USVI HEALTH CARE CLAIM 837 Companion Guide. Version 0.1 February 6, 2013
|
|
- Collin Washington
- 6 years ago
- Views:
Transcription
1 USVI HEALTH CARE CLAIM 837 Companion Version 0.1 February 6, 2013
2 Table of Contents 1.0 COMPANION GUE PURPOSE ATYPICAL PROVERS CONTROL STRUCTURE DEFINITIONS ISA - INTERCHANGE CONTROL HEADER SEGMENT IEA - INTERCHANGE CONTROL TRAILER GE FUNCTIONAL GROUP TRAILER VAL DELIMITERS FOR USVI MEDICA TRANSMISSION CONSTRAINTS COMPANION GUE FOR THE 837 PROFESSIONAL TRANSACTION COMPANION GUE FOR THE 837 INSTITUTIONAL TRANSACTION ADDITIONAL PROVER INFORMATION COMPANION GUE FOR THE 837 DENTAL TRANSACTION February 6, Companion
3 Record of change DATE DESCRIPTION OF CHANGE ORIGINATOR 11/1/12 Created to reflect 5010 USVI EDI 2/6/13 QA Review M. Searcy The Molina Healthcare Companion for USVI Medicaid is subject to change prior to July 1, 2013 or at the instruction of the Department. Therefore, it is the responsibility of the trading partner to ensure that the latest version of this guide is used when designing\building NX EDI transactions. The trading partner should frequently check for updates to the companion guide. Molina Healthcare accepts no liability for any costs that the trading partner may incur that arise from or are related to changes to the companion guide. February 6, Companion
4 1.0 COMPANION GUE PURPOSE This companion guide document for the transaction type listed below further defines situational and required data elements that are used for processing claims for programs administered by U.S. Virgin Island Department of Human Services. This document is not the complete EDI transaction format specifications. 2.0 ATYPICAL PROVERS This section is for Atypical Providers (performing non-health care services) who will be permitted to bill using their existing Medicaid numbers. The EDI formatting location of Billing, Referring, and Rendering Provider is dependent upon the situation being billed. Below are the circumstances and EDI billing locations of this information. Billing Provider Location This is used when the Billing Provider is a servicing provider only and/or if the Billing Provider is the same as the Pay-To Provider. Header Reference Definition Values Billing Provider Tax 2010AA REF01 Reference EI or SY Billing Provider Tax Billing Provider Secondary Billing Provider Secondary Rendering Provider 2010AA REF02 Billing Provider Additional Identifier 2010BB REF01 Reference 2010BB REF02 Billing Provider Additional Identifier 2310B REF01 Reference G2 Billing Medicaid Provider G2 Rendering Provider 2310B REF02 Reference Rendering Medicaid Provider February 6, Companion
5 3.0 CONTROL STRUCTURE DEFINITIONS 3.1 ISA - INTERCHANGE CONTROL HEADER SEGMENT Reference Definition Values ISA01 Authorization 00 ISA02 Authorization [space fill] ISA03 Security 00 ISA04 Security [space fill] ISA05 Interchange ZZ ISA06 Interchange Sender Insert with the unique number found on your USVI Transaction Form. ISA07 Interchange ZZ ISA08 Interchange Receiver VI_MMIS_4MOLINA ISA09 Interchange Date The date format is YYMMDD ISA10 Interchange Time The time format is HHMM ISA11 Repetition Separator ^ ISA12 Interchange Control Version ISA13 Interchange Control Must be identical to the interchange trailer IEA02 (defined by sending Trading Partner) ISA14 Acknowledgment Request 1 ISA15 Usage Indicator T= Test Data P = Production Data ISA16 Component Element Separator : 3.2 IEA - INTERCHANGE CONTROL TRAILER Reference Definition IEA01 IEA02 of included Functional Groups Interchange Control Values Count of included Functional Groups Must be identical to the value in ISA13 February 6, Companion
6 3.3 GS Functional Group Header Reference Definition Values GS01 Functional Identifier HC = Health Care Claim (837) GS02 Application Sender s Must be identical to the value in ISA06 GS03 Application Receiver s VI_MMIS_4MOLINA GS04 Date The date format is CCYYMMDD GS05 Time The time format is HHMM GS06 Group Control Assigned and maintained by the sender GS07 Responsible Agency X GS08 Version/Release/Industry Identifier Appropriate Version for the claim 3.4 GE FUNCTIONAL GROUP TRAILER Reference Definition Values GE01 of Transaction of Transaction Sets Included Sets Included GE02 Group Control Must be identical to the value in GS VAL DELIMITERS FOR USVI MEDICA Definition ASCII Decimal Hexadecimal Separator ~ 126 7E Element Separator * 42 2A Compound Element Separator : 58 3A 4.0 TRANSMISSION CONSTRAINTS 1. Only one Interchange per transmission 2. Only one transaction type per interchange 3. Maximum of 5,000 claims per transmission 4. Single transmission file size must be less than 5MB February 6, Companion
