CAS Line Adjustment CAS02 Claim Adjustment Reason Only Medicare deductible, coinsurance, and blood deductible adjustments are used by IHCP for crossover claim processing. 1 Deductible 2 Coinsurance 66 Blood Deductible Jan

16 CAS04 Quantity IHCP maximum quantity processed is CAS05 Claim Adjustment Reason Only Medicare deductible, coinsurance, and blood deductible adjustments are used by IHCP for crossover claim processing. 1 Deductible 2 Coinsurance 66 Blood Deductible CAS07 Quantity IHCP maximum quantity processed is CAS08 Claim Adjustment Reason Only Medicare deductible, coinsurance, and blood deductible adjustments are used by IHCP for crossover claim processing. 1 Deductible 2 Coinsurance 66 Blood Deductible CAS10 Quantity IHCP maximum quantity processed is CAS11 Claim Adjustment Reason Only Medicare deductible, coinsurance, and blood deductible adjustments are used by IHCP for crossover claim processing. 1 Deductible 2 Coinsurance 66 Blood Deductible CAS13 Quantity IHCP maximum quantity processed is CAS14 Claim Adjustment Reason Only Medicare deductible, coinsurance, and blood deductible adjustments are used by IHCP for crossover claim processing. 1 Deductible 2 Coinsurance 66 Blood Deductible CAS16 Quantity IHCP maximum quantity processed is CAS17 Claim Adjustment Reason Only Medicare deductible, coinsurance, and blood deductible adjustments are used by IHCP for crossover claim processing. 1 Deductible 2 Coinsurance 66 Blood Deductible CAS19 Quantity IHCP maximum quantity processed is C HL Patient Hierarchical Level The IHCP patient is always the subscriber Jan

17 4 TI Additional Information 4.1 Business Scenarios Not applicable 4.2 Payer Specific Business Rules and Limitations All references to the IHCP in this Companion Guide refer to Indiana Health Coverage Programs. All references to the IHCP provider number in this Companion Guide refer to the Indiana Health Coverage Programs Legacy Provider number (LPI) NPI/LPI Crosswalk Billing Provider The IHCP uses a crosswalk to establish a one-to-one match between the provider NPI and LPI. The crosswalk must successfully identify a unique billing provider LPI for the claim to be accepted and processed. Three data elements are used in the crosswalk to identify a unique billing provider LPI if the NPI is associated with multiple provider locations: NPI Loop 2010AA NM109 Taxonomy (if sent) Loop 2000A PRV03 Billing Provider Office Location ZIP Loop 2010AA N403 If the crosswalk does not establish a unique one-to-one match for the billing provider, the claim will reject during front end editing and be reported on the Submission Summary Report (SSR) Other Provider The IHCP uses a crosswalk to establish a one-to-one match between the provider NPI and LPI. The crosswalk must successfully identify a unique provider LPI. Two data elements are used in the crosswalk to identify a unique provider LPI if the NPI is associated with multiple provider locations: NPI Loop appropriate for applicable other provider NM109 Taxonomy Loop appropriate for applicable other payer PRV03 If the crosswalk does not establish a unique one-to-one match for the other provider, the claim will deny in IndianaAIM and be reported on the remittance advice. Jan

18 4.2.2 Submission Summary Report (SSR) The IHCP creates a Submission Summary Report (SSR) in response to all 837 submissions in addition to returning the 999 Acknowledgement. This report provides summary information about the results of pre-adjudication claim and encounter processing. The SSR also lists data to identify claims that receive HIPAA compliance rejection errors, IHCP specific rejection errors and compliance warning edits Processing Guidelines With the implementation of NPI, transactions must be submitted with the NPI for health care providers. Atypical providers may submit with either an NPI or LPI Negative quantities or amounts necessary for the adjudication of the claim are rejected All quantities have pre-adjudication edits. Refer to the appropriate segments for IHCP formats Other data elements with lengths greater than IHCP definitions are truncated The IHCP processes a maximum of 450 service lines, or details on the 837I transaction. Claims with details in excess of 450 are rejected by a compliance error Interchange Control Header Interchange Sender ID (ISA06) This is the four-byte sender ID assigned by the IHCP Interchange Receiver ID (ISA08) Required value is IHCP Functional Group Header Application Sender (GS02) This is the four-byte sender ID assigned by the IHCP Application Receiver s (GS03) Required value is IHCP Fee-for-service Claims Replacement requests submitted before 3 p.m. during a normal business day may take up to one business day to process. The primary reason this may occur is that the original claim has already been through a financial cycle. Jan

19 The provider ID and service location information must be identical on a replacement as it appears on the claim that is being replaced The provider NPI must crosswalk to the same IHCP LPI that appears on the claim being replaced A replacement cannot be older than one year from the last activity that took place on the claim being replaced A replacement request cannot be performed against a denied claim due to a previous void request The provider ID, service location and recipient information must be identical on a void as it appears on the claim that is being voided The provider NPI must crosswalk to the same IHCP LPI that appears on the claim being voided A void cannot be processed against a claim that was denied in IndianaAIM The type of claim on a replacement or void must be the same type on the claim being replaced or voided A replacement or void must be made against the most recent occurrence of the claim A replacement or void must be made against an IHCP claim that is found in the IndianaAIM database Encounter Claims The billing provider patient account number must be sent in Loop 2300 CLM The MCE ICN must be sent in Loop 2330B REF02 Other Payer Claim Control Number The MCE ID, provider ID, state region and recipient information must be identical on a replacement or void as it appears on the claim being replaced or voided The type of claim on a replacement or void must be the same type on the claim being replaced or voided A replacement or void cannot be older than two years from the dates of service on the claim being replaced or voided A replacement or void must be made against the most recent occurrence of the claim. Jan

20 A replacement or void must be made against an IHCP claim that is found in the IndianaAIM database A void cannot be processed against a claim that was denied in IndianaAIM A replacement request cannot be performed against a denied claim due to a previous void request Coordination of Benefits (COB) Assumptions Non-Medicare third party liability (TPL) is only reported at the claim level Medicare paid amounts, deductible, coinsurance and blood deductible amounts must be reported at the service line level. 4.3 Frequently Asked Questions Not applicable 4.4 Other Resources This section lists other references or resources. HP EDI Solutions 950 North Meridian Street, Suite 1150 Indianapolis, IN Fax: (317) INXIXTradingPartner@hp.com Indiana Medicaid for Providers website Electronic Data Interchange (EDI) Solutions IHCP News, Bulletins and Banner pages Jan

21 5 TI Change Summary This section describes the differences between the current Companion Guide and previous guide(s). Version CO Revision Date Revision Page Numbers Revision Reason Completed by 2.0 Jan 2013 New CAQH CORE format Systems Jan 2014 Update CO 2145 Update Systems Jan