Advanced EDI 999 and 277CA

Transcription

1 Advanced EDI 999 and 277CA

2 Agenda Review of Critical Terms 999 Deep Dive & Test Run 277 Deep Dive & Test run

3 REVIEW OF CRITICAL TERMS

4 Nesting ISA Interchange Header GS Batch 1 Group Header ST Response 1 Transaction Header SE Response 1 Transaction Footer ST Response 2 Transaction Header SE Response 2 Transaction Footer ST Response 3 Transaction Header SE Response 3 Transaction Footer GE Batch 1 Group Footer GS Batch 2 Group Header ST Response 1 Transaction Header SE Response 1 Transaction Footer GE Batch 2 Group Footer IEA Interchange Footer

5 Hierarchical Level Loop 2010BA (Subscriber loop) Segment Segment Segment Segment NM1*IL*1*DOE*JANE****MI* ~ N3*123 ANYWHERE ST~ N4*MURRAY*UT*84107~ DMG*D8* *F~ Element Element Element

6 Hierarchical Level Loop 2000B Hierarchical Level Loop 2010BB

7 DEEP DIVE

8 999 Functional or Implementation Acknowledgement Purpose Characteristics Version Reports syntax and implementation errors for the functional group (GS to GE) Typically within 24 hours Typically batch level X231

9 999 Hierarchy Functional Group Response Transaction Set Response ISA / IEA GS / GE Error: Loop & Segment Error: Data Element ST/SE

10 Hierarchy Example Header / Footer Functional Group Response Transaction Set Response Error: Loop & Segment Error: Data Element ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

11 AK1, AK2 Report original transaction type and ID IK5, AK9 Report status ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

12 IK5 Transaction Set Response Trailer IK5*R*I5~ Acknowledgement code Syntax error code

13

14 AK9 Functional group response trailer AK9*R*1*1*0~ Acknowledgement code Number of transaction sets included Number of received transaction sets Number of accepted transaction sets

15 AK1, AK2 Report original transaction type and ID IK5, AK9 Report status ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

16 AK1 Functional Group Response Header AK1*HC* *005010X222A1 ~ Orig. GS01 Value HC = Health Care Claim (837) HB = Eligibility, Group Coverage control or Benefit number Information (271) HS = Eligibility, Coverage or Benefit Request (270) BE Uses = Benefit the Enrollment orig. & Information GS06 value (834) RA = Payment Order/Remittance Advice (820) HI = Health Care Services Review Information (278) HR = Health Care Claim Status Request (276) HN = Health Care Information Status Notification (277/277CA) PI = Patient Information (275) HP = Health Care Claim Payment/Advice (835) FA = Functional Acknowledgement (999) Original transaction version

17 AK2 Transaction set response header AK X222A1~ Required when an error is present. If there is no error, it is up to the sender s discretion. Transaction type in error Transaction Set Control Number Uses the ST02 value Original Transaction version

18 Functional Group Response Transaction Set Response ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

19 Error: Loop & Segment Error: Data Element ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

20 IK3, CTX, IK4, CTX Identify the location and type of error ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

21 IK3 Error identification IK3*DTP*22*2300*8~ Required when an error is present. Segment in error Segment position Numerical segment count from ST Loop in error Syntax error code

22 CTX Business Unit Identifier CTX*CLM01^2SMITH002~ Required when error in the IK3 is within a business unit and the unit is known Context identification Context reference - value from original submission

23 IK4 Implementation Data Element Note IK4*3*1251*I12* ~ Required when the error [ ] applies to a data element and the location [ ] can be identified [ ]. Data element Reference number in Data element Copy of bad position in data element syntax error data error dictionary code element

24 CTX Segment Context (loop 2100) OR Element Context (loop 2110) CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ Required when error in the IK3 was triggered by a situational requirement, and error is at the segment level. Segment Segment Loop Position in Reference in Context code position identifier segment segment

25 Header / Footer Functional Group Response Transaction Set Response Error: Loop & Segment Error: Data Element ISA*00* *00* *ZZ*HT *ZZ*HT *150318*1212*{*00501* *0*P*^~ GS*FA*HT *HT * *1212*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*00111*005010X222A1~ IK3*DTP*22*2300*8~ CTX*CLM01^2SMITH002~ IK4*3*1251*I12* ~ CTX*SITUATIONAL TRIGGER*DTP*26**3*1251~ IK5*R*I5~ AK9*R*1*1*0~ SE*10*0001~ GE*1*1~ IEA*1* ~

26 999 Example Goals 1. Identify the status 2. Identify the original transaction 3. Identify the error location/reason

