835 Payment Advice NPI Dual Receipt

Transcription

1 Chapter 5 NPI Dual Receipt This Companion Document explains the from Anthem Blue Cross and Blue Shield (Anthem) during the 835 National Provider Identifier (NPI) Dual Receipt period. The ANSI ASC X12N, which is produced weekly, provides information for the payee regarding claims in their final status. The 835 includes information about the payee, the payer, the amount, and any payment identifying information. For each provider, the 835 presents claims by patient name (last name, first name) in alphabetical order. Use the charts in this chapter for information about any dated within the following time period: December 19, 2006 through May 22, 2007 During this period, if we have your NPI in our files, your 835 will include your NPI, tax ID, and legacy ID (Anthem Provider Number). If we do not have your NPI in our files, the 835 will include the tax ID and legacy provider number. The charts in this Companion Document apply to all trading partners including those eligible for an NPI and those who are exempt from the NPI (such as taxi services, home modifications, vehicle modifications, insect control, and respite services). For the 835 NPI Dual Receipt period, this chapter includes charts to explain the 835 segments and data elements that we use. Use this Companion Document in conjunction with the 835 Implementation Guide (IG). The charts provide information that is specific to Anthem. The information is supplemental and does not modify or add to information in the 835 Implementation Guides. Beginning May 23, 2007 Will Report NPI (Not Legacy) Numbers Only See Part II, Chapter 4, On May 23, 2007, the Dual Receipt period will be over, and you must use the NPI only in your 837 Claims you may no longer submit the legacy number (Anthem Provider Number) and Anthem must use your NPI on the 835. On that date, the Anthem Dual Receipt period will end, and we will remove Part III of the Companion Guide from our web site. Two Types of 835s and Blue 835 If you submit 837 electronic claims, you may elect to receive two different types of the 835 the and the Blue. The represents claims adjudicated by Anthem in Virginia. The Blue 835 represents Medicare Crossover and supplemental claims adjudicated by another Blue Cross Blue Shield Plan. Unless otherwise specified, references to the refer to both 835 types. Electronic Funds Transfer (EFT) Trading partners who submit 837 electronic claims are eligible to receive the 835 Payment Advice and payment by electronic funds transfer (EFT). In order to receive EFT, you must also receive the. In other words, you may receive both EFT and the 835, but may not receive EFT without the 835. One 835 transaction can serve as the single payment device for multiple claims. CG Release 4.0 (July 2006) Part III: 5-1 Anthem, Virginia

2 835s in Response to Paper Claims If a trading partner who receives an electronic remittance submits a paper claim, we still generate a compliant 835 transaction with required elements. The resulting 835, however, will not be as complete as an 835 resulting from an electronic claim. For example, we will not return corrected segments for insured name, insured identification number and the originally submitted procedure codes. Therefore, if you file on paper only, but receive the 835, you must obtain an NPI as soon as possible. NPI Data Elements The following 835 data elements were modified for 835 NPI Dual Receipt. These data elements are also included within the chart in this Companion Document. Segment 835 Data Elements Related to NPI Data Element Values for 835s Dated 12/19/06 through 05/22/07 NPI Is Not on File, or NPI Is on file: Exempt from NPI: 1000B Payee Identification N1 Payee Name N103 Identification FI Federal Taxpayer s XX NPI N104 Payee Identification (Tax ID Number) (NPI) Payee Additional Information In one occurrence: PQ Payee Identification TJ Federal Taxpayer s (Anthem Provider Number) (Tax ID Number) Additional Payee Identifier In another occurrence: Not Applicable PQ Payee Identification Not Applicable (Anthem Provider Number) Additional Payee Identifier 2100 Claim Payment Information NM1 Service Provider NM108 Identification FI Federal Taxpayer s XX NPI Name NM109 Identification (Tax ID Number) (NPI) Rendering Provider Identification Summary Level PLB Provider Adjustment Rendering Provider Secondary Identifier PLB01 Provider Identifier 1A Blue Cross Provider Number 1B Blue Shield Provider Number (Anthem Provider Number) (Anthem Provider Number) Not Applicable Not Applicable (NPI) This Companion Document consists of one section: Section Title Page 5.1 Charts 5-3 CG Release 4.0 (July 2006) Part III: 5-2 Anthem, Virginia

