June 8, 2018 Dear Provider: Cook Children s Health Plan (CCHP) greatly appreciates you and your staff serving our members healthcare needs. We recogni

Transcription

1 June 8, 2018 Dear Provider: Cook Children s Health Plan (CCHP) greatly appreciates you and your staff serving our members healthcare needs. We recognize that timely, accurate claim payment is a vital part of your business. We recently implemented claims edits and received feedback from several providers that the edits caused an unexpected hardship to their billing workflow. As a result of your feedback we are suspending the following specific claim file indicator and Coordination of Benefits (COB) claim edits until September 1, 2018 to allow time for providers to work with their billing partner/vendor to make appropriate changes. Claim Filing Indicator (Loop 2000B, SBR09) must be 11 = CHIP (CCHP1*). Claim Filing Indicator (Loop 2000B, SBR09) must be MC = STAR/STAR Kids (CCHP9**). Other Subscriber Address (Loop 2330A, N3/N4) is required. Other Payer Address (Loop 2330B, N3/N4) is required. Claim Check or Remittance Date (Loop 2330B, DTP) is required when another payer had adjudicated the claim. Other Payer Claim Control Number (Loop 2330B, REF*F8) is required when another payer has adjudicated the claim. Individual Relationship Code (Loop 2000B, SBR02) must equal Self. You can begin resubmitting claims on June 11, 2018 for any claim rejections related to the claim file indicator or COB edits listed above. Reminder: The following taxonomy edits are required elements. These edits will remain in place. If the Attending/Referring provider NPI (Loop 2310A, NM109) is submitted, the attending provider information segment (Loop 2310A, PRV) must be submitted because the provider s taxonomy code impacts adjudication. The provider information segment (Loop 2000A, PRV) must be submitted because the provider s taxonomy code impacts adjudication. 801 Seventh Avenue Box 2488 Fort Worth, Texas

2 The provider information segment (Loop 2310B, PRV) must be submitted because the provider s taxonomy code impacts adjudication. Attached please find updated EDI billing information that should assist with your CCHP electronic claims submissions. We thank you for taking care of our members and apologize for any disruption the recent claim edits may have caused to your billing. Should you have any questions, or if you are unsure about how these edits have affected your claims please feel free to contact your Provider Relations team at (800) Sincerely, Cook Children s Health Plan * CCHP1 = CHIP Availity Payor ID ** CCHP9 = STAR/STAR Kids Availity Payor ID Attachments: CCHP Electronic Data Interchange (EDI) Billing Requirements Aid Institutional CCHP Electronic Data Interchange (EDI) Billing Requirements Aid - Professional 801 Seventh Avenue Box 2488 Fort Worth, Texas

3 Electronic Data Interchange (EDI) Requirements - Professional Segment Field = Description Qualifier/Value Usage Notes Example BILLING PROVIDER SPECIALTY INFORMATION / LOOP: 2000A / SEGMENT PRV Billing Taxonomy PRV01 = Provider Code BI - Billing PRV02 = Reference Identification Qualifier PXC - Health Care Provider Taxonomy Code PRV*BI*PXC* X~ PRV03 = Reference Identification Provider Taxonomy Code PRV03 must contain the provider's assigned taxonomy BILLING PROVIDER NAME / LOOP: 2010AA / SEGMENT NM1 NM101 = Entity Identifier Code 85 - Billing Provider NM102 = Entity Type Qualifier 1 -Person 2 - Non-Person Entity NM108 = Identification Code Qualifier XX Billing NPI NM1*85*2*MID TEXAS CARDIOLOGY GROUP*****XX* ~ NM109 = Identification Code NPI Number REF01 = Reference Identification Qualifier EI Enter your TAX ID number REF02 = Reference Identification Employer's Identification Number SBR02 = Individidual Relationship Code 18 = Self SBR09 = Claim Filing Indicator Code 11 = Non Medicaid (CHIP) MC = Medicaid (STAR, STAR KIDS) NM101 = Entity Identifier Code 82 - Rendering Provider NM102 = Entity Type Qualifier BILLING PROVIDER ADDRESS / LOOP: 2010AA / SEGMENT N3 BILLING PROVIDER CITY, STATE, ZIP CODE / LOOP: 2010AA / SEGMENT N4 BILLING PROVIDER TAX IDENTIFICATION / LOOP: 2010AA / SEGMENT REF SUBSCRIBER INFORMATION / LOOP: 2000B / SEGMENT SBR RENDERING PROVIDER NAME / LOOP: 2310B / SEGMENT NM1 1 -Person 2 - Non-Person Entity NM108 = Identification Code Qualifier XX NM109 = Identification Code NPI Number Billing Address Billing Address Billing TIN REF*EI* ~ Subscriber SBR*P*18*******MC Rendering NPI NM1*82*1*SMITH*JOHN*C***XX* ~