7 FIELD DEFINITIONS Label A B C D E Column Definition The name of the loop as documented in the appropriate 837 TR3. A loop number used to identify a group of segments that are collectively repeated in a serial fashion up to a specified maximum number of times as documented in the appropriate 837 TR3. The field position number and segment number as specified in the appropriate 837 TR3. The data element name as indicated in the appropriate 837 TR3. The Values and further describing the appropriate 837 TR3 field data that USVI Medicaid will accept. 5.0 COMPANION GUE FOR THE 837 PROFESSIONAL TRANSACTION The 837 Professional Versions used in creating the guide. Health Care Claim: Professional Transaction ASC X12N 837(005010X222) May 2006 Errata Health Care Claim: Professional Transaction ASC X12N 837(005010X222A1) June 2010 /Page from Version/Release/Industry GS X222A1 Identifier Beginning of Hierarchical Transaction BHT02 Transaction Set Purpose 00 Original Beginning of Hierarchical BHT06 Transaction Type CH Chargeable February 6, Companion
8 /Page from Transaction Submitter 1000A NM109 Submitter Contact 1000A PER03 Communication Receiver 1000B NM103 Last or Receiver 1000B NM109 Billing Provider 2010AA NM108 Billing Provider 2010AA NM109 Insert with the unique number found on your USVI Transaction Form. TE Telephone Minimum requirement, PER 05 PER08 may also be sent. VI_MMIS_4MOLINA VI_MMIS_4MOLINA XX National Provider. Atypical Providers refer to Atypical Section. Billing Provider National Provider. Usage changed to situational. Billing Provider Address 2010AA N403 Postal Billing Provider Zip must be the full 9 digits Subscriber Hierarchical Level 2000B HL04 Hierarchical Child Subscriber 2000B SBR09 Claim Filing Indicator Subscriber 2010BA NM102 Entity Type Subscriber 2010BA NM108 Subscriber 2010BA NM109 0 No subordinate HL in the Hierarchical Structure February 6, Companion MC 1 Person MI Member USVI Medicaid 10 digit Recipient
9 /Page from Payer 2010BB NM103 Last or VI_MMIS_4MOLINA Payer 2010BB NM108 Payer 2010BB NM109 Claim 2300 CLM01 Claim Submitter s Patient Account / Identifier Claim 2300 CLM06 Yes/No Condition or Response Claim 2300 CLM08 Yes/No Condition or Response Health Care Diagnosis 2300 HI01-2 Industry Diagnosis PI Payer VI_MMIS_4MOLINA Patient Control Y Yes Y Yes Required on all claims. Transportation claims use when unknown. XX National Provider Referring Provider National Provider XX National Provider Rendering Provider National Provider Referring Provider 2310A NM108 Referring Provider 2310A NM109 Rendering Provider 2310B NM108 Rendering Provider 2310B NM109 Rendering Provider 2310B PRV01 Provider PE Performing SBR-Other Subscriber 2320 SBR09 Claim Filing Indicator Please ensure to use the correct indicator code(s) when billing VI Medicaid as a secondary or tertiary payer. Do not send MC in this February 6, Companion
10 /Page from for secondary or tertiary claims. Valid values are: 11 Other Non- Federal Programs 12 Preferred Provider (PPO) 13 Point of Service (POS) 14 Exclusive Provider (EPO) 15 Indemnity Insurance 16 Health Maintenance (HMO) Medicare Risk 17 Dental Maintenance AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance February 6, Companion
11 /Page from LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veterans Affairs Plan WC Workers Compensation health Claim ZZ Mutually Defined Line Adjustment 2430 CAS01 Claim Adjustment Group Line Adjustment 2430 CAS02 Claim Adjustment Reason Line Adjustment 2430 CAS03 Monetary Amount Adjusted Amount Line Level Line Adjustment 2430 CAS04 Quantity/Adjusted Units Line Level CR Correction and Reversals CO OA PI PR For adjustment reason codes see COMPANION GUE FOR THE 837 INSTITUTIONAL TRANSACTION The 837 Institutional Versions used in creating the guide. Health Care Claim: Professional Transaction ASC X12N 837(005010X223) May 2006 February 6, Companion
12 Errata Health Care Claim: Institutional Transaction ASC X12N 837(005010X223A1) October 2007 Errata Health Care Claim: Institutional Transaction ASC X12N 837(005010X223A2) June 2010 /Page from Version/Release/Industry GS X223A2 Identifier Beginning of Hierarchical Transaction BHT02 Transaction Set Purpose 00 Original Beginning of Hierarchical Transaction BHT06 Transaction Type CH Chargeable Submitter 1000A NM109 Submitter Contact 1000A PER03 Communication Receiver 1000B NM103 Last or Receiver 1000B NM109 Billing Provider 2010AA NM108 Billing Provider 2010AA NM109 Insert with the unique number found on your USVI Transaction Form. TE Telephone Minimum requirement, PER 05 PER08 may also be sent. VI_MMIS_4MOLINA VI_MMIS_4MOLINA XX National Provider. Atypical Providers refer to Atypical Section. Billing Provider National Provider. Usage changed to situational. Billing Provider Address 2010AA N403 Postal Billing Provider Zip must be the February 6, Companion
13 /Page from full 9 digits Subscriber Hierarchical Level 2000B HL04 Hierarchical Child Subscriber 2000B SBR09 Claim Filing Indicator Subscriber 2010BA NM102 Entity Type Subscriber 2010BA NM108 Subscriber 2010BA NM109 Payer 2010BB NM103 Last or Payer 2010BB NM108 Payer 2010BB NM109 Claim 2300 CLM01 Claim Submitter s Patient Account / Identifier Claim 2300 CLM06 Yes/No Condition or Response Claim 2300 CLM08 Yes/No Condition or Response Discharge Hour 2300 DTP01 Date Time Period Discharge Hour Claim 2300 DTP02 Date Time Period Format Admission Date/Hour 2300 DTP01 Date Time Admission Date/Hour 2300 DTP02 Date Time Period Format Admission Date/Hour 2300 DTP03 Date Time Period Institutional Claim 2300 CL101 Admission Type 0 No subordinate HL in the Hierarchical Structure February 6, Companion MC 1 Person MI Member USVI Medicaid 10 digit Recipient VI_MMIS_4MOLINA PI Payer VI_MMIS_4MOLINA Patient Control Y Yes Y Yes 096 TM 435 D8 or DT
