USVI HEALTH CARE CLAIM 837 Companion Version 0.1 February 6, 2013
Table of Contents 1.0 COMPANION GUE PURPOSE... 4 2.0 ATYPICAL PROVERS... 4 3.0 CONTROL STRUCTURE DEFINITIONS... 5 3.1 ISA - INTERCHANGE CONTROL HEADER SEGMENT... 5 3.2 IEA - INTERCHANGE CONTROL TRAILER... 5 3.4 GE FUNCTIONAL GROUP TRAILER... 6 3.5 VAL DELIMITERS FOR USVI MEDICA... 6 4.0 TRANSMISSION CONSTRAINTS... 6 5.0 COMPANION GUE FOR THE 837 PROFESSIONAL TRANSACTION... 7 6.0 COMPANION GUE FOR THE 837 INSTITUTIONAL TRANSACTION... 11 6.1 ADDITIONAL PROVER INFORMATION... 17 7.0 COMPANION GUE FOR THE 837 DENTAL TRANSACTION... 18 February 6, 2013 2 837 Companion
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 NX12 5010 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, 2013 3 837 Companion
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, 2013 4 837 Companion
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 00501 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, 2013 5 837 Companion
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 GS06 3.5 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, 2013 6 837 Companion
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 GS08 005010X222A1 Identifier Beginning of Hierarchical Transaction BHT02 Transaction Set Purpose 00 Original Beginning of Hierarchical BHT06 Transaction Type CH Chargeable February 6, 2013 7 837 Companion
/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, 2013 8 837 Companion MC 1 Person MI Member USVI Medicaid 10 digit Recipient
/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 799.0 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, 2013 9 837 Companion
/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, 2013 10 837 Companion
/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 http://wpc-edi.com 6.0 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, 2013 11 837 Companion
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 GS08 005010X223A2 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, 2013 12 837 Companion
/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, 2013 13 837 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
/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, 2013 14 837 Companion
/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, 2013 15 837 Companion
/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, 2013 16 837 Companion
/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 http://wpc-edi.com 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, 2013 17 837 Companion
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 GS08 005010X224A2 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, 2013 18 837 Companion
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, 2013 19 837 Companion
/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, 2013 20 837 Companion
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, 2013 21 837 Companion