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: Dental (837) Companion Guide Version Number: 3.3 Revision Date: April 2017 April D 3.3 1

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 DXC Technology April D 3.3 2

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. April D 3.3 3

4 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/IHCP Provider Identifier Crosswalk 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 April D 3.3 4

5 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. April D 3.3 5

6 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. April D 3.3 6

7 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 TR3s are available at Unique ID Name X224 Health Care Claim: Dental (837) X224A2 Health Care Claim: Dental (837) Errata April D 3.3 7

8 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 X224A2 Health Care Claim: Dental (837) Page # Loop ID Reference Name s Length Notes/Comments 66 BHT Beginning of Hierarchical Transaction 67 BHT06 Transaction Type A NM1 Submitter Name A NM109 CH RP Indiana Health Coverage Programs (IHCP) uses CH for fee-for-service (FFS) claim and RP for encounter claims IHCP assigned sender ID; the first character is alphabetic followed by three numeric characters A PRV Billing Provider Specialty Information A PRV03 Reference IHCP may need the taxonomy code for a successful NPI to IHCP Provider Identifier crosswalk. The crosswalk must successfully identify a unique billing. Refer to NPI/IHCP Provider Identifier Crosswalk in Section AA N4 Billing Provider City, State, ZIP AA N403 Postal Refer to NPI/IHCP Provider Identifier Crosswalk in Section B SBR Subscriber Information B SBR09 Claim Filing MC IHCP uses MC Medicaid April D 3.3 8

9 Indicator BA NM1 Subscriber Name BA NM108 Qualifier BA NM BB NM1 Payer Name BB NM103 Name Last or Organization Name BB NM BB REF Billing Provider Secondary BB REF01 Reference Qualifier BB REF02 Reference MI HP HP G2 LU IHCP Medicaid claims are coded with MI 12 IHCP member ID for Medicaid claims is 12 digits For HIP Link Claims, the member ID must be prefixed with an L i.e. L IHCP uses HP for IHCP claims IHCP uses HP for IHCP claims IHCP atypical providers use this segment to send their IHCP Provider Identifier. 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. MCE identifiers are 10-characters long; ninenumeric plus one alpha region code CLM Claim Information The IHCP recommends 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 PWK Claim Supplemental Information Encounter claims must send the billing provider s patient account number in this element. IHCP valid values are located in the IHCP Provider Manual IHCP uses 1 Original 7 Replacement 8 Void April D 3.3 9

10 PWK02 Report Transmission PWK CN1 Contract Information CN101 Contract Type REF Service Authorization Exception BM 05 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. IHCP uses code 05 to indicate the provider has a capitated payment arrangement REF02 Reference 3 IHCP only recognizes value 3 - Emergency Care NTE Claim Note For HIP Link claims, other payer allowed amount is required NTE01 Note Reference ADD 3 HIP Link Claims Other Payer Allowed Amount, required for HIP Link claims valid code for 837D is ADD (Additional Information) NTE02 Description 80 HIP Link Claims Other Payer Allowed Amount reported in this data element, required for HIP Link claims i.e B PRV Rendering Provider Specialty Information B PRV03 Reference B REF Rendering Provider Secondary B REF02 Reference IHCP may need the taxonomy code for a successful NPI to IHCP Provider ID crosswalk. The crosswalk must successfully identify a unique IHCP rendering provider ID. Refer to NPI/IHCP Provider Identifier Crosswalk in Section IHCP uses this segment to identify the IHCP IHCP Provider Identifier of an atypical rendering provider. 10 IHCP atypical rendering provider identifiers are 10 characters long CAS Claim Level April D

11 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 For HHW encounter claims, the payer identifier should be from this list: MHS MDwise Anthem CareSource For HIP encounter claims, the payer identifier should be from this list: MDwise Anthem MHS CareSource ESP ACS For HCC encounter claims, the payer identifier should be from this list: MHS Anthem MDwise B REF Other Payer IHCP uses this segment for MCEs to send their April D

12 Claim Control Number LX Service Line Number ICN for encounter claims. IHCP processes a maximum of 50 LX segments for each claim SV3 Dental Service SV303 Facility Value IHCP valid values are located in the IHCP Provider Manual SV306 Quantity IHCP maximum quantity processed is A REF Rendering Provider Secondary A REF02 Reference IHCP uses this segment to identify the IHCP Provider Identifier of an atypical rendering provider. 10 IHCP atypical rendering provider identifiers are 10 characters long CAS Line Adjustment 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 C HL Patient Hierarchical Level The IHCP patient is always the subscriber. April D

