EyeMed Vision Care. HEALTH CARE CLAIM: PROFESSIONAL Companion Document to ASC X12N 837 (004010X098A1)

Transcription

1 HEALTH CARE CLAIM: PROFEIONAL Companion Document to AC X12N 837 (004010X098A1) Welcome to EyeMed Vision Care s HIPAA TC implementation process. We have developed this guide to assist you in preparing to trade HIPAA 837 Professional Claim transactions with us. This Companion Guide to the AC X12N 837 Implementation Guide adopted under HIPAA clarifies and specifies the data content for data that is electronically transmitted to EyeMed. Transmissions based on this Companion Guide, used in tandem with the X12N Implementation Guide, are compliant with both X12 syntax and the HIPAA Implementation Guide. This Companion Guide is intended to convey information that is within the framework of the AC X12N Implementation Guide adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the HIPAA Implementation Guide. This document is to be used as a companion to the HIPAA Implementation Guide for trading enrollment transactions with EyeMed Vision Care. The first section describes the loops and segments EyeMed will capture, along with specific data element requirements and guidelines. The second section describes the situational loops, segments, and data elements that EyeMed will not be capturing; therefore, you are not required to include these when you trade with us. We look forward to testing with you and establishing an effective trading relationship. 2003, EyeMed Vision Care 1 Version 01, 06/12/2003

2 Pg# eg DE Req PIC Min Max 837 Health Care Claim ubmission Use Description X12 Codes X12 Code Definition Values Notes INTERCHANGE CONTROL HEADER TABLE 1 HEADER IA M R INTERCHANGE CONTROL HEADER G M R FUNCTIONAL GROUP HEADER 62 T M 1/1 R TRANACTION ET HEADER 63 BHT M 1/1 R BEGINNING OF HIERARCHICAL TRANACTION LOOP 2010 AA R BILLING PROVIDER NAME 84 NM1 O 1/1 R BILLING PROVIDER NAME LOOP 2010 AB PAY-TO PROVIDER NAME 99 NM1 O 0/1 PAY-TO PROVIDER NAME LOOP 2000 B R UBCRIBER HIERARCHICAL LEVEL 110 BR O 1/1 R UBCRIBER INFORMATION BR O AN 1/30 Insured Group or Policy Number Known as Group Code or Plan ID provided by EyeMed LOOP 2010 BA BR04 93 O AN 1/60 Insured Group Name Known as Plan Name R UBCRIBER NAME 117 NM1 O 1/1 R UBCRIBER NAME NM X ID 1/2 Identification Code Qualifier MI Use Member Identification Number LOOP 2000 C PATIENT HIERARCHICAL LEVEL 154 PAT O 1/1 R PATIENT INFORMATION LOOP 2010 CA R PATIENT NAME 157 NM1 O 1/1 R PATIENT NAME NM X ID 1/2 Identification Code Qualifier MI Use Member Identification Number 161 N3 O 1/1 R PATIENT ADDRE 162 N4 O 1/1 R PATIENT CITY/TATE/ZIP CODE N O ID 3/15 R Postal Code EyeMed will pick up the first 5 positions of "Postal Code". 164 DMG O 1/1 R PATIENT DEMOGRAPHIC INFORMATION 166 REF O 0/1 PATIENT ECONDARY IDENTIFICATION REF M ID 2/3 R Reference Identification Qualifier LOOP 2300 R CLAIM INFORMATION 166 CLM O 1/1 R CLAIM INFORMATION CLM M AN 1/2 R Facility Type Code 200 DTP O 0/1 DATE - HEARING AND VIION PRECRIPTION DATE 182 DTP O 0/1 DATE - INITIAL TREATMENT 180 DTP O 0/1 DATE - ORDER DATE 220 AMT O 0/1 PATIENT AMOUNT PAID 227 REF O 0/1 PRIOR AUTHORIZATION OR REFERRAL NUMBER REF M ID 2/3 R Reference Identification Qualifier 229 REF O 0/1 CLAIM ORIGINAL REFERENCE NUMBER (ICN/DCN) 265 HI O 0/1 HEALTH CARE DIAGNOI CODE LOOP 2310 B RENDERING PROVIDER NAME 290 NM1 O 0/1 RENDERING PROVIDER NAME LOOP 2310 D ERVICE FACILITY LOCATION 303 NM1 O 0/1 ERVICE FACILITY LOCATION 1W 23 IG Y 9F G1 Member Identification Number Client Number Insurance Policy Number ocial ecurity Number ee Implementation Guide for Code List Referral Number Prior Authorization Number Y G1 EyeMed will pick up the code "Y" (ocial ecurity Number) and will ignore all other values. Other codes don't apply EyeMed will pick up code "G1" and will ignore all other values. 2003, EyeMed Vision Care 2 Version 01, 06/12/2003

