837 Professional EDI Specifications & Companion Guide

Transcription

1 APS Healthcare, Inc. Helping People Lead Healthier Lives sm Information Technology Division 8403 Colesville Rd. Silver Spring, MD Professional EDI Specifications & Companion Guide The purpose of this guide is to focus on segments in the edi that APS requires to be sent in a specific manner July 2005 This Companion Guide is issued in an effort to provide the trading partners of APS Healthcare Bethesda, Inc. with the most up-to-date information related to standard transactions. Any and all information in this guide is subject to change at any time without notice. Each time you test or submit a standard transaction, we recommend that you refer to the most recently posted Companion Guide to ensure you are using the most current information available. 1

2 CONTENTS Companion Guide Claim Level 2310B Rendering Provider Information Loop 3 Service Line 2420A Rendering Provider Information Loop 7 Specifications Specifications for mapping enveloping of 837P..12 Specifications for mapping body of 837P...15 Disclosure Statement This document has been designed to assist both technical and business areas of our trading partners who wish to submit HIPAA standard transactions. It contains specifications of the transaction, contact information, and other information we believe may be helpful to our trading partners in working with us toward compliance with HIPAA transaction and code set requirements. All instructions in this document were written using information known at the time of publication and may change. The most up-to-date version of the Companion Guide is available on the APS Healthcare, Inc. Web site ( Please be sure that any printed version you use is the same as the latest version available at the APS Healthcare Web site. The X12 file responses you receive during testing are not a guarantee of payment. APS is not responsible for the performance of software you may use to complete these transactions. 2

3 Loop: 2310B RENDERING PROVIDER NAME Notes: 1. Information in Loop ID-2310 applies to the entire claim unless overridden on a service line by the presence of Loop ID-2420 with the same value in NM101. SPECIAL APS NOTE =========================================================== APS requires this loop to be present in any 837p claim as long as this provider is the same for each service line. If the provider for a given service line is different than the one listed here, then the 2420A loop for that service line should be filled out listing the different Provider. IF THE RENDERING PROVIDER AT THE SERVICE LINE IS THE SAME AS THAT LISTED AT THE CLAIM LINE LEVEL RENDERING PROVIDER, THE PROVIDER INFORMATION IS NOT TO BE FILLED OUT. APS WILL GET THE PERTINENT RENDERING PROVIDER INFO FROM THE CLAIM LINE LEVEL. =========================================================== Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. Required when the Rendering Provider NM1 information is different than that carried in either the Billing Provider NM1 or the Pay-to Provider NM1 in the 2010AA/AB loops respectively. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute provider (locum tenans) was used, that person should be entered here. Example: NM1*82*1*BEATTY*GARY*C**SR*XX* ~ STANDARD NM1 Individual or Organizational Name Level: Detail Position: 250 Loop: 2310 Repeat: 9 Requirement: Optional Max Use: 1 3

4 Purpose: To supply the full name of an individual or organizational entity Set Notes: 1. Loop 2310 contains information about the rendering, referring, or attending provider. Syntax: 1. If either NM108 or NM109 is present, then the other is required. 2. If NM111 is present, then NM110 is required. ELEMENT SUMMARY USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES REQUIRED NM101 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an individual The entity identifier in NM101 applies to all segments in this Loop ID CODE DEFINITION 82 Rendering Provider REQUIRED NM102 Entity Type Qualifier M ID 1/1 Code qualifying the type of entity SEMANTIC: NM102 qualifies NM103. CODE DEFINITION 1 Person 2 Non-Person Entity REQUIRED NM103 Name Last or Organization Name O AN 1/35 Individual last name or organizational name INDUSTRY: Rendering Provider Last or Organization Name ALIAS: Rendering Provider Last Name SITUATIONAL NM104 Name First O AN 1/25 Individual first name 4

5 INDUSTRY: Rendering Provider First Name Required if NM102=1 (person). USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES SITUATIONAL NM105 Name Middle O AN 1/25 Individual middle name or initial INDUSTRY: Rendering Provider Middle Name Required if NM102=1 and the middle name/initial of the person is known. NOT USED NM106 Name Prefix O AN 1/10 SITUATIONAL NM107 Name Suffix O AN 1/10 Suffix to individual name INDUSTRY: Rendering Provider Name Suffix ALIAS: Rendering Provider Generation Required if known. REQUIRED NM108 Identification Code Qualifier X ID 1/2 Code designating the system/method of code structure used for Identification Code FA crosswalk is only used in Medicare COB payer-to-payer claims. CODE DEFINITION 24 Employer s Identification Number 34 Social Security Number XX Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. 5

6 USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES REQUIRED NM109 Identification Code X AN 2/80 Code identifying a party or other code INDUSTRY: Rendering Provider Identifier ALIAS: Rendering Provider Primary Identifier FA crosswalk is only used in Medicare COB payer-to-payer claims. NOT USED NM110 Entity Relationship Code X ID 2/2 NOT USED NM111 Entity Identifier Code O ID 2/3 6