27 999: Example *180703*1323*^*00501* *0*P*:~ Patient SMITH in batch had an invalid value of F431 in 2300 HI01-2. This is an invalid diagnosis code. ISA*00* *00* *ZZ*HT *ZZ*HT GS*FA*HT *HT * *132314*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*30799*005010X222A1~ IK3*HI*22*2300*8~ CTX*CLM01:SMITH~ IK4*1:2*1271*7*F431~ IK5*R*5~ AK9*R*1*1*0~ SE*9*0001~ GE*1*1~ IEA*1* ~

28 999: Example *180316*5555*{*00501* *0*P*^~ Batch had an invalid value of in 2010 N403. ISA*00* *00* *ZZ*HT *ZZ*HT GS*FA*HT *HT * *5555*1*X*005010X231A1~ ST*999*0001*005010X231A1~ AK1*HC* *005010X222A1~ AK2*837*274819*005010X222A1~ IK3*N4*9*2010*8~ Billing provider ZIP codes must be 9 digits. IK4*3*166*I12*84102~ IK5*R*I5~ AK9*R*1*1*0~ SE*8*0001~ GE*1*1~ IEA*1* ~

29 999: Example 3 Batch had a situational error involving the 2400 SV101-7 and SV101-2 fields. The claim needs a service line description for that CPT code. ISA ZZ HT ZZ HT ^ P :~ GS FA HT HT X X231A1~ ST X231A1~ AK1 HC X222A1~ AK X222A1~ IK3 SV ~ IK4 1:7 352 I9~ CTX SITUATIONAL TRIGGER SV1 24 1:2~ IK5 R I5~ AK9 R 1 1 0~ SE ~ GE ~ IEA ~

30 277 Business Rules Acknowledgement Purpose Reports business rule errors for the functional group (GS to GE) Characteristics Typically within 48 hours Claim level details Version X214

31 277 Hierarchy Information Source 2000A Information Receiver 2000B Billing Provider Level 2000C ISA/IEA GS /GE ST / SE Patient Level 2000D Claim Status Information 2200D Service Line Information 2220D

32 Hierarchy Example Information Source 2000A Information Receiver 2000B Billing Provider Level 2000C Patient Level 2000D HL*1**20*1~ NM1*PR*2*CIGNA*****PI* ~ TRN*1* ~ DTP*050*D8* ~ DTP*009*D8* ~ HL*2*1*21*1~ NM1*41*2*UHIN SUBMITTER*****46*HT ~ TRN*2* ~ STC*A1:19:PR* *WQ*385~ QTY*90*1~ QTY*AA*1~ AMT*YU*221.00~ AMT*YY*164.00~ HL*3*2*19*1~ NM1*85*1*SHERMAN*JOHN*P***XX* ~ TRN*1* ~ REF*TJ* ~ QTY*QA*1~ QTY*QC*1~ AMT*YU*221.00~ AMT*YY*164.00~ HL*5*3*PT~ NM1*QC*1*SMITH*HERMAN****MI* ~ TRN*2* D95195F1~ STC*A7:88:QC* *U*164~ REF*1K* UTGN7777~ DTP*472*D8* ~

33 Information Source Hierarchical Level Information Source Level 2000A HL*1**20*1~ Information Source Name 2100A NM1*PR*2*CIGNA*****PI* ~ Information Receipt Control Identifier 2200A TRN*1* ~ DTP*050*D8* ~ DTP*009*D8* ~ Transmission Receipt Control ID Receipt Date Process Date

34 Information Receiver Information Receiver Level 2000B HL*2*1*21*1~ Information Receiver Name 2100B NM1*41*2*GENERAL PRACTICE*****46*HT ~ Information Receiver Application Identifier 2200B TRN*2* ~ STC*A1:19:PR* *WQ*385~ QTY*90*1~ QTY*AA*1~ AMT*YU*221.00~ AMT*YY*164.00~ Transmission Receiver Application Trace # Receiver Status Information Accepted Quantity Rejected Quantity Accepted Amount Rejected Amount

35 Status Information STC*A1:19:PR* *WQ*385~ Category Code Status Code Entity Code Date Accept/ Reject Amount Acknowledgements Pending Finalized Requests for additional information Error

36 Status Information STC*A1:19:PR* *WQ*385~ Category Code Status Code Entity Code Date Accept/ Reject Amount A0 A2: Acknowledgement/ Acceptance A3 A8: Acknowledgement/ Rejection

37 Why Here? Information Receiver B Includes an entire unit of work (e.g. single transaction of claims). Information contained at this level will be summary details pertaining to the unit of work being acknowledged. Ex: Duplicate File

