Companion Guide for the X223A2 Health Care Claim: Institutional (837I) Lines of Business: Private Business Senior Plans QUEST Blue Card FEP AFHC

Transcription

1 Companion Guide for the X223A2 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 Element (*) Asterisk Separator Delimiter: Composite (:) Colon Element Separator Delimiter: Segment Terminator (<NL>) New Line Hex Value 0A (line feed) or (~) Tilde ISA Interchange Control One ISA IEA per transmission Header ISA05 Interchange ID ZZ = Mutually Defined ISA06 Interchange Sender ID HMSA assigned submitter ID ISA07 Interchange ID 30 US Federal Tax ID ISA08 Interchange Receiver ID Both ISA07 must be equal to 30 and ISA08 must be equal to , otherwise HMSA will reject the file. ISA11 Repetition Separator ({) Left Brace ISA12 ISA13 Interchange Control Version Interchange Control Use a unique number assigned by the sender to identify the interchange data. It is used as an audit trail and in a check for duplicate exchange. A Control should never be reused. 0, 1 0 = TA1 will not be created ISA14 Acknowledgement Requested ISA15 Usage Indicator P, T P for production. T for test. HMSA will reject the file received with T in production and vice-versa. ISA16 GS Component Element Separator Functional Group Header : (Composite delimiter) HMSA will allow multiple Submitters within a GS GE functional group. HMSA will allow more than one Line of Business in an ISA IEA interchange GS02 Application Sender ACC = Accounting GS03 Application Receiver AH = Away From Home Care BC = Blue Card FE = Federal Employee Program (FEP) QT = QUEST RC = Senior Plans RG = Private Business CLM = more than one line of business included in the Functional Group. The subscriber number will

2 determine which line of business the claim will be processed under. GS06 Group Control Group Control should be unique for every GS GE functional group transmitted within the same day. A unique value will facilitate reconciliation with 999 functional acknowledgement transaction. GS08 Version/Release/Industry Identifier X223A2 for transactions submitted in version 5010A2. ST Transaction Set Header Recommend only one Billing Provider in each ST SE Transaction set. Providers can submit more than one Billing Provider in each ST SE but HMSA rejects will be done at the ST SE transaction set level. ST03 Implementation X223A2 Convention Reference BHT Beginning Of Hierarchical Transaction BHT03 Originator Application Transaction ID BHT06 Claim or Encounter ID List CH = Chargeable 1000A - Submitter Name NM1 1000A Submitter Name Use a unique number in this field. The assigned number must be unique within each file creation date (BHT04). This will be used as a duplicate check for each transaction. The fields for the duplicate check are: BHT03 (submission number), 1000A. NM109 (Submitter ID), BHT04 (create date), GS03 (line of business). NM109 Submitter Identifier HMSA Assigned Submitter ID PER Submitter EDI Contact 1000B Receiver Name NM1 1000B Receiver Name NM103 Receiver Name Use HAWAII MEDICAL SERVICE NM109 Receiver Primary Identifier 2000A Billing Provider Hierarchical Level HL 2000A Billing Provider Hierarchical Level PRV 2000A Billing Provider Specialty ASSOCIATION Use = HMSA s Federal Tax ID This Loop is required when Loop 2310B is not used. CUR 2000A Foreign Currency 2010AA Billing Provider Name NM1 2010AA Billing Provider Name N3 2010AA Billing Provider Use the physical address not the