3 Pg# eg DE Req PIC Min Max 837 Health Care Claim ubmission Use Description X12 Codes X12 Code Definition Values Notes NM M ID 2/3 R Entity Identifier Code 77 FA LI TL ervice Location Facility Independent Lab Testing Laboratory 77 EyeMed will expect service location 307 N3 O 0/1 R ERVICE FACILITY LOCATION ADDRE 308 N4 O 0/1 R ERVICE FACILITY LOCATION CITY/TATE/ZIP 310 REF O 0/1 ERVICE FACILITY LOCATION ECONDARY IDENTIFICATION REF M ID 2/3 R Reference Identification Qualifier ee Implementation Guide for Code List LU EyeMed will pick up code "LU" (Location Number) and will ignore all other values. LOOP 2400 ERVICE LINE 400 V1 O 1/1 R PROFEIONAL ERVICE VC M ID 2/2 R Product/ervice ID Qualifier ee Implementation Guide for Code List HC EyeMed expects to see Health Care Financing Administration Common Procedure Coding ystem (HCPC) codes 435 DTP O 1/1 R DATE - ERVICE DATE 472 REF O 1/1 LINE ITEM CONTROL NUMBER 484 AMT O 1/1 ALE TAX AMOUNT E M R TRANACTION ET TRAILER GE M R FUNCTIONAL GROUP TRAILER IEA M R INTERCHANGE CONTROL TRAILER 2003, EyeMed Vision Care 3 Version 01, 06/12/2003

4 Loops not picked up by EyeMed Loop 2010 BC Responsible Party Name Loop 2010 BD Credit/Debit Card Holder Name Loop 2305 Home Health Care Plan Information Loop 2310 A Referring Provider Name Loop 2310 C Purchased ervice Provider Name Loop 2310 E upervising Provider Name Loop 2320 Other ubscriber Information Loop 2330 A Other ubscriber Name Loop 2330 B Other Payer Name Loop 2330 C Other Payer Patient Information Loop 2330 D Other Payer Referring Provider Loop 2330 E Other Payer Rendering Provider Loop 2330 F Other Payer Purchased ervice Provider Loop 2330 G Other Payer ervice Facility Location Loop 2330 H Other Payer upervising Provider Loop 2420 A Rendering Provider Name Loop 2420 B Purchased ervice Provider Name Loop 2420 C ervice Facility Location Loop 2420 D upervising Provider Name Loop 2420 E Ordering Provider Name Loop 2420 F Referring Provider Name Loop 2420 G Other Payer Prior Authorization or Referral Number Loop 2430 Line Adjudication Information Loop 2440 Form Identification Code egments not picked up by EyeMed Loop 1000 A ubmitter Name N2 Additional ubmitter Name Information Loop 1000 B Receiver Name N2 Additional Receiver Name Information Loop 2000 A Billing/Pay-To Provider Hierarchical Level PRV Billing/Pay-To Provider pecialty Information CUR Foreign Currency Information Loop 2010 AA Billing Provider Name N2 Additional Billing Provider Name Information 2003, EyeMed Vision Care 4 Version 01, 06/12/2003

5 Billing Provider econdary Identification Credit/Debit Card Billing Information PER Billing Provider Contact Information Loop 2010 AB Pay-To Provider Name N2 Additional Pay-To Provider Name Information Pay-To Provider econdary Identification Loop 2000 B ubscriber Hierarchical Level PAT Patient Information Loop 2010 BA ubscriber Name N2 Additional ubscriber Name Information N3 ubscriber Address N4 ubscriber City/tate/Zip Code DMG ubscriber Demographic Information ubscriber econdary Identification Property and Casualty Claim Number Loop 2010 BB Payer Name N2 Additional Payer Name Information N3 Payer Address N4 Payer City/tate/Zip Code Payer econdary Identification Loop 2010 CA Patient Name N2 Additional Patient Name Information Property and Casualty Claim Number Loop 2300 Claim Information DTP Date - Referral Date DTP Date - Date Last een DTP Date - Onset of Current Illness/ymptom DTP Date - Acute Manifestation DTP Date - imilar Illness/ymptom Onset DTP Date - Accident DTP Date - Last Menstrual Period DTP Date - Last X-Ray DTP Date - Estimated Date of Birth DTP Date - Disability Begin DTP Date - Disability End DTP Date - Last Worked 2003, EyeMed Vision Care 5 Version 01, 06/12/2003