3 5.1 Charts During the 835 NPI Dual Receipt period (affecting 835s dated December 19, 2006 through May 22, 2007), use the instructions in this section for information on 835 data elements used by Anthem. Use this Companion Document in conjunction with the 835 Implementation Guide (IG). The charts in this section provide information that is specific to Anthem. The information is supplemental and does not modify or add to information in the 835 Implementation Guides. The 835 transaction set is divided into three levels as follows: The Header contains general payment information, such as amount, payee, payer, trace number, and payment method. The Detail contains the Explanation of Benefits (EOB) information related to adjudicated claims and services. The Summary contains the Provider Level Adjustment Segment, PLB, which provides information related to adjustments to the payment amount not specific to the Detail level. These adjustments can increase or decrease the actual payment. Unlike the transaction charts for other Companion Documents, the transaction charts in this section document each 835 data element we use. Other Companion Documents document only those data elements that require specific information for Anthem. This 835 Companion Document provides information for each data element because we anticipate that you may use this Companion Document as a resource to program financial systems Header Header The 835 Header level contains general payment information, such as paid amount, payee, payer, trace number, and payment method. Data Elements Affected by NPI Dual Receipt We updated the following 835 Header data elements for the 835 Dual Receipt period: 1000B N103 (ID ) and N104 (Payee ID ) 1000B (Reference ID ) and (Additional Payee Identifier) The following chart explains the header segments and data elements that require specific information for Anthem. ST Transaction Set Header (ST) Page 43 ST01 Transaction Set Identifier ST02 Transaction Set Control Number 835 Health Care Claim Payment/Advice (Value assigned by Anthem) BPR Financial Information Page 44 BPR01 Transaction Handling BPR02 Total Actual Provider Payment Amount BPR03 Credit/Debit Flag BPR04 Payment Method BPR16 Check Issue or EFT Effective Date I Remittance information only. Remittance detail is moving separately from the payment. H Notification Only (Amount Paid) C Credit to the provider s account CHK A check has been issued for payment NON Non-Payment Data (Check Issue Date) The amount may equal zero (0) or above. The amount may not equal less than zero (0). The value equals the remittance date used by Anthem. CG Release 4.0 (July 2006) Part III: 5-3 Anthem, Virginia

4 (Continued) Header TRN Reassociation Trace Number Page 52 Receiver Identification Page 57 DTM Production Date Page 60 When the 835 does not convey with dollar information, the TRN segment provides a trace number to reassociate the dollars and the remittance data. TRN01 Trace Type TRN02 Check or EFT Trace Number TRN03 Payer Identifier Receiver Identifier DTM01 Date/Time DTM02 Production Date Loop 1000A Payer Identification N1 Payer Name Page 62 N3 Payer Address Page 64 N4 Payer City, State, Zip Page 65 N101 Entity Identifier N102 Payer Name N301 Payer Address N401 Payer City Name N402 Payer State N403 Payer Zip Loop 1000B Payee Identification N1 Payee Name Page 72 N101 Entity Identifier N102 Payee Name N103 Identification N104 Payee Identification 1 Current Transaction Trace Number The value equals either the: (Check number) if the provider receives paper check, or (Advice Number) if the provider receives an EFT If BPR02 equals $0.00, this value will equal NO PAYMENT The value is Anthem s tax ID number preceded by 1. EV Receiver Identification Number (Trading Partner ID) EV displays if the receiver of the 835 is other than the payee. (For example, EV displays when the provider uses a clearinghouse or billing service). Anthem assigns the Trading Partner ID. Format: TNVxxx ( xxx is a 3-byte alphanumeric.) indicates the end date for the adjudication production cycle for claims included in this 835. (CCYYMMDD) The value indicates the processing date. PR Payer ANTHEM HEALTH PLANS OF VIRGINIA, INC. POST OFFICE BOX This value indicates Anthem s post office box. RICHMOND This value indicates the city for Anthem. VA This value indicates the state for Anthem This value indicates the zip code for Anthem. PE Payee (Provider Name) XX NPI FI Federal Taxpayer s (NPI) (Provider s Federal Tax ID Number) CG Release 4.0 (July 2006) Part III: 5-4 Anthem, Virginia

5 (Continued) Header In one occurrence: Payee Additional Identification TJ Federal Taxpayer s Page 77 Additional Payee Identifier PQ Payee Identification (Federal Taxpayer s ) This value is preceded by leading zeros to fill the 13 bytes allocated by Anthem. In another occurrence: Additional Payee Identifier (Anthem Provider Number) PQ Payee Identification Not Applicable (Anthem Provider Number) Not Applicable This value is preceded by leading zeros to fill the 13 bytes allocated by Anthem. CG Release 4.0 (July 2006) Part III: 5-5 Anthem, Virginia