14 /Page from Institutional Claim 2300 CL102 Admission Source Institutional Claim 2300 CL103 Patient Status Prior Authorization or Referral Prior Authorization or Referral 2300 REF01 Reference 2300 REF02 Reference Prior Authorization Other Diagnosis 2300 HI01-2 Industry Diagnosis Principal Procedure 2300 HI01-1 List Principal Procedure Other Procedure Other Procedure Other Procedure Attending Physician Attending Physician Attending Physician Attending Physician 2300 HI01-2 Industry Principal Procedure 2300 HI01-1 List G1 Prior Authorization Assigned Prior Authorization Use appropriate Reference BF International Classification of Diseases Clinical Modification (ICD-9- CM) Principal Procedure BQ International Classification of Diseases Clinical Modification (ICD-9- CM) Procedure Other Procedure 2300 HI01-2 Industry Procedure 2300 HI01-4 Date Time Period Procedure Date 2310A NM108 XX National Provider 2310A NM109 Attending Physician National Provider 2310A PRV01 Provider AT Attending 2310A PRV02 Reference PXC Health Care Provider Taxonomy February 6, Companion
15 /Page from Attending Physician 2310A PRV03 Reference Provider Taxonomy Referring Provider 2310A NM108 XX National Provider Referring Provider 2310A NM109 Referring Provider National Provider SBR-Other Subscriber 2320 SBR09 Claim Filing Indicator Please ensure to use the correct indicator code(s) when billing VI Medicaid as a secondary or tertiary payer. Do not send MC in this for secondary or tertiary claims. Valid values are; 11 Other Non- Federal Programs 12 Preferred Provider (PPO) 13 Point of Service (POS) 14 Exclusive Provider (EPO) 15 Indemnity Insurance 16 Health Maintenance (HMO) Medicare Risk 17 Dental February 6, Companion
16 /Page from Maintenance AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co DS Disability FI Federal Employees Program HM Health Maintenance LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veterans Affairs Plan WC Workers Compensation health Claim ZZ Mutually Defined Institutional Service Line 2400 SV202 Composite Medical Procedure Identifier Institutional Service Line 2400 SV207 Monetary Amount Line Item Denied Charge or Non- Covered Charge Required for all Outpatient claims February 6, Companion
17 /Page from Amount Line Adjustment 2430 CAS01 Claim Adjustment Group Line Adjustment 2430 CAS02 Claim Adjustment Reason Line Adjustment 2430 CAS03 Monetary Amount Adjusted Amount Line Level Line Adjustment 2430 CAS04 Quantity/Adjusted Units Line Level 6.1 ADDITIONAL PROVER INFORMATION Attending Physician NPI Location Required when the claim being billed is for an Inpatient Bill Type. CR Correction and Reversals CO OA PI PR For adjustment reason codes see VI Medicaid does not require the use of NPI when billing the Attending Physician number. Therefore the NPI OR Legacy may be submitted when billing the Attending Physician. 2310A Attending Physician Attending Physician Or /Page from Valid Values 2310A NM108 XX National Provider 2310A NM109 Attending Physician National Provider February 6, Companion
18 Attending Physician Secondary Attending Physician Secondary 2310A REF01 /Page from Reference Valid Values G2 Medicaid Provider 2310A REF02 Reference Medicaid Provider 7.0 COMPANION GUE FOR THE 837 DENTAL TRANSACTION The 837 Institutional Versions used in creating the guide. Health Care Claim: Dental Transaction ASC X12N 837(005010X224) May 2006 Errata Health Care Claim: Dental Transaction ASC X12N 837(005010X224A1) October 2007 Errata Health Care Claim: Dental Transaction ASC X12N 837(005010X224A2) June 2010 /Page from Version/Releas e/industry Identifier GS X224A2 Subscriber Hierarchical Level Subscriber Hierarchical Level Subscriber 2000B HL04 Hierarchical Level 2000B SBR09 Claim Filing Indicator 2010BA NM102 Entity Type 0 No subordinate HL in the Hierarchical Structure MC Medicaid 1 Person Subscriber 2010BA NM108 MI Member February 6, Companion
19 Subscriber /Page from 2010BA NM109 Payer 2010BB NM103 Last or Payer 2010BB NM108 Payer 2010BB NM109 USVI Medicaid 10 digit Recipient VI_MMIS_4MOL INA PI Payer VI_MMIS_4MOL INA Claim Claim Claim Referral Referral SBR-Other Subscriber 2300 CLM01 Claim Submitter s Patient Account 2300 CLM11-1 Related Causes 2300 CLM12 Special Program 2300 REF01 Reference 2300 REF02 Reference Referral 2320 SBR09 Claim Filing Indicator Patient Control AA Auto Accident OA Other Accident 01 EPSDT G3 Prior Authorization Assigned Prior Authorization Please ensure to use the correct indicator code(s) when billing VI Medicaid as a secondary or tertiary payer. Do not send MC in this February 6, Companion
20 /Page from Segm ent for secondary or tertiary claims. Valid values are; 11 Other Non-Federal Programs 12 Preferred Provider (PPO) 13 Point of Service (POS) 14 Exclusive Provider (EPO) 15 Indemnity Insurance 16 Health Maintenance (HMO) Medicare Risk 17 Dental Maintenance AM Automobile Medical BL Blue Cross/Blue Shield CH Champus CI Commercial Insurance Co February 6, Companion
