Cardinal Innovations Healthcare

Transcription

1 Cardinal Innovations Healthcare 837P Companion Guide Instructions Related to Transactions Based on ASC X12 Implementation Guide Version X222A1 Health Care Claim: 837 Professional Companion Guide Version Number: 3.1 May 17, 2018 May

2 This template is copyrighted 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X Companion Guide copyrighted by Cardinal Innovations Healthcare May

3 Preface Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing entity (Communications/Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document. The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASCX12 s copyrights and Fair Use statement. May

4 Table of Contents 1 TI Introduction Background Overview of HIPAA Legislation Compliance according to HIPAA Compliance according to ASC X Intended Use Intended Audience Purpose of Companion Guide Trading Partner Agreement Resources Version Updates Included ASC X12 Implementation Guides Instruction Tables TI Change Summary May

5 Transaction Instruction (TI) 1 TI Introduction 1.1 Background Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs Compliance according to HIPAA The HIPAA regulations at 45 CFR require that covered entities not enter into a trading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in a standard. Add any data elements or segments to the maximum defined data set. Use any code or data elements that are marked not used in the standard s implementation specifications or are not in the standard s implementation specification(s). Change the meaning or intent of the standard s implementation specification(s) Compliance according to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory, or clarifying content contained in the implementation guide. Modifying any requirement contained in the implementation guide. May

6 1.2 Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be stand-alone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12 s Fair Use and Copyright statements. 1.3 Intended Audience This companion guide is intended for business and technical users responsible for the testing and setup of electronic claims submissions between Trading Partners and Cardinal Innovations. 1.4 Purpose of Companion Guide The Companion Guide is to be used with, and to supplement, the requirements in the HIPAA ASC X12 Implementation Guides, without contradicting those requirements. The HIPAA ASC X12 Implementation Guides Implementation Guides define the national data standards, electronic format, and values for each data element within an electronic transaction. The purpose of the Companion guide is to provide Trading Partners with a guide to communicate specific Cardinal Innovations information required to successfully exchange transactions. 1.5 Trading Partner Agreement Providers or vendors who directly transmit electronic claims to Cardinal Innovations must complete a Cardinal Innovations Trading Partner Agreement (TPA). 1.6 Resources The following resources were used in preparing this Companion Guide. Washington Publishing Company ASC X12 NCTracks Version Updates This Companion Guide will be updated as needed based on changes to Federal guidelines and Cardinal Innovation Healthcare s claim adjudication requirements. May

7 2 Included ASC X12 Implementation Guides This table lists the X12N Implementation Guides for which specific transaction Instructions apply and which are included in Section 3 of this document. Unique ID X X222A1 Name Health Care Claim: Professional (837P) Health Care Claim: Professional (837P) May

8 3 Instruction Tables These tables contain one or more rows for each segment for which a supplemental instruction is needed. Legend SHADED rows represent loops and segments in the X12N implementation guide. NON-SHADED rows represent data elements in the X12N implementation guide X222A1 Health Care Claim: Professional Loop ID Reference Name Codes Notes/Comments Header ISA Interchange Control Header ISA03 ISA05 ISA06 ISA07 ISA08 Interchange Control Security Information Qualifier Interchange ID (Sender) Qualifier Interchange Sender ID Interchange ID (Receiver) ID Interchange Receiver ID Header GS Functional Group Header GS02 GS03 Application Sender s Code Application Receiver s Code Header ST Transaction Set Header ST03 Implementation Conversion Reference 1000A NM1 Submitter Name NM108 Identification Code Qualifier 00 Use 00 No Security Information Present. ZZ ZZ X222 A1 Use ZZ Mutually Defined. Use the Submitter ID issued to you by Cardinal Innovations. Same as GS02. Use ZZ Mutually Defined. Use Same as GS03. Use the Submitter ID issued to you by Cardinal Innovations. Same as ISA06. Use Same as ISA08. Refer to section 1.2 of Implementation Guide 46 Use 46 - Electronic Transmitter ID Number NM109 Identification Use the Submitter ID May

9 Loop ID Reference Name Codes Notes/Comments Code 1000B NM1 Receiver Name 2000A issued to you by Cardinal Innovations. Same as ISA ISA06 and GS02. NM103 Receiver Name Use Cardinal Innovations NM108 NM109 Identification Code Qualifier Receiver Primary Identifier Billing Provider Hierarchy Level 2000A PRV Billing Provider Specialty 46 Use 46 - Electronic Transmitter ID Number Use Same as ISA ISA08 and GS03. The Billing Provider Information is critical to successfully adjudicating a provider claim. The Billing Provider s NPI number, taxonomy code and ninedigit zip code must be enrolled at NCTracks in a current and active provider record with a service location code of 03 or greater. Billing Provider entries must also follow the NPI enumeration rules detailed in the X12 837P TR3 (Federal implementation guide). If a Provider site has its own unique NPI number, then that site must be listed as the Billing Provider in the 837P. Required by Cardinal Innovations. Enter the taxonomy code in the Billing Provider Loop. PRV01 Provider Code BI Use BI Billing Provider PRV02 Identification Code Qualifier PXC Use PXC Taxonomy Code PRV03 Taxonomy Code Use the Billing Provider s Taxonomy Code. This taxonomy code must be listed in an active NCTracks provider record that also contains the NPI used in 2010AA, NM109 and the nine digit zip code used in Loop 2010AA, N AA NM1 Billing Provider Name NM108 Billing Provider ID XX Use XX = NPI number May

