IntegraNet Claims 5010 Submission Companion Guide for 837 Professional and 837 Institutional Claims

Transcription

1 VERSION IntegraNet Claims 5010 Submission Companion Guide for 837 Professional and 837 Institutional Claims This companion guide for the ANSI ASC X12N 837 Professional and Institutional Claim transaction has been created for use in conjunction with the standard Implementation Guide. It should not be considered a replacement for the Implementation Guide, but rather used as an additional source of information. The companion guide contains data clarifications derived from specific business rules that apply exclusively to Claims submitted for Payment by IntegraNet Health The objectives of this document are: To clarify what information is needed by the IntegraNet Health Claims Department where the guide indicates that the choice is dependent on the Payer. To point out preferred selections for data element where multiple alternatives exist. This Companion Guide supplements the 837 Claim Implementation Guide ASC X12 Technical Report Type 3 (TR3), for transaction Professional claim sets X222 and Institutional claim sets X223. In order to create an IntegraNet HIPAA compliant transaction, you must first meet the requirements of the Implementation Guide and then incorporate the payer (IntegraNet) specific requirements. Every effort has been made to prevent errors in this document. However, if there is a discrepancy between this document and the Implementation Guide, the Implementation Guide is the final authority. Revision Date: 12/26/2018 IntegraNet 837 Companion Guide December 26, 2018

2 Contents IntegraNet 837 EDI Submissions... 1 Inbound Transactions Supported:... 1 Response Transactions Supported:... 1 Delimiters Supported... 1 File Submission Limits:... 1 Submission Gateways:... 2 IntegraNet Secure Website:... 2 FTP Submission:... 2 Testing Environment:... 3 Trading Partner Testing Procedures:... 3 Provider Billing Requirements... 3 Scenario: (Professional or Institutional Claims)... 4 Provider Group Scenario: (Professional Claims)... 4 Individual Provider Scenario: (Professional Claims)... 5 Service Facility Scenario: (Institutional Claims)... 5 IntegraNet Claims Companion Guide... 6 ISA - Interchange Control Header - Page B GS - Functional Group Header - B ST -- Transaction Set Header BHT -- Beginning of Hierarchical Transaction- Page NM1 -- Submitter Name - Page NM1 -- Receiver Name - Page PRV -- Billing/Pay-To-Provider Specialty - Page NM1 -- Billing Provider Name - Page REF -- Billing Provider Secondary Number - Page NM1 -- Pay-To Provider Name - Page REF Pay-To-Provider Secondary - Page SBR -- Subscriber Name - Page NM1 -- Payer Name - Page N3 -- Payer Address - Page IntegraNet 837 Companion Guide December 26, 2018

3 N4 -- Payer City/State/Zip - Page CLM -- Claim Information - Page NM1 --Referring Provider Name-Page NM1 --Rendering Provider Name-Page SBR - Other Subscriber Information - Page SV1 - Professional Service - Page NM1 --Rendering Provider Name-Page IntegraNet 837 Companion Guide December 26, 2018

4 IntegraNet 837 EDI Submissions IntegraNet Health Claims Department receives and process ANSI ASC X12N compliant 837 Professional and 837 Institutional EDI files for IntegraNet thru the IntegraNet Provider Portal. IntegraNet Claims processes all alpha characters in upper case. Do not use special characters. To properly process 837 transactions, IntegraNet Claims requires only ONE transaction type in each transmission file beginning with the ISA and ending with the ISE envelope segments. For example, if the submitter sends 837 transaction data for Professional and Institutional, there would be a separate file for each transaction (e.g. one containing only the 837P professional data, one containing only 837I institutional data.) Inbound Transactions Supported: 837 Professional Health Care Claim ASC X12N 837 (005010X222) 837 Institutional Health Care Claim ASC X12N 837 (005010X223) Response Transactions Supported: 997 Functional Acknowledgement 835 Health Care Claim Payment Advice - ASC X12N 835 (004010X091A1) HTML claim receipt (non ASC X12N) Delimiters Supported A delimiter is a character used to separate two data elements or sub-elements, or to terminate a segment. NAME CHARACTER NAME Data Element Separator * Asterisk Sub Element Separator : Colon Segment Terminator ~ Tilde File Submission Limits: Number of files per day: Unlimited Number of claims per day: Unlimited Claims per file: 5000 Submission days: Any day of week Files submitted via the secure website will receive response files after file upload. Files submitted via FTP before noon of the Business Day will receive response files the same Business Day IntegraNet 837 Companion Guide 1 December 26, 2018