6 5.1.2 Detail Table 2: Detail The 835 Detail level contains the Explanation of Benefits (EOB) information related to adjudicated claims and services. Data Elements Affected by NPI Dual Receipt We updated the following 835 Header data elements for the 835 Dual Receipt period: 2100 NM108 (ID ) and NM109 (ID ) 2100 (Reference ID ) and (Rendering Provider Secondary Identifier) The following chart explains the 835 Detail segments and data elements that require specific information for Anthem. Loop 2000 Header Number LX LX01 Assigned (Assigned Number) This value equals the sequential count on Header Number Number number of claims within the 835 transaction. Page 79 Loop 2100 Claim Payment Information CLP CLP01 Patient (Patient Account Number) Control Number Claim Payment Information Page 89 CLP02 Claim Status CLP03 Total Claim Charge Amount CLP04 Claim Payment Amount CLP05 Patient Responsibility Amount CLP06 Claim Filing Indicator CLP07 Payer Claim Control Number CLP08 Facility Type CLP09 Frequency 1 Claim processed as Primary 2 Claim processed as Secondary 3 Claim processed as Tertiary 4 Denied 22 Reversal of previous payment (Total charged amount from the original claim) (Amount Anthem paid on the claim) (Patient Liability Amount) 12 PPO 13 Point of Service 15 Non-participating provider HM HMO MC Medicaid MA Medicare Advantage (Part A) MB Medicare Advantage (Part B) (Internal claim number assigned by Anthem) (Facility Type First and second position of the Uniform Bill Type. Identifies the type of facility) (Claim Frequency Third position of the Uniform Bill Type ) The 835 from Anthem will include a maximum length of 20 characters. This data element applies only to institutional claims. This data element applies only to institutional claims. When receiving an 837 with adjusted bill type code (3 rd position = 5, 7, or 8) we treat that transaction as an inquiry/151. Therefore, the 835 will not reflect these adjustment bill type codes. CLP11 DRG (DRG ) This value equals the DRG (Diagnosis Related Group) code for FEP and Health- Keepers Plus (HMO Medicaid) claims. CLP12 DRG Weight (DRG Weight) CLP13 Discharge Fraction (DRG Discharge Fraction) This data element applies only to institutional claims. FEP and HealthKeepers Plus (HMO Medicaid) will send this weight. This data element applies only to institutional claims. FEP will send this fraction. CG Release 4.0 (July 2006) Part III: 5-6 Anthem, Virginia

7 (Continued) Detail (Continued) Loop 2100 Claim Payment Information CAS Claims Adjustment Page 95 This segment is only used if the Paid Amount is greater than the Charge Amount. CAS01 Claim Adjustment Group CO Contractual Obligations (Provider write-off) CR: Corrections and Reversals (Adjustments) OA: Other Adjustments (Bundled Lines, Non-Covered Charges) PR: Patient Responsibility (Copayment or Deductible) CAS02 Claim Adjustment Reason CAS03 Adjustment Amount (Claim Adjustment Reason ) (Dollar Amount of an Adjustment) Adjustment Reason s indicate the reason an adjustment was made to a claim. For the Adjustment Reason s go to The value indicates the dollar amount of the adjustment. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. NM1 Patient and Insured Name and Information Page 102 CAS05- CAS06 CAS08- CAS09 CAS11- CAS12 CAS14- CAS15 CAS17- CAS18 NM101 Entity Identifier NM102 Entity Type NM103 Patient Last Name NM104 Patient First Name NM105 Patient Middle Name QC Patient 1 Person (Patient s Last Name) (Patient s First Name) (Patient s Middle Name) NM108 Identification MI Member NM109 Patient Identifier (Member ) CG Release 4.0 (July 2006) Part III: 5-7 Anthem, Virginia