4 Electronic Data Interchange (EDI) Requirements - Professional PRV01 = Provider Code PE - Performing PRV02 = Reference Identification Qualifier PXC - Health Care Provider Taxonomy Code PRV03 = Reference Identification Provider Taxonomy Code PRV03 must contain the provider's assigned taxonomy SBR02 = Individidual Relationship Code 18 = Self ONLY when another insurance company has 11 = Non Medicaid (CHIP) SBR09 = Claim Filing Indicator Code MC = Medicaid (STAR, STAR KIDS) OTHER SUBSCRIBER NAME / LOOP: 2330A / SEGMENT NM1 NM101 = Entity Identifier Code IL - Insured or Subscriber NM102 = Entity Type Qualifier 1 -Person 2 - Non-Person Entity NM108 = Identification Code Qualifier MI - Member Identification Number NM109 = Identification Code Plan Code OTHER SUBSCRIBER ADDRESS / LOOP: 2330A / SEGMENT N4 NM101 = Entity Identifier Code PR - Payer NM102 = Entity Type Qualifier 2 - Non-Person Enitity NM108 = Identification Code Qualifier PI NM109 = Identification Code Payers ID RENDERING PROVIDER SPECIATY / LOOP: 2310B / SEGMENT PRV OTHER SUBSCRIBER INFORMATION / LOOP: 2320 / SEGMENT SBR OTHER SUBSCRIBER ADDRESS / LOOP: 2330A / SEGMENT N3 OTHER PAYER NAME / LOOP: 2330B / SEGMENT NM1 ONLY when another insurance company has ONLY when another insurance company has ONLY when another insurance company has ONLY when another insurance company has OTHER PAYER ADDRESS / LOOP: 2330B / SEGMENT N3 ONLY when another insurance company has OTHER PAYER ADDRESS / LOOP: 2330B / SEGMENT N4 ONLY when another insurance company has Rendering Taxonomy PRV*PE*PXC* X~ SBR*S*18*******MC NM1*IL*1*SMITHJOHN*****MI* ~ NM1*PR*2*NAME*****PI* ~

5 Electronic Data Interchange (EDI) Requirements - Professional DTP01 = Date/Time Qualifier Date Claim Paid DTP02 = Date Time Period Format Qual D8 - Date Expressed in Format CCYYMMDD DTP03 = Date Time Period Adjudication Date REF01 = Reference Identification Qualifier F8 - Original Reference Number REF02 = Reference Identification CLAIM CHECK OR REMITTANCE DATE / LOOP: 2330B / SEGMENT DTP OTHER PAYER CLAIM CONTROL NUMBER / LOOP: 2330B / SEGMENT REF Other Payer's Claim Control Number (Plans ICN) ONLY when another insurance company has ONLY when another insurance company has DTP*573*D8* ~ REF*F8* ~