10 Loop ID Reference Name Codes Notes/Comments Qualifier NM109 Billing Provider ID Use the Billing Provider s NPI number. This NPI number must be listed in an active NCTracks provider record that also contains the Taxonomy code used in 2000A, PRV03 and the nine digit zip code used in Loop 2010AA, N AA N4 Billing Provider City, State, Zip N403 Billing Provider Nine- Digit Zip Code Use the Billing Provider s nine-digit zip code. This nine-digit zip code must be listed in an active NCTracks provider record that also contains the NPI used in 2010AA, NM109 and the Taxonomy code used in 2000A, PRV AC Pay-to-Plan Cardinal Innovations will not use this loop 2000B SBR Subscriber Information SBR09 Claim Filing Indicator Code MC, ZZ Use MC for Medicaid claims 2010BA NM1 Subscriber Name NM108 NM109 Identification Code Qualifier Subscriber Primary Identifier MI Use ZZ State Funds claims Use MI - Member Identification Number For Medicaid, use the Member s 10 digit Medicaid ID ending in an alpha character. 2010BB NM1 Payer Name For State Funds, use the Member s ID number assigned by the MCO. NM103 Payer Name Use Cardinal Innovations NM108 Payer ID Qualifier PI Use PI Payer ID NM109 Payer Identifier Use Same as ISA ISA08 and GS CLM Claim Information 2300 REF Payer Claim Control Number May

11 Loop ID Reference Name Codes Notes/Comments 2310B REF01 REF02 Reference Identification Qualifier Reference Identification Rendering Provider Information 2310B NM1 Rendering Provider Name NM108 Rendering Provider ID Qualifier F8 XX Use F8 - Original Reference Number - when CLM05-3 is equal to 7 or 8 Use Cardinal Innovation s ICN associated with the original claim that is being replaced or voided Required by Cardinal Innovations if the Rendering Provider is different than the Billing Provider in Loop 2010AA. If used, the Rendering Provider Information is critical to successfully adjudicating the claim. The Rendering Provider s NPI number and taxonomy code must be enrolled at NCTracks in a current and active provider record with a service location code of 03 or greater. The zip code in Loop 2010AA N403 or Loop 2310C N403 should also appear in the Rendering Provider s NCTracks record. Use XX = NPI number NM109 Rendering Provider ID Use the Rendering Provider s NPI number. This NPI number must be listed in an active NCTracks provider record that also contains the Taxonomy code used in 2310B, PRV03. That record should also contain the nine-digit zip code used in Loop 2010AA N403 or Loop 2310C N B PRV Rendering Provider Specialty PRV01 Provider Code PE PE Rendering Provider PRV02 Identification Code Qualifier PXC PXC Taxonomy Code PRV03 Taxonomy Code Use the Rendering Provider s Taxonomy Code. This taxonomy code must be listed in an May

12 Loop ID Reference Name Codes Notes/Comments 2310C Service Facility Location Information active NCTracks provider record that also contains the NPI used in 2310B NM109 and preferably the nine digit zip code used in Loop 2010AA N403 or Loop 2310C N403. The Service Facility Location is the site where the service was delivered. Required by Cardinal Innovations if the Service Facility Location Information is different than the Billing Provider Information in Loop 2010AA. Service Facility Location entries must also follow the NPI enumeration rules detailed in the X12 837P TR3 (Federal implementation guide). If a Provider Site/Service Facility Location has its own unique NPI number, then that Site/Service Facility Location must be listed as the Billing Provider in the 837P. The NPI information in Loop 2310C is situational, meaning that the service might have been delivered at a site that does not have an NPI number. Also, the site might be a Billing Provider site that was not enumerated, meaning that the site does not have a unique NPI. In these cases, the 2310C, NM108 and NM109 will not be used. The address and nine-digit zip code are still required. NM108 Service Facility Location ID Qualifier XX 2310C NM108 is a situational field. Use XX = NPI number, if the Service Facility Location has an NPI number. NM109 Service Facility Location ID 2310C NM109 is a situational field. Use the May

13 Loop ID Reference Name Codes Notes/Comments N403 Service Facility Location Nine-Digit Zip Code 2320 Other Subscriber Information Service Facility Location s NPI number if the Service Facility Location has a unique NPI number. This NPI number must be listed in an active NCTracks provider record that also contain the ninedigit zip code used in Loop 2310C N403. If the Service Facility Location NPI field is used, then the Service Facility Location nine-digit zip code and NPI must be listed in an active NCTracks provider record. If the Service Facility Location NPI is not used, then the nine-digit Service Facility Location zip code must be linked to the Billing Provider NPI and Taxonomy code in Loop 2010AA, unless the place of service is a school or a home. AMT01 Amount Qualifier Code D Cardinal Innovations only uses D Payer Amount Paid AMT SV1 Professional Service SV Product/Service ID Qualifier HC Other Payer Paid Amount Use HC Health Care Finance Agency HCPC Codes May

14 4 TI Change Summary Version 1.0 January 1, 2014 Cardinal Innovations Version 2.0 February 1, 2018 Cardinal Innovations Version 3.0 March 21, 2018 Cardinal Innovations Version 3.1 March 28, 2018 Cardinal Innovations May