38 Billing Provider Billing Provider Level 2000C HL*3*2*19*1~ Billing Provider Name 2100C NM1*85*1*SHERMAN*JOHN*P***XX* ~ Provider of Service Information Trace Identifier 2200C TRN*1* ~ REF*TJ* ~ QTY*QA*1~ QTY*QC*1~ Provider of Service Trace Identifier Billing Provider Status Information Accepted Quantity Rejected Quantity AMT*YU*221.00~ Accepted Amount AMT*YY*164.00~ Rejected Amount

39 Billing Provider Billing Provider Level 2000C HL*3*2*19*1~ Billing Provider Name 2100C NM1*85*1*SHERMAN*JOHN*P***XX* ~ Provider of Service Information Trace Identifier 2200C TRN*1* ~ REF*TJ* ~ QTY*QA*1~ QTY*QC*1~ AMT*YU*221.00~ AMT*YY*164.00~ STC?

40 Why Here? Billing Provider C Required when needed to provide the status of a specific Billing Provider s group of claims. If not required, it may be provided at the sender s discretion, but cannot be required by the receiver. Ex: Missing/Invalid Tax ID

41 Patient Detail Patient Level 2000D HL*5*3*PT~ Patient Name 2100D NM1*QC*1*SMITH*HERMAN****MI* ~ Claim Status Tracking Number 2200D TRN*2* D95195F1~ STC*A7:88:QC* *U*164~ REF*1K* UTGN7777~ DTP*472*D8* ~ Claim Status Tracking # Claim Level Status Payer Claim Control # Claim Level Service Date Service Line Information 2220D Service Line Information, Service Line Level Status, Service line Date, etc.

42 Why Here? Patient Detail D To report the status, required action, and paid information of a claim or service line. Required. Ex: Invalid Subscriber ID Patient Not Eligible Billing Provider Entity ID Billing Provider NPI Property & Casualty Number Missing/Invalid Date of Service Pending Investigation of Other Insurance Coverage Incorrect Payer Claim Level Reference Number Procedure Code

43 277CA Example 1: Goals 1. Identify the Source (2000A) 2. Identify the Receiver (2000B) 3. Identify the Billing Provider (2000C) 4. Identify the Patient (2000D) BONUS: Identify the Status

44 Example 1 1. Identify the Source 2. Identify the Receiver 3. Identify the Billing Provider 4. Identify the Patient BONUS: Identify the Status HL ~ NM1 PR 2 PUBLIC EMPLOYEES HEALTH PROGRAM 46 HT ~ TRN ~ DTP 050 D ~ DTP 009 D ~ HL ~ NM GENERIC FAMILY PRACTICE 46 HT ~ TRN ~ STC A2:19: WQ 330~ QTY 90 2~ QTY AA 0~ AMT YU 330~ AMT YY 0~ HL ~ NM GENERIC FAMILY PRACTICE XX ~ TRN ~ STC A2:19:40 WQ 165~ REF TJ ~ QTY QA 1~ AMT YU 165~ HL 4 3 PT~ NM1 QC 1 LAST FIRST A MI ~ TRN ~ STC A2:19: WQ 165~ REF 1K ~ DTP 472 RD ~

45 277CA Example 2: Goals A Receive & Process Dates C Accepted & Rejected Amounts D Payer Claim Control Number D Claim Status BONUS: 2000D Date of Service

46 Example 2 1. (2000A) Receive & Process Dates 2. (2000C) Accepted & Rejected Amounts 3. (2000D) Payer Claim Control Number 4. (2000D) Claim Status BONUS: (2000D) Date of Service HL*1**20*1~ NM1*PR*2*CIGNA*****PI* ~ TRN*1* ~ DTP*050*D8* ~ DTP*009*D8* ~ HL*2*1*21*1~ NM1*41*2*UHIN SUBMITTER*****46*HT ~ TRN*2* ~ STC*A1:19:PR* *WQ*385~ QTY*90*1~ QTY*AA*1~ AMT*YU*221.00~ AMT*YY*164.00~ HL*3*2*19*1~ NM1*85*1*SHERMAN*JOHN*P***XX* ~ TRN*1* ~ REF*TJ* ~ QTY*QA*1~ QTY*QC*1~ AMT*YU*221.00~ AMT*YY*164.00~ HL*5*3*PT~ NM1*QC*1*SMITH*HERMAN****MI* ~ TRN*2* D95195F1~ STC*A7:88:QC* *U*164~ REF*1K* UTGN7777~ DTP*472*D8* ~

47 Resources X12 Code Lists: First Coast 277CA Lookup: Implementation guides available on Code lists not maintained by ASC X12 are referenced in the Appendix of each ASC X12 manual. o o Zip Codes (U.S. Postal Service) ICD-10 Codes

48 Contacts UHIN Customer Service Sara Vandermolen Corporate Trainer