6 Electronic Data Interchange (EDI) Requirements - Institutional Segment Field = Description Qualifier/Value Usage Notes Example BILLING PROVIDER SPECIALTY INFORMATION / LOOP: 2000A / SEGMENT PRV Billing Taxonomy PRV01 = Provider Code BI - Billing PRV02 = Reference Identification Qualifier PXC - Health Care Provider Taxonomy Code PRV*BI*PXC* X~ PRV03 = Reference Identification Provider Taxonomy Code PRV03 must contain the provider's assigned taxonomy BILLING PROVIDER NAME / LOOP: 2010AA / SEGMENT NM1 NM101 = Entity Identifier Code 85 - Billing Provider Billing NPI NM102 = Entity Type Qualifier 2 - Non-Person Entity NM108 = Identification Code Qualifier XX NM1*85*2*MID TEXAS CARDIOLOGY GROUP*****XX* ~ NM109 = Identification Code NPI Number REF01 = Reference Identification Qualifier EI Enter your TAX ID number REF02 = Reference Identification Employer's Identification Number SBR02 = Individidual Relationship Code 18 = Self SBR09 = Claim Filing Indicator Code BILLING PROVIDER ADDRESS / LOOP: 2010AA / SEGMENT N3 BILLING PROVIDER CITY, STATE, ZIP CODE / LOOP: 2010AA / SEGMENT N4 BILLING PROVIDER TAX IDENTIFICATION / LOOP: 2010AA / SEGMENT REF SUBSCRIBER INFORMATION / LOOP: 2000B / SEGMENT SBR 11 = Non Medicaid (CHIP) MC = Medicaid (STAR, STAR KIDS) ATTENDING PROVIDER SPECIATY / LOOP: 2310A / SEGMENT PRV PRV01 = Provider Code AT - Attending PRV02 = Reference Identification Qualifier PXC - Health Care Provider Taxonomy Code PRV03 = Reference Identification Provider Taxonomy Code PRV03 must contain the provider's assigned taxonomy Billing Address Billing Address Billing TIN REF*EI* ~ Subscriber SBR*P*18*******MC Attending Taxonomy PRV*AT*PXC* X~

7 Electronic Data Interchange (EDI) Requirements - Institutional RENDERING PROVIDER NAME / LOOP: 2310D / SEGMENT NM1 NM101 = Entity Identifier Code 82 - Rendering Provider Rendering NPI NM102 = Entity Type Qualifier 1 - Person NM108 = Identification Code Qualifier XX NM109 = Identification Code NPI Number ONLY when Rendering provider is different than the Attending provider reported in the 2310A loop NM1*82*1*SMITH*JOHN*C***XX* ~ SBR02 = Individidual Relationship Code 18 = Self ONLY when another insurance company has 11 = Non Medicaid (CHIP) SBR09 = Claim Filing Indicator Code MC = Medicaid (STAR, STAR KIDS) OTHER SUBSCRIBER NAME / LOOP: 2330A / SEGMENT NM1 NM101 = Entity Identifier Code IL - Insured or Subscriber NM102 = Entity Type Qualifier 1 -Person 2 - Non-Person Entity NM108 = Identification Code Qualifier MI - Member Identification Number NM109 = Identification Code Plan Code NM101 = Entity Identifier Code PR - Payer NM102 = Entity Type Qualifier 2 - Non-Person Enitity NM108 = Identification Code Qualifier PI NM109 = Identification Code Payers ID OTHER SUBSCRIBER INFORMATION / LOOP: 2320 / SEGMENT SBR OTHER SUBSCRIBER ADDRESS / LOOP: 2330A / SEGMENT N3 ONLY when another insurance company has OTHER SUBSCRIBER ADDRESS / LOOP: 2330A / SEGMENT N4 OTHER PAYER NAME / LOOP: 2330B / SEGMENT NM1 ONLY when another insurance company has ONLY when another insurance company has ONLY when another insurance company has OTHER PAYER ADDRESS / LOOP: 2330B / SEGMENT N3 ONLY when another insurance company has OTHER PAYER ADDRESS / LOOP: 2330B / SEGMENT N4 ONLY when another insurance company has SBR*S*18*******MC NM1*IL*1*SMITHJOHN*****MI* ~ NM1*PR*2*NAME*****PI* ~

8 Electronic Data Interchange (EDI) Requirements - Institutional DTP01 = Date/Time Qualifier Date Claim Paid DTP02 = Date Time Period Format Qual D8 - Date Expressed in Format CCYYMMDD DTP03 = Date Time Period Adjudication Date REF01 = Reference Identification Qualifier F8 - Original Reference Number REF02 = Reference Identification CLAIM CHECK OR REMITTANCE DATE / LOOP: 2330B / SEGMENT DTP OTHER PAYER CLAIM CONTROL NUMBER / LOOP: 2330B / SEGMENT REF Other Payer's Claim Control Number (Plans ICN) ONLY when another insurance company has ONLY when another insurance company has DTP*573*D8* ~ REF*F8* ~