7 Loop: 2420A RENDERING PROVIDER NAME Repeat: 1 Usage: SITUATIONAL Repeat: 1 SPECIAL APS NOTE IF THE RENDERING PROVIDER AT THE SERVICE LINE IS THE SAME AS THAT LISTED AT THE CLAIM LINE LEVEL RENDERING PROVIDER, THE PROVIDER INFORMATION IS NOT TO BE FILLED OUT AT THE SERVICE LINE LEVEL. APS WILL GET THE PERTINENT RENDERING PROVIDER INFO FROM THE CLAIM LINE LEVEL. 1. Because the usage of this segment is Situational this is not a syntactically required loop. If this loop is used, then this segment is a Required segment. See Appendix A for further details on ASC X12 syntax rules. 2. Required if the Rendering Provider NM1 information is different than that carried in the 2310B (claim) loop, or if the Rendering provider information is carried at the Billing/Pay-to Provider loop level (2010AA/AB) and this particular service line has a different Rendering Provider that what is given in the 2010AA/AB loop. The identifying payer-specific numbers are those that belong to the destination payer identified in loop 2010BB. 3. Used for all types of rendering providers including laboratories. The Rendering Provider is the person or company (laboratory or other facility) who rendered the care. In the case where a substitute Provider (locum tenans) was used, that person should be entered here. Example: NM1*82*1*SMITH*JUNE*L***XX* ~ STANDARD NM1 Individual or Organizational Name Level: Detail Position: 500 Loop: 2420 Repeat: 10 Requirement: Optional Max Use: 1 Purpose: To supply the full name of an individual or organizational entity Set Notes: 7

8 1. Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These segments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the same. Syntax: 1. If either NM108 or NM109 is present, then the other is required. 2. If NM111 is present, then NM110 is required. ELEMENT SUMMARY USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES REQUIRED NM101 Entity Identifier Code M ID 2/3 Code identifying an organizational entity, a physical location, property or an individual The entity identifier in NM101 applies to all segments in this iteration of Loop ID CODE DEFINITION 82 Rendering Provider REQUIRED NM102 Entity Type Qualifier M ID 1/1 Code qualifying the type of entity SEMANTIC: NM102 qualifies NM103. CODE DEFINITION 1 Person 2 Non-Person Entity REQUIRED NM103 Name Last or Organization Name O AN 1/35 Individual last name or organizational name INDUSTRY: Rendering Provider Last or Organization Name ALIAS: Rendering Provider Last Name SITUATIONAL NM104 Name First O AN 1/25 Individual first name INDUSTRY: Rendering Provider First Name 8

9 Required if NM102=1 (person). USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES SITUATIONAL NM105 Name Middle O AN 1/25 Individual middle name or initial INDUSTRY: Rendering Provider Middle Name Required if NM102=1 and the middle name/initial of the person is known. NOT USED NM106 Name Prefix O AN 1/10 SITUATIONAL NM107 Name Suffix O AN 1/10 Suffix to individual name INDUSTRY: Rendering Provider Name Suffix ALIAS: Rendering Provider Generation Required if known. REQUIRED NM108 Identification Code Qualifier X ID 1/2 Code designating the system/method of code structure used for Identification Code CODE DEFINITION 24 Employer s Identification Number 34 Social Security Number Social Security Number cannot be used for Medicare claims. XX Health Care Financing Administration National Provider Identifier Required value if the National Provider ID is mandated for use. Otherwise, one of the other listed codes may be used. REQUIRED NM109 Identification Code X AN 2/80 9

10 Code identifying a party or other code INDUSTRY: Rendering Provider Identifier ALIAS: Rendering Provider Primary Identifier USAGE REF. DES. DATA ELEMENT NAME ATTRIBUTES NOT USED NM110 Entity Relationship Code X ID 2/2 NOT USED NM111 Entity Identifier Code O ID 2/3 10

11 Information from the HIPAA implementation guide for the ASC X12N 837 (004010X098) May 2000 ASC X12N INSURANCE SUBCOMMITTEE X IMPLEMENTATION GUIDE HEALTH CARE CLAIM: PROFESSIONAL MAY WPC Copyright for the members of ASC X12N by Washington Publishing Company. Permission is hereby granted to any organization to copy and distribute this material internally as long as this copyright statement is included, the contents are not changed, and the copies are not sold. 11