5 Submission Gateways: IntegraNet Secure Website: IntegraNet Provider Portal For IntegraNet Website submission, call IntegraNet Health Claims Department or edi@abctservices.com Web Site Response Files: Option to download 997 with file processed datetime stamp. UserAssignedID HTML claim receipt with file processed datetime stamp _UserAssignedID.html o Claims where the member Id does not exist within data stores will be rejected. FTP Submission: FTP Connectivity call: IntegraNet Health Claims Department or edi@abctservices.com. After connectivity has been established the Trading Partner is assigned a UserAssignedID by the IntegraNet Health Claims Department. FTP Directory Structure Inbound Files: UserFTPDirectory\in Outbound Files: UserFTPDirectory\out FTP filename conventions/restrictions: DateTime_DP.UserAssignedID o UserAssignedID = sender s trading partner ID assigned at the beginning of Business-to-Business (B2B) testing. FTP Response Files: (UserFTPDirectory\out) 997 with file processed datetime stamp. UserAssignedID HTML claim receipt with of file processed datetime stamp _UserAssignedID.html o Claims where member Ids do not exist within data stores will be rejected. IntegraNet 837 Companion Guide 2 December 26, 2018

6 Testing Environment: Completion of the testing process must occur prior to electronic submission of production files. Assistance from the IntegraNet Health Claims Department is available throughout this process. Each test transmission is inspected thoroughly to ensure no format errors are present. Testing is conducted to verify the integrity of the format, not the integrity of the data; however, in order to simulate a production environment, we request that you send real transmission data. The number of test transmissions required depends on the number of format errors on a transmission and the relative severity of these errors. Additional testing may be required in the future to verify any changes made to the IntegraNet Provider Portal. Also, changes to the X12N formats may require additional testing. Trading Partner Testing Procedures: IntegraNet s secure website: provides this companion guide as well as enrollment packages for download. These documents can also be request via from the IntegraNet Health Claims Department at edi@abctservices.com. The trading partner completes and returns enrollment package. The trading partner is assigned a Logon Name and password. o If submission method is by FTP, IntegraNet Health Claims Department at edi@abctservices.com will assist in setting up FTP protocol. The IntegraNet Health Claims Department will issue a UserAssignedID for submitted file name conventions after the connectivity has been established. The trading partner contacts IntegraNet Health Claims Department to arrange a testing schedule. The trading partner submits test files. The IntegraNet Health Claims Department representative evaluates the flow of test data through the IntegraNet Provider Portal. If the test files are completed successfully, the IntegraNet Health Claims Department contacts the trading partner that the trading partner is approved for production file submission thru the IntegraNet Provider Portal. If the test files are unsuccessful, the IntegraNet Health Claims Department will contact the trading partner. The trading partner will remain in the testing environment until test files are completed successfully. Provider Billing Requirements The 837 Health Care Claim transaction provides a large amount of provider data at both the claim level and the service line level. IntegraNet Health Claims Department claim adjudication system only utilizes the provider data present at the claim level. Much of the provider data is situational and must be provided if the condition is met. Such as, the referring provider is required when a referral has been made, or the attending provider (institutional claim) is required when the claim is for an inpatient stay. IntegraNet 837 Companion Guide 3 December 26, 2018