3 Address mailing address. HMSA is using this information for processing N4 2010AA Billing Provider City/State/Zip N403 Postal HMSA requires Zip + 4 digits with no hyphen or spaces. REF 2010AA Billing Provider Tax PER 2010AA Billing Provider Contact 2010AB Pay To Address Name NM1 2010AB Pay To Address Name N3 2010AB Pay-To Address N4 2010AB Pay-To Provider City/State/Zip N403 Postal When present, this information will be used by HMSA for processing. When submitted, format should be Zip + 4 digits with no hyphen or spaces. 2010AC Pay-To Plan Name NM1 2010AC Pay-To Plan Name N3 2010AC Pay-To Plan Address N4 2010AC Pay-To Plan City, State, Zip REF 2010AC Pay-To Plan REF 2010AC Pay-To Plan Tax 2000B Subscriber Hierarchical Level HL 2000B Subscriber Hierarchical Level SBR 2000B Subscriber SBR02 Individual Relationship code SBR09 Claims Filing Indicator List 18 = Self HMSA will accept any valid qualifier, but will require usage of these particular qualifiers to denote the following types of claims: BL = Blue Cross/Blue Shield must be used for Blue Card FI = Federal Employees Program MC = Medicaid must be used when claim references Medicaid (such as claims for which EPSDT or Family Planning Indicators = Y ) 2010BA- Subscriber Name NM1 2010BA Subscriber Name NM102 Entity Type 1, 2 1 = Person = Subscriber NM103 Subscriber Last Name Do not use the following special pound sign (#) or caret symbol (^) NM104 Subscriber First Name Do not use the following special

4 NM108 NM109 Subscriber Primary Identifier N3 2010BA Subscriber Address N4 2010BA Subscriber City/State/Zip MI or II pound sign (#) or caret symbol (^) MI = HMSA ID HMSA Subscriber See HMSA Subscriber ID details in the Trading Partner Manual. This element is required for HMSA business needs. When submitted, format should be zip+4 digits with no hyphen or spaces. DMG 2010BA Subscriber Demographic DMG03 Subscriber Gender M, F, U M = Male or F = Female REF 2010BA Subscriber REF 2010BA Property And Casualty Claim 2010BB Payer Name NM1 2010BB Payer Name NM103 Payer Name HAWAII MEDICAL SERVICE NM108 PI or XV ASSOCIATION PI = Plan Identifier This element is required for HMSA business needs. NM109 Payer Identifier = HMSA s Federal Tax ID. N3 2010BB Payer Address N4 2010BB Payer City, State, ZIP REF 2010BB Payer REF 2010BB Billing Provider 2000C Patient Hierarchical Level HL 2000C Patient Hierarchical Level PAT 2000C Patient 2010CA Patient Name NM1 2010CA Patient Name N3 2010CA Patient Address N4 2010CA Patient City/State/Zip DMG 2010CA Patient Demographic DMG03 Patient Sex M, F, U M = Male or F = Female REF 2010CA Property and Casualty Claim 2300 Claim

5 CLM 2300 Claim CLM01 Claim Submitter Identifier/Patient Account CLM05-3 Claims Frequency Type Submission Reason DTP 2300 Discharge Hour DTP 2300 Statement Dates DTP 2300 Admission Date/Hour DTP 2300 Date- Repricer Received Date CL Institutional Claim PWK 2300 Claim Supplemental CN Contract AMT 2300 Patient Estimated Amount Due REF 2300 Service Authorization Exception REF 2300 Referral REF01 Reference 9F Patient Account Do not use the following special characters: Asterisk (*), equal sign (=), pound sign (#) or caret symbol (^) Use only 1 = Original; 7 = Resub; or 8 = Void 9F Referral REF02 Referral Do not use the following special pound sign (#) or caret symbol (^). Do not submit more than 15 characters REF 2300 Prior Authorization REF01 Reference G1 G1 Prior Authorization REF02 Prior Authorization Do not use the following special pound sign (#) or caret symbol (^). Do not submit more than 15 characters REF 2300 Payer Claim Control REF01 Reference F8 Original Reference REF02 Reference Original HMSA Claim ID REF 2300 Repriced Claim REF 2300 Adjusted Repriced Claim REF 2300 Investigational Device Exemption REF 2300 Claim Identifier for Transmission Intermediaries REF 2300 Auto Accident State REF 2300 Medical Record REF 2300 Demonstration Project Identifier