21 Other Subscriber /Page from 2320 AMT02 Monetary Amount Payer Paid Amount DS Disability FI Federal Employees Program HM Health Maintenance LM Liability Medical MA Medicare Part A MB Medicare Part B OF Other Federal Program TV Title V VA Veterans Affairs Plan WC Workers Compensation health Claim ZZ Mutually Defined Other Insurance paid Amount February 6, Companion
Vendor Specifications 837 Professional Claim ASC X12N Version for. State of Idaho MMIS
Vendor Specifications 837 Professional Claim ASC X12N Version 5010 for State of Idaho MMIS Date of Publication: 12/8/2017 Document Number: TL427 Version: 11.0 Revision History Versio Date Author Action/Summary
More informationVendor Specifications 837 Institutional Claim ASC X12N Version X223A2. for. State of Idaho MMIS
Vendor Specifications 837 Institutional Claim ASC X12N Version 005010X223A2 for State of Idaho MMIS Date of Publication: 6/16/2016 Document Number: TL426 Version: 8.0 Revision History Version Date Author
More informationKyHealth Choices MMIS Batch Health Care Institutional Health Care Claim and Encounter Claims (837I) Companion Guide Version 3.0 Version X096A1
KyHealth Choices MMIS Batch Health Care Institutional Health Care Claim and Encounter Claims (837I) Companion Guide Version 3.0 Version 004010 X096A1 Cabinet for Health and Family Services Department for
More information837P Health Care Claim Companion Guide
837P Health Care Claim Companion Guide Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010 Companion Guide Version
More informationCompanion Guide for the X223A2 Health Care Claim: Institutional (837I) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC
Companion Guide for the 005010X223A2 Health Care Claim: Institutional (837I) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC Segment Loop Name TR3 Values Notes Delimiter: Data
More informationPurpose of the 837 Health Care Claim: Professional
Oklahoma Medicaid Management Information System Interface Specifications 837 Professional Health Care Claim HIPAA Guidelines for Electronic Transactions Companion Document The following is intended to
More informationAppendix 3B. Crosswalk from Retired Minimum Data Element List to Appendix 3A MA Companion Guide
Appendix 3B. Crosswalk from Retired Minimum Data Element List to Appendix 3A MA A3B.1 LOOPS AND SEGMENTS APPLIED TO EDR AND CRR SUBMISSIONS... 3 A3B.2 COLUMN HEADING CROSSWALK FROM APPENDIX 3A MA COMPANION
More informationKyHealth Choices MMIS Batch Health Care Dental Health Care Claim and Encounter Claims (837D) Companion Guide Version 2.0 Version X097A1
KyHealth Choices MMIS Batch Health Care Dental Health Care Claim and Encounter Claims (837D) Companion Guide Version 2.0 Version 004010 X097A1 Cabinet for Health and Family Services Department for Medicaid
More information13. IEHP P PROFESSIONAL CLAIM COMPANION GUIDE A. Included ASC X12 Implementation Guides X222A1 Health Care Claim: Professional
13. IEHP 5010 837P PROFESSIONAL CLAIM COMPANION GUIDE 1. 005010X222A1 Health Care Claim: Professional Standard Companion Guide (CG) Transaction Information Effective January 1, 2018 IEHP Instructions related
More information10/2010 Health Care Claim: Professional - 837
837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.8 Update 10/20/10 (Latest Changes in RED font) Author: Publication: EDI Department LA Medicaid
More informationSeg Loop Name TR3 Values Notes Delimiter: Data Element. (:) Colon Separator
Companion Guide for the 005010X223A1 Health Care Claim: Institutional (837I) Lines of Business: Private Business, 65C Plus, QUEST, Blue Card, FEP, Away From Home Care Delimiter: Data Element (*) Asterisk
More informationStandard Companion Guide Transaction Information. Instructions related to Transactions based on ASC X12 Implementation Guides, Version
County Medically Indigent Services Program (CMISP), Physicians Emergency Medical Services (PEMS), and Non-contracted Hospital ER Services Policy (NHERSP) Standard Companion Guide Transaction Information
More informationHIPAA 837I (Institutional) Companion Guide
Companion Guide Prepared for Health Care Providers For use with the Cardinal Innovations claims processing system Version 5.0 January 2011 Table of Contents 1. Introduction...3 2. Approval Procedures...4
More information837 Professional Health Care Claim - Outbound
Companion Document 837P 837 Professional Health Care Claim - Outbound Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional
More informationRefers to the Technical Reports Type 3 Based on ASC X12 version X279A1
HIPAA Transaction Standard Companion Guide Refers to the Technical Reports Type 3 Based on ASC X12 version 005010X279A1 270/271 Health Care Eligibility Benefit Inquiry and Response Companion Guide Version
More informationAppendix 3A. MA Companion Guide: CMS Supplemental Instructions for EDR and CRR Data Elements
Appendix 3A. MA Companion Guide: CMS Supplemental Instructions for EDR and CRR Data s A3A.1 LOOPS AND SEGMENTS APPLIED TO EDR AND CRR SUBMISSIONS... 3 A3A.2 CONTROL SEGMENTS: CMS SUPPLEMENTAL INSTRUCTIONS
More information837I Health Care Claim Companion Guide
837I Health Care Claim Companion Guide Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010 Companion Guide Version