7 The Billing/Pay-To loop (2000A) is a required loop. At a minimum the transaction must have a billing provider. The pay-to, rendering (professional claim) or service facility loops are dependent upon what is entered in the billing loop. Billing Provider Name loop (2010AA) - is a required loop used to identify the original entity that submitted the electronic claim/encounter. The billing provider entity may be a health care provider, a billing service or some other representative of the provider. Pay-To Provider Name loop (2010AB) - is a situational loop, required if the pay-to provider is a different entity from the billing provider. Rendering Provider Name loop (2310B) PROFESSIONAL ONLY is a situational loop, required if the rendering provider information is different than that carried in either the billing provider or pay-to provider (2010AA/AB) loops Depending on the scenario one or more of the previously mentioned loops might be present in the 837 Health Care Claim transaction. Refer to the scenarios below to determine the loops to be included in your transaction. Scenario: (Professional or Institutional Claims) In this scenario the provider, provider group or facility (institutional claims) contracts with a billing agent to perform their billing and reconciliation functions. In this case the following information should be provided: Billing Provider Name loop (2010AA) this loop will contain the billing agent information. Pay-To Provider Name (2010AB) this loop will contain the provider, provider group or facility (institutional claims) information. The entity receiving payment for the claim. Rendering Provider Name loop (2310B) PROFESSIONAL CLAIMS. This loop will only be included if the rendering provider is different from the pay-to provider. Provider Group Scenario: (Professional Claims) In this scenario the provider, who performed the services, is a member of a group. In this case the following information should be provided: Billing Provider Name loop (2010AA) this loop will contain the provider group information. Pay-To Provider Name loop (2010AB) this loop will be included if payment is being made to the rendering provider and not the group. It will contain the rendering provider information. Rendering Provider Name loop (2310B) this loop will only be included if the provider group is being paid for the claim (the pay-to provider loop (2010AB) is not included in the transaction). The rendering provider information will be provided in this loop. IntegraNet 837 Companion Guide 4 December 26, 2018

8 Individual Provider Scenario: (Professional Claims) In this scenario the provider is submitting the claim for payment. In this case the following information should be provided: Billing Provider Name loop (2010AA) this loop will contain the rendering provider information. Pay-To Provider Name loop (2010AB) this loop will not be included. Rendering Provider Name loop (2310B) this loop will not be included. Service Facility Scenario: (Institutional Claims) In this scenario the facility is submitting the claim for payment. In this case the following information should be provided: Billing Provider Name loop (2010AA) this loop will contain the facility information. Pay-To Provider Name loop (2010AB) this loop will not be included. Note: If a clearinghouse is employed to format and transmit the 837 transaction, the clearinghouse information should be sent in the Submitter Name loop (1000A). IntegraNet 837 Companion Guide 5 December 26, 2018

9 IntegraNet Claims Companion Guide In the examples given in this Companion Guide, a lowercase "b" denotes a blank space. ISA - Interchange Control Header - Page B3 Usage: Required Segment Max Use within Transaction: 1 Example: ISA*00*bbbbbbbbbb*00*bbbbbbbbbb*ZZ*ABXbbbbbbb*ZZ*IntegraNetbbbbbbbbbb*010801*1452*U*00401* *0*P*:~ ISA01 Authorization R 2/2 ID 00 Information ISA02 Author Information R 10/10 AN Spaces Please use ten spaces ISA03 ISA04 ISA05 ISA06 Security Information Security Information Sender Interchange ID Interchange Sender ID R 2/2 ID 00 R 10/10 AN Spaces Please use ten spaces R 2/2 ID ZZ R 15/15 AN The sender s trading partner ID assigned at the beginning of Business-to-Business (B2B) testing, used for testing and production purposes. Insert spaces after data to meet 15byte requirement. ISA07 ISA08 Interchange Receiver ID Interchange Receiver ID R 2/2 ID ZZ R 15/15 AN IntegraNet Enter IntegraNet. Insert spaces after data to meet 15-byte requirement. ISA15 Usage Indicator R 1/1 ID P or T Use T for Test Data; P for Production Data GS - Functional Group Header - B8 Usage: Required Segment Max Use within Transmission: >1 Example: GS*HC*ABX*IntegraNet* *1452*1215*X*004010X098A1~ ELEMENT NAME USE Min/Max GS02 Application R 2/15 Senders Code Data Type Codes/Values The sender s trading partner ID assigned at the beginning of Business-to-Business (B2B) testing, used for testing and production purposes. GS03 GS08 Application Receiver's Code Version Code R 2/15 IntegraNet Enter IntegraNet. R 1/ X222, X223 Professional X222 Institutional X223 ABCT.EDI December 1,