6 REF 2300 Peer Review Organization (PRO) Approval K File NTE 2300 Claim Note NTE 2300 Billing Note CRC 2300 EPSDT Referral HI 2300 Principal Diagnosis HI01-9 Yes/No Condition or Response HI 2300 Admitting Diagnosis HI 2300 Patient s Reason for Visit HI 2300 External Cause of Injury HI 2300 Diagnosis Related Group (DRG) HI 2300 Other Diagnosis HI 2300 Principal Procedure HI 2300 Other Procedure HI Occurrence Span HI 2300 Occurrence HI 2300 Value HI 2300 Condition HI01 Health Care List Use the POA information at this level instead of K3 segment. HI01-1 List BG Condition HI01-2 Industry Condition D0 = Service Date D1 = Charges D2 = Rev /HCPCS/HIPPS D3 = Subsequent interim PPS D4 = ICD Diagnosis/Procedure D8 = Medicare Primary D9 = Any other change E0 Patient Status HI 2300 Treatment HCP 2300 Claim Pricing/Repricing 2310A Attending Provider Name NM1 2310A Attending Provider Name PRV 2310A Attending Provider Specialty REF 2310A Attending Provider

7 2310B Operating Physician Name NM1 2310B Operating Physician Name REF 2310B Operating Physician 2310C - Other Operating Physician Name NM1 2310C Other Operating Physician Name REF 2310C Other Operating Physician 2310D - Rendering Provider Name NM1 2310D Rendering Provider Name REF 2310D Rendering Provider 2310E - Service Facility Location Name NM1 2310E Service Facility Location Name N3 2310E Service Facility Location Address Use the physical address not the mailing address. HMSA is using this information for processing. N301 Address Service Facility Street Address N4 2310E Service Facility Location City/State/Zip N403 Postal Required for processing. Format Should be Zip + 4 positions with no hyphen or spaces. REF 2310E Service Facility Location 2310F -- Referring Provider Name NM1 2310F Referring Provider Name REF 2310F Referring Provider 2320 Other Subscriber Other Sub/ Other Payer loops repeated once for each Payer SBR 2320 Other Subscriber SBR01 SBR09 Payer Responsibility Sequence Claim Filing Indicator Commonly reported values: P= Primary S = T = Tertiary Commonly reported values: Describes responsibility for Payer in 2330B Other Payer Names Loop Use BL (Blue Cross/Blue Shield) when HMSA is Other Payer. A valid

8 CAS 2320 Claim Level Adjustments 16= Health Maintenance Organization (HMO) Medicare Risk BL=Blue Cross/Blue Shield CI=Commercial Insurance Co. MA=Medicare Part A MB=Medicare Part B Claim Filing Indicator is required prior to the mandated use of Plan ID. Not used after Plan ID is mandated. MA, MB or 16 must be used to identify prior payer = Medicare Although separate claim submission is not normally required for dual membership situations, use BL when HMSA is Other Payer in 2330B. This would typically be used when submitting for Tertiary benefits. The CAS segment in the 2320 loop is used to report prior payers claim level adjustments that caused the amount paid to differ from the amount originally charged. This segment is used if the payer in this loop has reported claim level adjustment information on the primary payer s remittance advice. This line can be repeated if there are multiple adjustment groups. CAS01 CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 Claim Adjustment Group Claim Adjustment Reason CO=Contractual Obligations CR = Corrections and Reversals OA = Other Adjustments PI = Payer Initiated Reductions PR = Patient Responsibility If primary payer EOB provides line level adjustments, do not include any amounts reported at the line level in the claim level. This code tells HMSA who (the patient or the provider) is responsible for any adjustments made Identifies the reason for the claim being adjusted. For example: 1 = deductible 2 = coinsurance 3 = copayment Note: Your paper remittance may already contain standard code values. If so, please use the codes furnished by the primary payer. If primary payer uses proprietary reasons explaining reductions, those values will need to be mapped to standard codes for submission.