More information837 Professional Health Care Claim Outbound. Section 1 837P Professional Health Care Claim: Basic Instructions
Companion Document 837P 837 Professional Health Care Claim Outbound This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and
More information837I Institutional Health Care Claim - for Encounters
Companion Document 837I - Encounters 837I Institutional Health Care Claim - for Encounters Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care
More information837 Institutional Health Care Claim Outbound. Section 1 837I Institutional Health Care Claim: Basic Instructions
Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained
More informationVendor Specifications 278 Healthcare Services Request for Review and Response ASC X12N Version for. State of Idaho MMIS
Vendor Specifications 278 Healthcare Services uest for Review and Response ASC X12N Version 5010 for State of Idaho MMIS Date of Publication: 07/25/2017 Document Number: TL418 Version: 5.0 Revision History
More information837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions
Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained
More information837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.3 Update 06/17/04
837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 1.3 Update 06/17/04 Author: Publication: EDI Department LA Medicaid Companion Guide The purpose of
More informationANSI ASC X12N 837P Health Care Claim Professional. TCHP Companion Guide
ANSI ASC X12N 837P Health Care Claim Professional TCHP Companion Guide Published: July 20, 2016 Contents Purpose... 3 Security and Privacy Statement... 3 Overview of HIPAA Legislation... 3 Compliance according
More informationVIII STANDARD ENCOUNTER COMPANION GUIDE A. Transaction Introduction
A. Transaction Introduction Standard Companion Guide (CG) Transaction Information Effective March 27, 2015 IEHP Instructions related to Implementation Guides (IG) based On X12 Version 005010X222A1 Health
More informationCompanion Guide for the X222A1 Health Care Claim: Professional (837P) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC
Companion Guide for the 005010X222A1 Health Care Claim: Professional (837P) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC Segment Loop Description TR3 Values Notes Delimiter:
More information837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions
Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained
More information837 Health Care Claim: Professional
837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 2.0 Final Author: Information Systems Trading Partner: MHO200750134 EDI Companion Guide Molina Healthcare
More informationKY Medicaid. 837P Companion Guide. Cabinet for Health and Family Services Department for Medicaid Services. March 28, 2017 KY MEDICAID COMPANION GUIDE
KY Medicaid 837P Companion Guide Cabinet for Health and Family Services Department for Medicaid Services March 28, 2017 DMS Approved [2017 005010] 1 Document Change Log Version Changed Date Changed By
More information837I Inbound Companion Guide
837I Inbound Companion Institutional Claim Submission Version 2.2 Table of Contents REVISION HISTORY...3 SECTION 01: INTRODUCTION...4 Overview...4 Data Flow...5 Processing Assumptions...5 Basic Technical...6
More informationADJ. SYSTEM FLD LEN. Min. Max.
Loop Loop Repeat Segme nt Element Id Description X12 Page No. ID Min. Max. ADJ. SYSTEM FLD LEN Usage Req. ANSI VALUES COMMENTS 1 ISA Interchange Control Header B.3 1 R ISA08 Interchange Receiver ID AN
More information837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions
Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained
More information837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions
Companion Document 837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained
More information837I Institutional Health Care Claim
Section 2B 837I Institutional Health Care Claim Companion Document Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for Institutional
More informationEyeMed Vision Care. HEALTH CARE CLAIM: PROFESSIONAL Companion Document to ASC X12N 837 (004010X098A1)
HEALTH CARE CLAIM: PROFESSIONAL Companion Document to ASC X12N 837 (004010X098A1) Welcome to EyeMed Vision Care s HIPAA TCS implementation process. We have developed this guide to assist you in preparing
More information12. IEHP I INSTITUTIONAL CLAIM COMPANION GUIDE A. Included ASC X12 Implementation Guides
1. 005010X223A2 Health Care Claim: Institutional Standard Companion Guide (CG) Transaction Information Effective January 1, 2018 IEHP Instructions related to Implementation Guides (IG) based and on X12
More informationKY Medicaid. 837I Companion Guide. Cabinet for Health and Family Services Department for Medicaid Services. March 28, 2017 KY MEDICAID COMPANION GUIDE
KY Medicaid 837I Companion Guide Cabinet for Health and Family Services Department for Medicaid Services March 28, 2017 DMS Approved 2017 005010 1 Document Change Log Version Changed Date Changed By Reason
More informationVersion Number: 1.0 Introduction Matrix Wellmark Values. November 01, 2011
