Health Care Claim: Institutional (837)

Transcription

1 Health Care Claim: Institutional (837) Standard Companion Guide Transaction Information November 2, 2015 Version 3.1

2 Express permission to use ASC X12 copyrighted materials within this document has been granted. Copyright 2015 Hewlett Packard Enterprise Development LP November 2, X223A2 1

3 Preface Companion guides (CGs) may contain two types of data, instructions for electronic communications with the publishing entity (Communications/ Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC (Accredited Standards Committee) X12 IG (Transaction Instructions). Either the Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The components can be published as separate documents or as a single document. The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASC X12 s copyright and Fair Use statement. November 2, X223A2 2

4 Table of Contents Transaction Instruction (TI) TI Introduction Background Overview of HIPAA Legislation Compliance According to HIPAA Compliance According to ASC X Intended Use Included ASC X12 Implementation Guides Instruction Tables X223A2 Health Care Claim: Institutional TI Change Summary TI Additional Information Payer Specific Business Rules and Limitations Other Resources...13 November 2, X223A2 3

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 translations 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 (Section 1), example (Sections 2 and 3) or appendix (Section 4) information contained in the implementation guide November 2, X223A2 4

6 Modifying any requirements; including loop, segment or element names, notes or rules, examples, appendix, or code list subsets from Section 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. 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. Unique ID Name X222 Health Care Claim: Professional X223 Health Care Claim: Institutional X224 Health Care Claim: Dental X279 Health Care Eligibility Benefit Inquiry and Response X221 Health Care Claim Payment/ Advice X212 Health Care Claim Status Request and Response X217 Health Care Services Review-Request for Review and Response X220 Benefit Enrollment and Maintenance X218 Payroll Deducted and Other Group Premium Payment for Insurance Products 3. Instruction Tables The instruction tables contain a row for each segment where X223 Health Care Claim: Institutional has something additional to convey. In addition to the row for each segment, one or more additional rows are used to describe X223 Health Care Claim: Institutional usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. November 2, X223A2 5

7 Legend SHADED rows represent segments in the X12N implementation guide. NONSHADED rows represent data elements in the X12N implementation guide. Loop specific comments should be indicated in the first segment of the loop X223A2 Health Care Claim: Institutional 223 Health Care Claim: Institutional (Errata) Loop ID Reference Name Codes Notes/Comments N/A ISA ISA-Interchange Control Header N/A ISA01 Authorization Information N/A ISA03 Security Information No Authorization Information Present No Security Information Present N/A ISA05 Interchange ID ZZ ZZ Mutually Defined N/A ISA06 Interchange Sender ID Use the 9- or 10-digit code assigned by the Kansas Medical Assistance Program (KMAP). KMAP providers are assigned a 10-digit number. All other submitters are assigned a 9-digit number. N/A ISA07 Interchange ID ZZ ZZ Mutually Defined N/A ISA08 Interchange Receiver ID Receiver Identification N/A GS Functional Group Header N/A GS02 Application Sender s Code N/A GS03 Application Receiver s Code 1000B NM1 Information Source Name 1000B NM103 Name Last or Organization Name 1000B NM108 Identification Code 2010AA NM1 Billing Provider Name 2010AA NM108 Identification Code This will be equal to the value in ISA06. This will be equal to the value in ISA08. KANSAS MEDICAL ASSISTANCE PROGRAM Electronic Transmitter Identification Number (ETIN) XX XX National Provider Identifier (NPI) 2010AA REF Billing Provider Tax Identification 2010AA REF01 Reference Identification 2000B SBR Subscriber Information EI EI Employer s Identification Number November 2, X223A2 6