10 ST -- Transaction Set Header - 61 Usage: Required Segment Max Use within Transaction: 1 Loop ID: None Example: ST*837*987654~ ST01 Transaction Code R 3/3 ID 837 ST02 Transaction Set Control Number R 4/9 AN The unique number that will be returned on your 997. In order to ensure this unique number is returned on your 997, it is recommended this number not repeat for 180 days. BHT -- Beginning of Hierarchical Transaction- Page 63 Usage: Required Segment Max Use within Transaction: 1 Loop ID: None Example: BHT*0019*00*0123* *0932*CH~ BHT02 Transaction R 2/2 ID 00 Set Purpose Code BHT06 Transaction Type Code R 2/2 ID CH NM1 -- Submitter Name - Page 67 Usage: Required Segment Max Use within Loop: 1 Loop ID: 1000A Example: NM1*41*2*ABX SUBMITTER*****46*TP123456~ ELEMENT NAME USE Min/Max Data Type Codes/Values NM109 Submitter R 2/80 AN The sender s trading partner ID Name assigned at the beginning of Business-to-Business (B2B) testing, used for testing and production purposes. NM1 -- Receiver Name - Page 74 Usage: Required Segment Max Use within Loop: 1 Loop ID: 1000B Example: NM1*40*2* INTEGRANET HEALTH*****46*IntegraNet~ ELEMENT NAME USE Min/Max Receiver Name NM103 R 1/35 Data Type AN Codes/Values INTEGRANET HEALTH Enter INTEGRANET HEALTH NM109 Receiver Primary R 2/80 AN IntegraNet Enter IntegraNet PRV -- Billing/Pay-To-Provider Specialty - Page 79 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2000A Example: PRV*BI*ZZ*207R00000X~ NOTE: Per the CMS feedback page,"... the guide [IG] is therefore inconsistent with the enumeration of providers allowed by the NPI final rule. In order to define a sub-part or component that is not enumerated with a distinct NPI, the Billing Provider field A PRV - may be used." ABCT.EDI December 1,

11 PRV01 Provider Code R 1/3 ID BI 'BI' - Billing PRV02 PRV03 Reference Reference R 2/3 AN ZZ Mutually Defined R 1/30 ID Provider Taxonomy Code NM1 -- Billing Provider Name - Page 84 Usage: Required Segment Max Use within Loop: 1 Loop ID: 2010AA Example: NM1*85*2*ABC BILLING PROVIDER*****XX* ~ ELEMENT NAME USE Min/Max Data Type Codes/Values NM108 Code R 1/2 ID XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers NM109 Code R 1/30 AN Enter the Appropriate 10 Digit National Provider ID (NPI) REF -- Billing Provider Secondary Number - Page 91 Usage: Required Segment Max Use within Loop: 8 Loop ID: 2010AA Example: REF*EI* ~ NOTE: Billing Provider Secondary Id is required when the Billing Provider is the Pay-To Provider (Loop 2010AB) is not sent. REF01 Reference R 2/3 ID EI EI - Employers Number REF02 Billing Provider Additional R 1/30 AN Employer's Number NM1 -- Pay-To Provider Name - Page 99 Usage: Required Segment If Pay to is different than Billing Provider Max Use within Loop: 1 Loop ID: 2010AB Example: NM1*87*2*PHP NAME***** XX* ~ NOTE: required. NM102 Entity Type R 1/1 ID Non-Person entity NM103 Pay-to Provider R 1/35 AN Name Last or Organization Name NM108 R 1/2 ID 24 Code XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers NM109 R 1/30 AN Code Enter the Appropriate 10 Digit National Provider ID (NPI) ABCT.EDI December 1,