Wellmark Blue Cross and Blue Shield HIPAA Transaction Standard Companion Guide Section 2, 837 Institutional Refers to the X2N Technical Report Type 3 ANSI Version 500A2 Version Number:.0 Introduction Matrix
More information837 Health Care Claim: Institutional
837 Health Care Claim: Institutional HIPAA/V4010X096A1/837: 837 Health Care Claim: Institutional Version: Final Modified: 11/29/2006 Current: 11/29/2006 837I4010a1.ecs 1 For internal use only 837I4010a1.ecs
More informationHealth Care Claim: Institutional (837)
Health Care Claim: Institutional (837) Standard Companion Guide Transaction Information November 2, 2015 Version 3.1 Express permission to use ASC X12 copyrighted materials within this document has been
More informationEarly Intervention Central Billing Office. Companion Document and Transaction Specifications for HIPAA 837 Claim Transactions
Early Intervention Central Billing Office Companion Document and Transaction Specifications for HIPAA 837 Claim Transactions Version 1.0 - January 2012 Table of Contents 1. Introduction... 1 1.1 Document
More informationANSI ASC X12N 837P Health Care Claim Professional. TCHP Companion Guide
ANSI ASC X12N 837P Health Care Claim Professional TCHP Companion Guide Updated: October 10, 2017 Contents Purpose... 3 Security and Privacy Statement... 3 Overview of HIPAA Legislation... 3 Compliance
More information835 Payment Advice NPI Dual Receipt
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,
More informationIndiana Health Coverage Programs
Indiana Health Coverage Programs Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010 Health Care Claim: Institutional
More information5010 Upcoming Changes:
HP Systems Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S 5010 Upcoming Changes: 837 Institutional Claims and Encounters Transaction Based on Version 5, Release 1 ASC X12N 005010X223 Revision
More informationKY Medicaid. 837P Companion Guide. Cabinet for Health and Family Services Department for Medicaid Services. August 1, 2017 KY MEDICAID COMPANION GUIDE
KY Medicaid 837P Companion Guide Cabinet for Health and Family Services Department for Medicaid Services August 1, 2017 DMS Approved [2017 005010] 1 Document Change Log Version Changed Date Changed By
More informationEDS SYSTEMS UNIT. Companion Guide: 837 Institutional Claims and Encounters Transaction
EDS SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide: 837 Institutional Claims and Encounters Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0
More informationTroubleshooting 999 and 277 Rejections. Segments
Troubleshooting 999 and 277 Rejections Segments NM103 - last name or group name NM104 - first name NM105 - middle initial NM109 - usually specific information tied to that company/providers/subscriber/patient
More information837 Institutional Health Care Claim Outbound
837I This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained in this document
More informationANSI ASC X12N 837I Health Care Claim Institutional. TCHP Companion Guide
ANSI ASC X12N 837I Health Care Claim Institutional TCHP Companion Guide Updated: October 10, 2017 Contents Purpose... 3 Security and Privacy Statement... 3 Overview of HIPAA Legislation... 3 Compliance
More informationHealthpac 837 Message Elements - Professional
Healthpac 837 Message Elements - Version 1.4 March 17, 2003 1 Healthpac 837 Message Elements Table of Contents 1 INTRODUCTION...2 1.1 GENERAL COMMENTS...2 1.2 RELATED DOCUMENTS...3 2 MESSAGE ELEMENTS...4
More informationIndiana Health Coverage Programs
Indiana Health Coverage Programs Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010 Health Care Claim: Dental (837)
More informationIndiana Health Coverage Programs
Indiana Health Coverage Programs Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010 Health Care Claim: Institutional
More informationStandard Companion Guide Transaction Information
Standard Companion Guide Transaction Information Instructions Related to Transactions Based on ASC X12 Implementation Guide, Version 005010 Professional 005010X222A1 PHC Companion Guide Version Number:
More information837 Health Care Claim: Professional
837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 2.0 Final Author: Information Systems Trading Partner: MHC330342719 Notes: EDI Companion Guide Molina
More informationHEALTHpac 837 Message Elements Institutional
HEALTHpac 837 Message Elements Version 1.2 March 17, 2003 1 Table of Contents 1 INTRODUCTION...2 1.1 GENERAL COMMENTS...2 1.2 RELATED DOCUMENTS...3 2 MESSAGE ELEMENTS...4 2.1 HEADER...4 2.2 INFO SOURCE...5
More informationANSI ASC X12N 277P Pending Remittance
ANSI ASC X12N 277P Pending Remittance Acute Care COMPANION GUE For Non-covered Transactions April 29, 2016 Texas Medicaid & Healthcare Partnership Page 1 of 19 Revision Date: 5/5/2016 Table of Contents
More information837 Health Care Claim: Professional
837 Health Care Claim: Professional HIPAA/V4010X098A1/837: 837 Health Care Claim: Professional Version: 2.0 Final Author: Information Systems Trading Partner: MHW91128479 EDI Companion Guide Molina Healthcare
More informationTCHP MEDICAID PROFESSIONAL COMPANION DOCUMENT Addenda Version X12 Page Mi n.