8 2000B SBR09 Claim Filing Indicator Code 2010BA NM1 Subscriber Name MC Medicaid 2010BA NM102 Entity Type 1, 2 1 Person 2010BB NM1 Payer Name 2 Nonperson 2010BB NM103 Payer Name KANSAS MEDICAL ASSISTANCE PROGRAM 2300 PWK Claim Supplemental Information 2300 PWK06 Identification Code Must be unique with each claim and with each attachment associated with the same claim HI Value Information 2300 HI01-01 Code List Code BE BE Value Information 2300 HI01-2 Value Code 80, 81, 82, Covered Days 81 Noncovered Days 82 Coinsurance Days 83 LTR Days 2300 HCP Claim Pricing/Repricing Information 2300 HCP02 Monetary Amount Used only to report postadjudication data. Should be the value the claim was adjudicated to pay. The HCP segment should be omitted when the claim was denied. 2310A NM1 Attending Physician Name 2310A NM108 Identification Code 2310A REF Attending Physician Secondary Identification 2310A REF01 Reference Identification 2310B NM1 Operating Physician Name 2310B NM108 Identification Code XX G2 XX XX National Provider Identifier (NPI) G2 Medicaid Provider Number XX National Provider Identifier (NPI) November 2, X223A2 7

9 2310B REF Operating Physician Secondary Identification 2310B REF01 Reference Identification 2310C NM1 Other Provider Name 2310C NM108 Identification Code 2310C REF Other Provider Secondary Identification 2310C REF01 Reference Identification G2 XX G2 G2 Medicaid Provider Number XX National Provider Identifier (NPI) G2 Medicaid Provider Number 2400 HCP Line Pricing/Repricing Information 2400 HCP02 Monetary Amount Used only to report postadjudication data. Should be the value the service was adjudicated to pay CTP Drug Pricing 2410 CTP04 Quantity Must be populated when loop 2410 is submitted CTP05-01 Unit or Basis for Measurement Code Must be populated when loop 2410 is submitted REF Prescription or Compound Drug Association Number 2410 REF02 Reference Identification Prescription of linkage number. 2420A NM1 Attending Physician Name 2420A NM108 Identification Code 2420A REF Attending Physician Secondary Identification 2420A REF01 Reference Identification XX 1D XX when submitting a NPI 1D Medicaid Provider Number Only used when the provider is not mandated to submit an NPI. N/A GE Functional Group Trailer N/A GE02 Group Control Number This is equal to the value in GS06. N/A IEA Interchange Control Trailer N/A IEA02 Interchange Control Number This is equal to the value in ISA13. November 2, X223A2 8

10 4. TI Change Summary Document Change Date Page Reason for Change Version Number Number(s) Version 1.0 June 18, 2010 Creation of manual. Version 2.0 February 01, Added overview of changes for errata version of Version 2.1 July 12, Discontinuance of QTY segments. Day count information now within the 2300 Health Insurance HI segment. Version 2.2 August 01, , 12, 14 Added REF segment info for loop Updated employer identification number and added compound drug billing in TI Additional Information section. Version 3.0 January 30, , 7,8,9, 11, ASC X12 review. 13, 14 Version 3.1 November 2, 2015 Cover, 1, 10 HPE updates. November 2, X223A2 9

11 5. TI Additional Information 5.1 Payer Specific Business Rules and Limitations Subscriber, Insured, and Member = Beneficiary in the KMAP Environment The Kansas Medical Assistance Program (KMAP) does not allow for dependents to be enrolled under a primary subscriber, rather all enrollees/beneficiaries are primary subscribers within each program or managed care organization (MCO). If dependent level segments are received, they will be ignored during processing. KMAP Health Plan ID = KMAP Tax ID KMAP uses the KMAP tax ID in all instances requiring a health plan ID. At such a time as the National Health Plan ID is approved and available, that number will be used. Submitters Submissions by entities/individuals not on file at KMAP will be rejected. KMAP/HPE Provides a 999 Acknowledgment for All Batch Transactions Processed The acknowledgment will be received within 48 hours unless there are unforeseen technical difficulties. Responses to request transactions, such as a 270 or 276 request, are generated when the transaction is processed without errors. Responses for claim transactions processed without errors appear on the billing provider s remittance advice. Note: The 835 and unsolicited 277 are only provided weekly. Uppercase Versus Lowercase All alphabetic characters must be submitted in uppercase, including both AN and ID data element types. Provider Identification KMAP will use the National Provider Identification (NPI), where available, in all instances that require provider identification. In instances where a provider is exempt from requirements to use an NPI and an NPI is not available, the provider s KMAP provider ID will be used. All information needed to identify a provider must be submitted where possible, including the name, taxonomy code, tax ID, and address with the nine-digit ZIP code. Absence of required information could cause incorrect processing of claims. November 2, X223A2 10