6 DTP Date - Authorized Return to Work DTP Date - Admission DTP Date - Discharge DTP Date - Assumed and Relinquished Care Dates PWK Claim upplemental Information CN1 Contract Information AMT Credit/Debit Card Maximum Amount AMT Total Purchased ervice Amount ervice Authorization Exception Code Mandatory Medicare (ection 4081) Crossover Indicator Mammography Certification Number Claim Laboratory Improvement Amendment (CLIA) Number Repriced Claim Number Adjusted Repriced Claim Number Investigational Device Exemption Number Loop 2310 B Claim Identification Number for Clearing Houses and Other Transmission Intermediaries Ambulatory Patient Group (APG) Medical Record Number Demonstration Project Identifier K3 File Information NTE Claim Note CR1 Ambulance Transport Information CR2 pinal Manipulation ervice Information CRC Ambulance Certification CRC Patient Condition Information: Vision CRC Homebound Indicator HCP Claim Pricing/Repricing Information Rendering Provider Name PRV Rendering Provider pecialty Information N2 Additional Rendering Provider Name Information 2003, EyeMed Vision Care 6 Version 01, 06/12/2003

7 Loop 2310 D Loop 2400 LOCATION UE NAME NOTE Rendering Provider econdary Identification ervice Facility Location N2 Additional ervice Facility Location Name Information ervice Line V4 Prescription Number PWK DMERC CMN Indicator CR1 Ambulance Transport Information CR2 pinal Manipulation ervice Information CR3 Durable Medical Equipment Certification CR5 Home Oxygen Therapy Information CRC Ambulance Certification CRC Hospice Employee Indicator CRC DMERC Condition Indicator DTP Date - Certification Revision Date DTP Date - Referral Date DTP Date - Begin Therapy Date DTP Date - Last Certification Date DTP Date - Order Date DTP Date - Date Last een DTP Date - Test DTP Date - Oxygen aturation/arterial Blood Gas Test DTP Date - hipped DTP Date - Onset of Current ymptom/illness DTP Date - Last X-Ray DTP Date - Acute Manifestation DTP Date - Initial Treatment DTP Date - imilar Illness/ymptom Onset QTY Anesthesia Modifying Units MEA Test Result CN1 Contract Information Repriced Line Item Reference Number REF Adjusted Repriced Line Item Reference Number 2003, EyeMed Vision Care 7 Version 01, 06/12/2003

8 Prior Authorization or Referral Number Mammography Certification Number Clinical Laboratory Improvement Amendment (CLIA) Identification Referring Clinical Improvement Amendment (CLIA) Facility Identification Immunization Batch Number Ambulatory Patient Group (APG) Oxygen Flow Rate Universal Product Number (UPN) AMT Approved Amount AMT Postage Claimed Amount K3 File Information NTE Line Note P1 Purchased ervice Information HD Health Care ervices Delivery HCP Line Pricing/Repricing Information Elements not picked up by EyeMed Loop 2000 B ubscriber Hierarchical Level BR ubscriber Information BR02 Relationship Code BR05 Insurance Type Code BR09 Claim Filling Indicator Code Loop 2000 C Patient Hierarchical Level PAT Patient Information PAT05 Date Time Period Format Qualifier PAT06 Patient Death Date PAT07 Unit or Basis for Measurement Code PAT08 Patient Weight PAT09 Pregnancy Indicator Loop 2300 Claim Information CLM Claim Information CLM10 Patient ignature ource Code CLM11 Accident/Employment/Related Causes CLM11-2 Related Causes Code CLM11-3 Related Causes Code 2003, EyeMed Vision Care 8 Version 01, 06/12/2003

9 CLM11-4 Auto Accident tate or Province Code CLM11-5 Country Code CLM12 pecial Program Indicator CLM16 Participation Agreement CLM20 Delay Reason Code HI Health Care Diagnosis Code HI02 Health Care Code Information HI03 Health Care Code Information HI04 Health Care Code Information HI05 Health Care Code Information HI06 Health Care Code Information HI07 Health Care Code Information HI08 Health Care Code Information Loop 2400 ervice Line V1 Professional ervice V105 Place of ervice Code V107 Composite Diagnosis Code Pointer V107-2 Composite Diagnosis Code Pointer V107-3 Composite Diagnosis Code Pointer V107-4 Composite Diagnosis Code Pointer V111 EPDT Indicator V112 Family Planning Indicator V115 Co-Pay tatus Code Guidelines for Interpreting Companion Guide: If Usage = "Not Used", the element/segment is omitted from the Companion Guide and "Data Not Picked Up" worksheet Element Names are from Industry tandard, if available If an element is required but is not mapped, the element is not listed in the "Data Not Picked Up" worksheet If an element is not required (="O" or "X") and is not mapped, the element is listed in the "Data Not Picked Up" worksheet 2003, EyeMed Vision Care 9 Version 01, 06/12/2003