Loop Loop Repeat 4010 Segment/ Data Description TCHP MEDICAID PROFESSIONAL X12 Page No. ID 401 0Mi n. 4010 Usag e Valid Values Comments 1 ISA INTERCHANGE CONTROL HEADER B.3 R ISA08 Interchange Receiver
More information5010 Upcoming Changes:
HP Systems Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S 5010 Upcoming Changes: 270/271 Eligibility Benefit Transaction Based on Version 5, Release 1 ASC X12N 005010X279 Revision Information
More informationNational Uniform Claim Committee
National Uniform Claim Committee 1500 Claim Form Map to the X12 837 Health Care Claim: Professional November 2008 The 1500 Claim Form Map to the X12 837 Health Care Claim: Professional includes data elements,
More informationHP SYSTEMS UNIT. Companion Guide: 270/271 Eligibility Benefit Transaction
HP SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide: 270/271 Eligibility L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 1 2 A S C X 1 2 N 2 7 0 / 2 7
More informationNational Uniform Claim Committee
National Uniform Claim Committee 02/12 1500 Claim Form Map to the X12 Health Care Claim: Professional (837) August 2018 The 1500 Claim Form Map to the X12 Health Care Claim: Professional (837) includes
More information837 PROFESSIONAL CLAIMS AND ENCOUNTERS TRANSACTION COMPANION GUIDE
837 PROFESSIONAL CLAIMS AND ENCOUNTERS TRANSACTION COMPANION GUIDE JULY 23, 2015 A S C X 1 2 N 8 3 7 (0 0 5 0 10 X 222A1) VERSION 2 TABLE OF CONTENTS 1.0 Background 3 1.1 Overview 3 1.2 Introduction 4
More informationEDS SYSTEMS UNIT. Companion Guide: 837 Professional Claims and Encounters Transaction
EDS SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide: 837 Professional Claims and Encounters Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0
More informationNational Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (005010)
National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (005010) DMC Managed Care Claims - Electronic Data Interchange Strategy
More information820 Payment Order/Remittance Advice
820 Payment Order/Remittance Advice HIPAA/V5010X218: 820 Payment Order/Remittance Advice, Louisiana Medicaid Version: 1.0 Created: 9/20/2011 The purpose of this guide is to clarify the usage of the X12
More informationTexas Medicaid. HIPAA Transaction Standard Companion Guide
Texas Medicaid HIPAA Transaction Standard Companion Guide Refers to the Implementation Guide Long Term Care 837 Health Care Claim: Institutional Based on ASC X12 version 005010 CORE v5010 Companion Guide
More informationKY Medicaid. 837 Dental Companion Guide. Cabinet for Health and Family Services Department for Medicaid Services
KY Medicaid 837 Dental Companion Guide Cabinet for Health and Family Services Department for Medicaid Services March 28, 2017 Document Change Log Version Changed Date Changed By Reason 2.0 11/02/2011 Kathy
More informationWEDI SNIP Claredi EDI Edit Description Claim Type 837P 837I. 1 H10006 Value is too long X X
EDI Claim Edits UnitedHealthcare applies Health Insurance Portability and Accountability Act (HIPAA) edits for professional (837p) and institutional (837i) claims submitted electronically. Enhancements
More informationEDS SYSTEMS UNIT. Pre-Release Companion Guide: 270/271 Eligibility Benefit Transaction
EDS SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Pre-Release Companion Guide: 270/271 Eligibility Benefit Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0
More informationFallon Health. 835 Fallon Health Companion Guide. Health Care Payment Advice. 835 Companion Guide
Fallon Health Health Care Payment Advice 835 Companion Guide Refers to the ASC X12N 835 Technical Report Type 3 Guide (Version 005010X221A1) Companion Guide Version Number: 1.3 October 2017 1 Disclosure
More information837 PROFESSIONAL CLAIMS AND ENCOUNTERS TRANSACTION COMPANION GUIDE
837 PROFESSIONAL CLAIMS AND ENCOUNTERS TRANSACTION COMPANION GUIDE JUNE 22, 2011 A S C X 1 2 N 8 3 7 (0 0 5 0 10 X 222A1) VERSION 1 TABLE OF CONTENTS 1.0 Background 3 1.1 Overview 3 1.2 Introduction 4
More informationIAIABC EDI IMPLEMENTATION GUIDE
IAIABC EDI IMPLEMENTATION GUIDE for MEDICAL BILL PAYMENT RECORDS RELEASE 1.1 JULY 1, 2009 EDITION INTERNATIONAL ASSOCIATION OF INDUSTRIAL ACCIDENT BOARDS AND COMMISSIONS This page is meant to be blank.
More informationVendor Specifications 834 Outbound Benefit Enrollment and Maintenance ASC X12N Version 5010A1. for. State of Idaho MMIS
Vendor Specifications 834 Outbound Benefit Enrollment and Maintenance ASC X12N Version 5010A1 for State of Idaho MMIS Date of Publication: 7/31/2017 Document Number: TL421 Version: 5.0 Revision History
More informationFacility Instruction Manual:
Facility Instruction Manual: Submitting Secondary Claims with COB Data Elements Overview This supplement to the billing section of the Passport Health Plan (PHP) Provider Manual provides specific coding
More informationThe Source of Payment Typology A National Standard
The Source of Payment Typology A National Standard Presentation to ASC X12 September 29, 2015 Hetty Khan National Center for Health Statistics Agenda Background Description Purpose Uses Maintenance Background
More information835 Health Care Claim Payment/Advice
Companion Document 835 835 Health Care Claim Payment/Advice Basic Instructions This section provides information to help you prepare for the ANSI ASC X12 Health Care Claim Payment/Advice (835) transaction.