12 Claims Allowed per Transaction (ST/SE Envelope) The HIPAA implementation guide states on the CLM (Claim Information) segment that the developers recommend trading partners limit the size of the transaction (ST/SE envelope) to a maximum of 5,000 CLM segments. This is a recommendation and willing trading partners can agree to set limits higher. KMAP allows 50,000 claims per transaction (ST/SE envelope). KMAP processes files at the transaction level so if one or even two claims within the transaction fails for compliance errors, the entire file does not process, and a 997 transaction is returned. Although it is allowed, it is not recommended that a transaction ST/SE envelope contain 50,000 claims. Encounters If BHT06 equals RP (Reporting), the value received in the ISA06 must contain a valid ID for an encounter submitter. If BHT06 equals RP and ISA06 is not a valid ID for an encounter submitter, a rejected 997 is generated reflecting an invalid value was received. Claims and Encounters Should Be Submitted in Separate ISA-IEA Envelopes KMAP will return the appropriate response transaction to the trading partner whose ID is present within the ISA06 data element. Identification of Medicare Versus Non-Medicare Payers o If loop 2320 (Other Subscriber Information) is present and SBR09 (Claim Filing Indicator) equals MA (Medicare Part A) or MB (Medicare Part B), the payer is considered Medicare and a crossover claim type is assigned. Otherwise, the payer is assumed not to be Medicare. o Medicare Paid Amount The Medicare Paid Amount is the sum of the Payer Paid Amounts (AMT01=D) obtained from loop 2320 (Other Subscriber Information) where the payer is Medicare. Loop 2320 can repeat multiple times per claim. o Non-Medicare Payer Paid Amount The non-medicare Paid Amount is the sum of the Payer Paid Amounts (AMT01=D) obtained from loop 2320 (Other Subscriber Information) where the payer is not Medicare. o Medicare Paid Date The Medicare Paid Date is obtained from loop 2330B (Other Payer Name) where the payer is Medicare. If there are multiple Medicare payers, this is the paid date from the last Medicare payer in the loop sequence. November 2, X223A2 11

13 o o o Medicare Deductible The Medicare Deductible is the sum of the CAS segment amounts at BOTH the claim header (loop 2320) and detail (loop 2430) where the Adjustment Group is PR (Patient Responsibility), the Adjustment Reason is 1 (Deductible), and the payer is Medicare. Medicare Coinsurance The Medicare Coinsurance is the sum of the CAS segment amounts at BOTH the claim header (loop 2320) and detail (loop 2430) where the Adjustment Group is PR (Patient Responsibility), the Adjustment Reason is 2 (Coinsurance), and the payer is Medicare. Medicare Blood Deductible The Medicare Blood Deductible is the sum of the CAS segment amounts at BOTH the claim header (loop 2320) and detail (loop 2430) where the Adjustment Group is PR (Patient Responsibility), the Adjustment Reason is 66 (Blood Deductible), and the payer is Medicare. Negative Values Submitted in the CLM02 or SV203 Data Elements If a claim is submitted with a negative value in either the CLM02 or SV203, there is potential that the entire transaction could fail due to balancing issues. Compound Drug Billing An 837 for multiple ingredient compound will have one 2400 loop for each ingredient with HCPCS code in SV101-2, the provider s charge for that ingredient in SV102, and the associated units in SV104. When required by situational rules, the 2410 loop is sent with NDC number in LIN03 with the associated quantity in CTP04. Loop ID-2410 REF02 must have the same prescription number or the same linkage number if provided without a prescription for each ingredient of the compound to enable the payer to differentiate and link the ingredients to a single compound. 5.2 Other Resources For full implementation guides and other 5010 standards - store.x12.org. November 2, X223A2 12