9 CAS03 CAS06 CAS09 CAS11 CAS14 CAS17 Monetary Adjustment Amount Represents the dollar amount being adjusted CAS04 CAS07 CAS10 CAS13 CAS16 CAS19 Service Line Adjusted Units AMT 2320 Coordination of Benefits (COB) Payer Paid Amount Represents the units of service being adjusted This segment is required when the claim has been adjudicated by the payer identified in the 2330B loop. AMT Amount D= Payer Amount Paid AMT Monetary Amount Dollar amount that correlates to AMT01 identifier. AMT 2320 Remaining Patient Liability AMT 2320 Coordination of Benefits (COB) Total Non-Covered Amount OI 2320 Other Insurance Coverage MIA 2320 Inpatient Adjudication MOA 2320 Outpatient Adjudication 2330A Other Subscriber Name This amount should equal total charges minus claim level and line level adjustments. Note: It is acceptable to show 0 (zero) as an amount paid, provided the CAS segment(s) properly explains why no payment was made. Submit if returned by prior payer on remittance advice (835) Note: When Medicare is primary payer and MOA03 or MOA05 or MOA20 or MOA21 or MOA22 contain values MA18 or N89, this indicates that Medicare crossover occurred and claim should not be submitted to HMSA until more than 30 days have passed from Medicare remittance date. NM1 2330A Other Subscriber Name NM108 MI, II When HMSA is Other Payer, use MI NM109 /Other HMSA Subscriber See

10 Insured Identifier/Subscriber Primary Identifier HMSA Subscriber ID details in the Trading Partner Manual. This element is required for HMSA business needs. N3 N4 REF Other Subscriber Address Other Subscriber City, State, ZIP Other Subscriber This is the membership id number used by the prior payer. (When Medicare is prior payer, this should contain HIC number.) 2330B Other Payer Name NM1 2330B Other Payer Name This is the Insurance Plan Name or Program Name from the previous payer. NM103 NM108 NM109 N3 N4 Last Name or Organization Name Other Payer Primary Identifier Other Payer Address Other Payer City, State, ZIP DTP 2330B Claim Check or Remittance Date Required when Loop 2320 Other Subscriber is used. Don t use the following special characters: asterisk (*), equal sign (=), pound sign (#), or caret symbol (^). PI or XV If HMSA is Other Payer use PI = Payer ID If HMSA is Other Payer use (HMSA s Federal Tax ID) Required when payer identified in 2330B/NM1 has previously adjudicated the claim. Do not report Loop 2330B if remittance date is being reported at the line level (Loop 2430) When prior payer is Medicare, do not submit claim until at least 31 days have passed since Medicare remittance date and HMSA has not processed the claim for secondary. This allows ample time for the Medicare crossover claim to be received and processed. DTP B Date/Time 573 Date Claim Paid DTP B Date/Time Period Adjudication or Payment Date REF 2330B Other Payer Identifier REF 2330B Other Payer Prior Authorization REF01 Reference G1 G1 = Treatment Authorization

11 REF02 Prior Authorization REF 2330B Other Payer Referral REF01 Reference 9F Treatment Authorization - Don t use the following special pound sign (#), or caret symbol (^). 9F = Referral REF02 Prior Referral Do not use the following special pound sign (#), or caret symbol (^). REF 2330B Other Payer Claim Adjustment Indicator REF 2330B Other Payer Claim Control 2330C Other Payer Attending Provider NM1 2330C Other Payer Attending Provider REF 2330C Other Payer Attending Provider 2330D Other Payer Operating Physician NM1 2330D Other Payer Operating Physician REF 2330D Other Payer Operating Physician 2330E Other Payer Other Operating Physician NM1 2330E Other Payer Other Operating Physician REF 2330E Other Payer Other Operating Physician Identifier 2330F Other Payer Service Facility Location NM1 2330F Other Payer Service Facility Location REF 2330F Other Payer Service Facility Location 2330G Other Payer Rendering Provider Name NM1 2330G Other Payer Rendering Provider Name REF 2330G Other Payer Rendering Provider 2330H Other Payer Referring Provider NM1 2330H Other Payer Referring Provider REF 2330H Other Payer Referring Provider