More informationFlorida Blue Health Plan
Florida Blue Health Plan HIPAA Transaction Standard Companion Guide For Availity Health Information Network Users Refers to the Technical Reports Type 3 Based on ASC X12 version 005010X222A1 837I Health
More informationBlue Shield of California
Blue Shield of California HIPAA Transaction Standard Companion Guide Section 1 Refers to the Implementation Guides Based on X12 version 005010 Companion Guide Version Number: 1.9 February, 2018 [February
More informationSubmitting Secondary Claims with COB Data Elements - Facilities
Overview Submitting Secondary Claims with COB Data Elements - Facilities This supplement to the billing section of the AmeriHealth Caritas Pennsylvania Claims Filing Instruction Manual provides specific
More information5010 Upcoming Changes: Response Transaction. Based on Version 5, Release 1 ASC X12N X212
HP Systems Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S 5010 Upcoming Changes: 276/277 Claim Status Request and Response Transaction Based on Version 5, Release 1 ASC X12N 005010X212
More informationTheraManager Help Note
Subject: EDI Claim Troubleshooting Guide TheraManager Help Note This Help Note consists of a list of selected elements within an EDI claim (ANSI 837, version 5010) and the TheraManager screen where the
More informationTable of Contents: 837 Institutional Claim
Table of Contents: 837 Institutional Claim Overview 1 Claims Processing 1 Acknowledgements 1 Anesthesia Billing 1 Coordination of Benefits (COB) Processing 2 Code Sets 2 Corrections and Reversals 2 Data
More informationHIPAA Transaction Companion Guide 837 Professional Health Care Claim
HIPAA Transaction Companion Guide 837 Professional Health Care Claim Refers to the Implementation Guides Based on X12 version 005010 Companion Guide Version Number: 1.2 August 2017 Disclaimer Statement
More informationEyeMed Vision Care. HEALTHCARE BENEFIT ELIGIBILITY INQUIRY Companion Document to ASC X12N 270 (004010X092)
HEALTHCARE BENEFIT ELIGIBILITY INQUIRY Companion Document to ASC X12N 270 (004010X092) Welcome to EyeMed Vision Care s HIPAA TCS implementation process. We have developed this guide to assist you in preparing
More information834 Benefit Enrollment and Maintenance
Companion Document 834 834 Benefit Enrollment and Maintenance Basic Instructions This section provides information to help you prepare for the ANSI ASC X12.84, Benefit Enrollment and Maintenance (834)
More informationHCFA Mapping to BCBSNC Local Proprietary Format (LPF) and the HIPAA 837-Professional Implementation Guide
HCFA Mapping to BCBSNC Local Proprietary at (LPF) n/a Header and Trailer - Header & Footers information will be in the ISA/IEA, GS/GE & THE ST/SE HDR 1-3 TRL1-3 1 Leave blank n/a n/a 1a Insured s ID Enter
More informationThe "Abridged" tab displays only those data elements pulled from PsychConsult for the 837 file submission.
Using the Document The "Complete" tab of this spreadsheet represents all data elements included in an 837 file submission. The "Abridged" tab displays only those data elements pulled from for the 837 file
More informationJoint Venture Hospital Laboratories
Joint Venture Hospital Laboratories Companion Guide ASC X12N 837I (005010X223A2) Health Care Claim: Institutional 837 ASC X12N 837P (005010X222A1) Health Care Claim: Professional 837 Version 1.3.3 October
More informationStandard Companion Guide
Standard Companion Guide Refers to the Implementation Guide Based on X12 Version 005010X221A1 Health Care Claim Payment/Advice (835) Companion Guide Version Number: 2.0 February 2018 Page 1 of 13 CHANGE
More informationEDS SYSTEMS UNIT. Pre-Release Companion Guide: 835 Remittance Advice Transaction
EDS SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Pre-Release Companion Guide: 835 Remittance Advice Transaction L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 1 9
More informationHIPAA Transaction Standard Companion Guide
HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 Companion Guide Version Number: 2.2 March 2013 March 2013 005010 1 Disclosure Statement This
More information837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions
Companion Document 837I 837 Institutional Health Care Claim This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not
More informationHIPAA Transaction Standard Companion Guide
HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 Companion Guide Version Number: 2.4 December 2013 December 2013 005010 1 Disclosure Statement
More information837 Institutional Inbound Claims (005010X223A2) 5010 COB Companion Guide Version 1.0 Draft
837 Institutional Inbound Claims (005010X223A2) 5010 COB Companion Guide Draft Effective February 24, 2017 Prepared for LA Care Health Plan and Trading Partners Document Revision/Version Control Version
More informationInstitutional Claim (UB-04) Field Descriptions
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. Institutional Claim (UB-04) Field s Following are Kaiser Foundation Health Plan of Washington s
More information837 Encounter Companion Guide to the HIPAA Implementation Guide. Professional, Institutional, and Dental Claims
837 Encounter Companion Guide to the HIPAA Implementation Guide Professional, Institutional, and Dental Claims June 2015 Minnesota Health Care Programs (MHCP) Provider Helpdesk 651-431-2700 1-800-366-5411
More informationChapter 10 Companion Guide 835 Payment & Remittance Advice
Chapter 10 Companion Guide 835 Payment & Remittance Advice This companion guide for the ANSI ASC X12N 835 Healthcare Claim PaymentAdvice transaction has been created for use in conjunction with the ANSI
More informationCommonwealth of Virginia (State Programs) 834 Benefit Enrollment and Maintenance: Audit File
Sample: ISA*00* *00* *30*54-6024817 *30*99-9999999 *050503*1436*U*00401*100000411*0*P*~ GS*BE*COMMW VIRGINIA*99-9999999*20050503*053645*50320059*X*004010X095A1~ ST*834*1001~ BGN*00*125839*20050503*053645*ET***4~
More information