12 REF Pay-To-Provider Secondary - Page 101 Usage: Situational Segment Max Use within Loop: 8 Loop ID: 2010AA Example: REF*EI* ~ NOTE: required if the Pay-To Loop 2010AB is sent REF01 Reference R 2/3 ID EI EI - Employers Number REF02 Billing Provider Additional R 1/30 AN Employer's Number SBR -- Subscriber Name - Page 117 Usage: Required Segment Max Use within Loop: 1 Loop ID: 2010BA Example: NM1*IL*1*DOE*JOHN*T**JR*MI* ~ NM108 R 1/35 ID MI Code NM109 Subscriber Primary R 2/80 AN Member Enter Member ID NM1 -- Payer Name - Page 130 Usage: Required Segment Max Use within Loop: 1 Loop ID: 2010BB Example: NM1*PR*2* INTEGRANET HEALTH*****PI*IntegraNet~ ELEMENT NAME USE Min/Max Data Type NM103 Payer Name R 1/35 AN Codes/Values INTEGRANET Enter INTEGRANET HEALTH NM108 Code R 1/2 ID PI NM109 Payer R 2/80 AN IntegraNet Enter IntegraNet N3 -- Payer Address - Page 134 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2010BB Example: N3*1813 W. HARVARD AVE. SUITE 404 ~ N301 Payer Address Line R 1/55 AN 1813 W. HARVARD AVE. SUITE 404 For IntegraNet ABCT.EDI December 1,

13 N4 -- Payer City/State/Zip - Page 135 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2010BB Example: N4*ROSEBURG*OR*97471~ For IntegraNet N401 Payer City R 2/30 AN ROSEBURG Name N402 Payer State R 2/2 ID OR Code N403 Payer Postal Zone or Zip Code R 3/15 ID CLM -- Claim Information - Page 170 Usage: Required Segment Max Use within Loop: 99 Loop ID: 2300 Example: CLM* *500***11::1*Y*A*Y*Y~ ELEMENT NAME USE Min/Max Data Type Codes/Values Patient CLM01 Account R 1/38 AN Populate this element with Plan Tracking Number. Number CLM02 Total Claim Charge Amount R 1/18 R NM1 --Referring Provider Name-Page-282 Usage: Situational Segment Max Use within Loop: 1 Loop ID:2310A Example: NM1*DN*1*SMITH*JOHN*W**JR*XX* ~ NM108 Code R 1/2 ID XX XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers NM109 Subscriber Primary R 2/80 AN Enter the Appropriate 10 Digit National Provider ID (NPI) NM1 --Rendering Provider Name-Page-290 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2310B Example: NM1*82*1*DOE*JOHN****XX* ~ NM108 Code R 1/2 ID XX XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers NM109 Subscriber Primary R 2/80 AN Enter the Appropriate 10 Digit National Provider ID (NPI) ABCT.EDI December 1,

14 SBR - Other Subscriber Information - Page 318 Usage: Required Segment Max Use within Loop: 1 Loop ID: 2320 Example: SBR*P*18*123456*PHP NAME*MC****MC~ ELEMENT NAME USE Min/Max Data Type Codes/Values SBR01 Payer R 1/1 ID P' indicates the PHP as the primary payer. Responsibility Sequence Number Code SBR03 Insured Group or Policy R 1/30 AN Required for ABCT Submission. Cannot be blank. Enter the PHP number. Number SBR04 Other Insured Group Name R 1/60 AN The name of the PHP. Do not use special characters. SV1 - Professional Service - Page 400 Usage: Required Segment Max Use within Loop: 1 Loop ID: 2400 Example: SV1*HC:99211:25*12.25*UN*1*11**1:2:3**N~ SV101-1 Product or Service ID R 2/2 ID HC SV102 Line Item Charge Amount R 1/18 R Submission requires line item charges regardless of how the PHP compensates it's provider(s). NM1 --Rendering Provider Name-Page-501 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2420A Example: NM1*82*1*DOE*JOHN****XX* ~ NM108 Code R 1/2 ID XX XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers NM109 Subscriber Primary R 2/80 AN Enter the Appropriate 10 Digit National Provider ID (NPI) ABCT.EDI December 1,