12 2330I Other Payer Billing Provider NM1 2330I Other Payer Billing Provider REF 2330I Other Payer Billing Provider 2400 Service Line LX 2400 Service Line SV Institutional Service Line SV201 Product/Service ID Revenue s must be submitted as a 4-position code. PWK 2400 Line Supplemental DTP 2400 Date-Service Date REF 2400 Line Item Control REF 2400 Repriced Line Item Reference REF 2400 Adjusted Repriced Line Item Reference AMT 2400 Service Tax Amount AMT 2400 Facility Tax Amount NTE 2400 Third Party Organization Notes HCP 2400 Line Pricing/Repricing 2410 Drug LIN 2410 Drug CTP 2410 Drug Quantity REF 2410 Prescription Or Compound Drug Association REF Reference 2420A Operating Physician Name NM1 2420A Operating Physician Name REF 2420A Operating Physician 2420B Other Operating Physician Name NM1 2420B Other Operating Physician Name REF 2420B Other Operating Physician 2420C Rendering Provider Name NM1 2420C Rendering Provider Name Do not use the following special pound sign (#), or caret symbol (^). Do not use the following special pound sign (#), or caret symbol (^).

13 REF 2420C Rendering Provider 2420D Referring Provider Name NM1 2420D Referring Provider Name REF 2420D Referring Provider 2430 Line Adjudication SVD 2430 Line Adjudication This segment is required when the claim has been previously adjudicated by the payer identified in the 2330B loop and the payer has reported line level payment and/or applied line level adjustments that cause the amount considered by the payer to differ from the amount originally charged. Other Payer Primary Identifier (Loop 2330B, NM109) Report line adjudication information if provided by primary payer. Indicates type of code being reported SVD Other Payer Primary Identifier SVD Service Line Amount Dollar Amount Paid SVD03-1 Product/Service ID SVD03-2 Procedure Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD03-3 Procedure Modifier 1 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD03-4 Procedure Modifier 2 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD03-5 Procedure Modifier 3 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD03-6 Procedure Modifier 4 Required when prior payer adjudicated claim with a modifier code that is different from the code billed to the payer SVD Quantity (Units of Represents paid units of service Service) CAS 2430 Line Adjustment Segment is required when the claim has been adjudicated by the payer identified in the 2330B loop and the payer applied line level adjustments that caused the amount considered by the payer to differ from the amount originally charged.

14 This explains why the other payer paid less (or more) than billed. most commonly required is deductible, coinsurance and/or copay amounts, negotiated/contractual rate reduction and/or explanation for non-payment. CAS01 CAS02 CAS05 CAS08 CAS11 CAS14 CAS17 Claim Adjustment Group Claim Adjustment Reason CO=Contractual Obligation CR = Corrections and Reversals OA = Other Adjustments PI = Payer Initiated PR = Patient Responsibility Do not enter at claim level any amounts included at line level. This code tells HMSA who (the patient or the provider) is responsible for any adjustments made Identifies the reason for claim being adjusted. CAS03 CAS06 CAS09 CAS12 CAS15 CAS18 Monetary Adjustment Amount Represents the dollar amount being adjusted CAS04 CAS07 CAS10 CAS13 CAS16 CAS19 Service Line Adjusted Units Represents the units of service being adjusted DTP 2430 Line Check or Remittance Date AMT 2430 Remaining Patient Liability SE Transaction Set Trailer GE Function Group Trailer

15 IEA Interchange Control Trailer *Updates: 6/30/12 - Added detail for Claim Correction & Resubmissions. *Updates 09/11/13 Added COB details