8 (Continued) Detail (Continued) Loop 2100 Claim Payment Information NM1 Insured Name Page 105 NM1 Corrected Patient/Insured Name Page 108 NM1 Service Provider Name Page 111 NM101 Entity Identifier NM102 Entity Type NM103 Subscriber Last Name NM104 Subscriber First Name NM105 Subscriber Middle Name NM108 Identification NM109 Patient Identifier NM101 Entity Identifier NM102 Entity Type NM103 Corrected Patient or Insured Last Name NM104 Corrected Patient or Insured First Name NM105 Corrected Patient or Insured Middle Name NM108 Identification NM109 Corrected Insured ID Number NM101 Entity Identifier NM102 Entity Type NM103 Rendering Provider Last or Organization Name NM104 Rendering Provider First Name NM108 Identification NM109 Identification IL Insured 1 Person (Insured s Last Name) (Insured s First Name) (Insured s Middle Name) MI Member (Member ) 74 Corrected Insured 1 Person (Corrected Insured s Last Name) (Corrected Insured s First Name) (Corrected Insured s Middle Name) C Corrected Insured (Corrected Insured ID Number) 82 Rendering Provider 1 Person (Rendering Provider Last Name) (Rendering Provider First Name) XX NPI you are exempt from NPI: FI Federal Taxpayer s (NPI) you are exempt from NPI: (Federal Tax ID Number) CG Release 4.0 (July 2006) Part III: 5-8 Anthem, Virginia

9 (Continued) Detail (Continued) Loop 2100 Claim Payment Information Other Claim Related Identification Page 126 Other Claim Related Identifier IL Group Policy Number BB Authorization Number (Group Number) (Precertification Number): For Inpatient Claims (Preauthorization Number): For Medical Claims Rendering Provider Identification Page 128 Rendering Provider Secondary Identifier Not used you are exempt from NPI: 1A Blue Cross Provider Number 1B Blue Shield Provider Number Not used you are exempt from NPI: (Anthem Provider Number) For NPI not on file or NPI exemption, this data element is populated when the provider number is different from the servicing provider number. When populated, this value is preceded by leading zeros to fill the 13 bytes allocated by Anthem. DTM Claim Date DTM01 Date/Time 050 The date the claim was received by Anthem Page 130 DTM02 Date (Claim Date) (Date claim was received) PER Claim Contact Information Page 132 We do not use this segment. Call Provider Services for remittance inquiries Anthem Group Business Richmond...(804) Toll Free...(800) Federal Employee Program, Personal Health Care, or Medicare Extended Toll Free...(800) HealthKeepers, Inc. Richmond...(804) Toll Free...(800) Anthem HealthKeepers Plus...(800) (Including FAMIS) Peninsula Health Care, Inc. Toll Free...(800) Anthem HealthKeepers Plus...(800) (Including FAMIS) Priority Health Care, Inc. Tidewater Area...(757) Toll Free...(800) Anthem HealthKeepers Plus...(800) FAMIS...(800) CG Release 4.0 (July 2006) Part III: 5-9 Anthem, Virginia

10 (Continued) Detail Loop 2110 Service Payment Information SVC Service Payment Information SVC01 Composite Medical Procedure Identifier See SVC06-1 through SVC06-7 Page 139 SVC01-1 Product or Service ID AD: American Dental Association s HC: Health Care Financing Administration Common Procedural Coding System s (HCPCS) NU: National Uniform Billing Committee s (NUBC) This value qualifies the values in SVC06-2 through SVC06-6. SVC01-2 Procedure/Service ID (Procedure ) SVC01-3 SVC01-4 SVC01-5 SVC01-6 SVC02 Charge Amount (Total Charge Amount) SVC03 Provider Payment Amount (Tentative Payment Amount) for Facility Claims (Payment Amount) for Medical Claims SVC04 National Uniform Billing Committee Revenue SVC05 Units of Service Paid Count (UB92 Revenue ) This value is included when an NUBC revenue code was considered in addition to a procedure code identified in SVC01. If the original claim and adjudication only referenced an NUBC revenue code, that code is entered in SVC01 and this element is not used. # # represents the number of units of service paid. CG Release 4.0 (July 2006) Part III: 5-10 Anthem, Virginia