13 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 Provider Identifier (IHCP Provider ID) NPI/IHCP Provider Identifier Crosswalk Billing Provider The IHCP uses a crosswalk to establish a one-to-one match between the provider NPI and IHCP Provider ID. The crosswalk must successfully identify a unique IHCP billing provider ID. The IHCP billing provider ID must represent an active provider. Three data elements are used in the crosswalk to identify a unique IHCP billing provider ID 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 deny in claims processing. A 277U response will be sent back to the Trading Partner who submitted the claim file reporting an error with the billing provider. See the IHCP 277U Companion Guide for more information Other Provider The IHCP uses a crosswalk to establish a one-to-one match between the provider NPI and IHCP Provider ID. The crosswalk must successfully identify a unique IHCP provider ID. Two data elements are used in the crosswalk to identify a unique IHCP provider ID if the NPI is associated with multiple provider locations: NPI Loop appropriate for applicable other provider NM109 April D

14 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 and be reported on the remittance advice 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 IHCP Provider Identifier 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 50 service lines, or details on the 837D transaction. Claims with details in excess of 50 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 IHCP expects only one iteration of the functional group control segment (GS/GE) 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. April D

15 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 Provider ID 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 Provider ID that appears on the claim being voided A void cannot be processed against a claim that was previously denied 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 Indiana CoreMMIS 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. April D

16 A replacement or void must be made against an IHCP claim that is found in the Indiana CoreMMIS database A void cannot be processed against a claim that was denied in Indiana CoreMMIS A replacement request cannot be performed against a denied claim due to a previous void request Coordination of Benefits (COB) Assumptions Third party liability (TPL) is only reported at the claim level. 4.3 Frequently Asked Questions Not applicable 4.4 Other Resources This section lists other references or resources. DXC EDI Solutions 950 North Meridian Street, Suite 1150 Indianapolis, IN Fax: (317) INXIXTradingPartner@hpe.com Indiana Medicaid for Providers website Electronic Data Interchange (EDI) Solutions IHCP Provider Manual News, Bulletins and Banner pages April D

17 5 TI Change Summary This section describes the differences between the current Companion Guide and previous guide(s). AIM Change Summary Version CO CO Name Revision Revision Revision Page Numbers / Change / Update Details Completed by Date Status 2.0 Jan 2013 Implemented CAQH CORE format HIP2.0 RII April 2015 Implemented Pg. 10 Added HIP MCE IDs for HIP D submissions HIP2.0 RII April 2015 Implemented Pg. 14 Added to TI Additional Information for Encounter Claims HCC RII April 2015 Implemented Pg. 8 Added RP as a transaction type in BHT06 for Encounter Claims Pg. 10 Added HCC MCE IDs for Hoosier Care Connect (HCC) HIP LINK R2 August 2015 Implemented Pg. 8-9: Loop 2010BA NM109 Added information for HIP Link Claims: For HIP Link Claims, the member ID must be prefixed with an L Pg. 9: Loop 2300 NTE01 Added HIP Link Claims Other Payer Allowed Amount uses TPO Third Party Organization Notes Pg. 9: Loop 2300 NTE02 Added HIP Link Claims Other Payer Allowed Amount reported in this data element CoreMMIS Change Summary Version CO CO Name Revision Revision Revision Page Numbers / Change / Update Details Completed by Date Status HPE Rebranding - EDI Forms Mar Implemented Throughout document - Changed Hewlett Packard (HP) to Hewlett Packard Enterprise (HPE). Correction Apr Implemented Pg. 13 Added bullet IHCP expects only one iteration of the functional group control segment. CR CareSource MCE Onboarding Oct Implemented Pg. 11: Loop 2330B NM109 - Added CareSource HIP encounter claims payer identifier Pg. 12: Revised bullet , claim will deny in claims processing if a one-to-one match for billing provider is not established, this will no longer be reported on a Submission Summary Report. Pg. 13: Removed bullet "4.2.2 Submission Summary Report (SSR)" 3.0 Dec Implemented Indiana CoreMMIS Implementation 3.1 Jan Implemented Pg. 11: Loop2330B NM109 Added HHW encounter claims payer identifiers Pg.9 Loop2300 CLM01 - Removed 'IHCP supports April D

18 patient account numbers of up to 20-characters.' IHCP now supports Implementation Guide standard maximum length. 3.2 Feb 2017 Implemented Pg. 11 Loop2330B NM109 Removed reference to Medicare Payer ID validation. The Medicare Payer ID will no longer be validated. 3.3 April 2017 Implemented Updated throughout document Hewlett Packard Enterprise (HPE) to DXC Technology April D