11 (Continued) Detail (Continued) Loop 2110 Service Payment Information (Continued) SVC Service Payment Information Page 139 DTM Service Date Page 146 SVC06 Composite Medical Procedure Identifier SVC06-1 Product/ Service ID SVC06-2 Procedure/ Service ID SVC06-3 SVC06-4 SVC06-5 SVC06-6 SVC07 Original Units of Service Count DTM01 Date/Time DTM02 Service Date See SVC06-1 through SVC06-7 AD American Dental Association s HC Health Care Financing Administration Common Procedural Coding System s (HCPCS) ID NU International Classification of Diseases Clinical Modification (ICD-9-CM) Procedures National Uniform Billing committee (NUBC) UB92 s (Procedure ) Data elements SVC06-1 through SVC06-6 are included as applicable in the following circumstances: The adjudication procedure code in SVC01 is different from the submitted procedure code on the original claim. As needed to reference originally submitted procedures on a bundled claim. As needed to reference an Anthem Medical Policy change. This segment is used to reference the originally submitted Product/Service ID. # This data element appears only if the value for paid units of service in SVC05 is different from the submitted units of service. This data element is not used when the submitted and paid units are the same. 150 Service Period Start For claim lines with Start and End dates, two repetitions of DTM01 and DTM02 display, one for 150 (Start) and one for 151 (End). For claim lines with a single date of service: This segment will not repeat. 472 (Service) will display in DTM01. (CCYYMMDD) For claim lines with Start and End dates: Two repetitions of DTM01 and DTM02 display, one for 150 (Start) and the other for 151 (End). DTM02 repetition corresponding with DTM01=150 will equal Service Period Start date. DTM02 repetition corresponding with DTM01=151 will equal Service Period End date. When DTM01=472 (Service): This segment will not repeat. The Service Date will display in DTM02. CG Release 4.0 (July 2006) Part III: 5-11 Anthem, Virginia

12 (Continued) Detail (Continued) Loop 2110 Service Payment Information CAS Claims Adjustment CAS01 Claim Adjustment Page 148 Group This segment is used for adjustments. CO Contractual Obligations (Provider write-off) CR: Corrections and Reversals (Adjustments) OA: Other Adjustments (Bundled Lines, Non- Covered Charges) PR: Patient Responsibility (Copayment or Deductible) CAS02 Claim Adjustment Reason CAS03 Adjustment Amount (Claim Adjustment Reason ) (Dollar Amount of an Adjustment) Adjustment Reason s indicate the reason an adjustment was made to a claim. For the Adjustment Reason s go to The value indicates the dollar amount of the adjustment. A negative amount increases the payment, and a positive amount decreases the payment contained in CLP04. Service Identification Page 154 CAS05- CAS06 CAS08- CAS09 CAS11- CAS12 CAS14- CAS15 CAS17- CAS18 Provider Identifier 6R Provider Control Number (Line Item Control Number) AMT Service Supplemental Amount Page 158 AMT01 Amount AMT02 Service Supplemental Amount B6 Allowed-Actual (Service Supplemental Amount) This segment is used to convey information only. It is not part of the financial balancing of the 835. Use this segment only when values of specific amounts identified by the AMT01 qualifier are non zero. LQ Health Care Remark s Page 162 LQ01 List LQ02 Remark HE Claim Payment Remark s (Remittance Remark See Source 411 referenced in the ) The 835 may include up to five codes per line. This data element is not applicable for Federal Employee Program (FEP) claims. The for FEP claims will include (as necessary) Adjustment Reason s (CAS segment) and will not include additional Remark s in this segment. CG Release 4.0 (July 2006) Part III: 5-12 Anthem, Virginia

13 Table 3: Payment Advice Summary Level The Summary level contains the Provider Level Adjustment Segment, PLB, which provides information related to adjustments to the payment amount not specific to the Detail level. These adjustments can increase or decrease the actual payment. Data Element Affected by NPI Dual Receipt We updated the following 835 Summary Level data element for the 835 Dual Receipt period: PLB01 (Provider Identifier) The following chart explains the 835 summary segments and data elements that require specific information for Anthem. Summary Level PLB Segment Provider Adjustment Page 164 If the previous week s balance was negative or positive and a partial or full recovery was applied the adjustment occurs in this segment. PLB01 Provider Identifier PLB02 Fiscal Period Date (Anthem Provider Number) (NPI) (Last date of current year) This date is the last day of the current year. For example, for any date during the year 2005, PLB02 would be populated with PLB03-1 Adjustment Reason PLB04 Adjustment Amount FB Forwarding Balance (Recovery) IR Internal Revenue Service Withholding PI Uniform Periodic Payment (UPP Provider) (Adjustment Amount) See the PLB04 Adjustment Amount Explanation chart below. If the monetary amount for: the previous week s balance was negative less than zero (0) PLB04 Adjustment Amount Explanation and then, then, the adjustment or recovery amount in PLB04 is: a partial or full recovery was applied greater than zero (0) and displays as a negative amount. this week s claims is positive greater than zero (0) recovery was applied to a prior recovery balance this week s remittance amount is negative the recovery amount is added to the outstanding recovery balance and less than zero (0) and displays as a positive amount. CG Release 4.0 (July 2006) Part III: 5-13 Anthem, Virginia