12 SPECIFICATIONS FOR THE 837P ENVELOPING FOR 837P Mapping Loop Segment Element Instructions Hdr ISA 1 Hardcode '00' Notes 2 Hardcode ten spaces 3 Hardcode '00' 4 Hardcode ten spaces 5 Hardcode 'ZZ' Map your trading partner 6 id 7 Hardcode 'ZZ' 8 Hardcode '54160' APS's id 9 6 digit current date in YYMMDD format 4 digit current time in 10 HHMM format 11 Hardcode 'U' 12 Hardcode '00401' Trading Partner Sender id value Hardcode ' ' and increment by 1 each 13 time a new ISA is written 14 Hardcode '0' Hardcode 'T' if this is a test file, 'P' if this is 15 production 16 Hardcode ':' Hdr GS 1 Hardcode 'HC' Test or production indicator 12

13 Map GS id for trading 2 partner 3 Hardcode '54160' 4 5 Hardcode 8 digit date in CCYYMMDD format 4 digit current time in HHMM format Hardcode '1' for each new ISA and increment by 1 everytime a new GS to GE is started within 6 the same ISA GS control # 7 Hardcode 'X' Hardcode 8 '004010X098A1' Hdr ST 1 Hardcode '837' Hardcode '0001' and increment by 1 for each new ST in the same GS 2 to GE Hdr BHT 1 Hardcode '0019' 2 Hardcode '00' This indicates that the edi is an 837 professional 3 This should have the date and time and a 4 digit number. The 4 digit number should be incremented each time a new ST to SE is created. The format should look like this CCYYMMDDHHMM digit date CCYYMMDD 5 4 digit hour HHMM 6 Hardcode 'CH' Hdr REF 1 Hardcode '87' If this is test, hardcode '004010X98DA1'. If this is production, hardcode '004010X98A1' This indicates that the edi is an 837 professional A NM1 1 Hardcode '41' Submitter information 2 Hardcode '2' 13

14 Map name of the sender 3 of this do not map 8 Hardcode '46' 9 ID of sender 1000A PER 1 Hardcode 'IC' Name of clearinghouse or provider sending this Hardcode 'TE' 4 Telephone # of sender 1000B NM1 1 Hardcode '40' Receiver information 2 Hardcode '2' Hardcode 'APS Health 3 Care' 4 do not map 8 Hardcode '46' 9 Hardcode '54160' 2000A HL 1 Hardcode '1' 2 do not map 3 Hardcode '20' 4 Hardcode '1' For directions on mapping the body of the edi, see BODY OF 837P' Trailer SE 1 Trailer GE 1 2 ST 02 Number of segments contained within and including the ST and SE segments # of transaction sets contained within this GS to GE 2 GS 06 Trailer IEA 1 Hardcode '1' segment count ST 02 and SE 02 must be the same value Count of ST to SE's contained within this particular GS to GE GS 06 must be the same value as GE 02 14

15 2 ISA 13 ISA 13 must be ths same value as IEA 02 BODY OF 837P Notes Loop Segment Element Mapping Instructions When inputting the billing provider, be sure to include the correct EIN for that entity. 2010AA NM1 1 Hardcode '85' 2 Hardcode '2' Billing (Pay To) provider name 3 Map over Billing Provider Name 4 do not map 8 Hardcode '24' EIN of Billing (Pay To) provider 9 Map over EIN for NM1 03 Street address of billing provider 2010AA N3 1 Map over street address of Billing Provider City of billing provider 2010AA N4 1 Map over city of BP State of billing provider 2 Map over state of BP Zip code of billing provider 3 Map over zip of BP 2000B HL 1 Hardcode '2' 2 Hardcode '1' 3 Hardcode '22' It is important to disclose to APS if APS is not the patient's primary insurance 2000B SBR 1 4 If patient is subscriber, hardcode '0'. Else ha '1' to denote that the patient is a dependent subscriber and that there will be a 2000C loo If APS is the primary insurance for this patie hardcode 'P', if APS is the secondary insura this patient, hardcode 'S' Hardcode '18' only if the patient is the subsc 2 Otherwise, do not map 3 do not map 4 do not map 8 do not map 15

16 This indicates what kind of insurance is being used BA NM1 1 Hardcode 'IL' 2 Hardcode '1' Claim filing indicator code. See 837p implem guide for list of codes Subscriber's last name only. Any suffix such as 'Jr' or 'III' goes in NM1 07 and not here at the end of the last name 3 Map subscriber's last name Subscriber's first name 4 Map subscriber's first name 5 Map subscriber's middle initial if known Prefix is not used. An example of a prefix would be Dr or Mrs Example of a suffix is 'Sr' or 'III' 7 Map subscriber's suffix if known 8 Hardcode 'MI' Enter subscriber id 9 Map subscriber's id Subscriber's street address 2010BA N3 1 Street address of subscriber Subscriber's city 2010BA N4 1 Subscriber's city of residence Subscriber's state 2 Subscriber's State 2-character code of resid Subscriber's zip code 3 Subscriber's zip of residence 2010BA DMG 1 Hardcode 'D8' Enter subscriber's birthdate. This is not required if the patient is different from the subscriber 2 Map subscriber's birthdate CCYYMMDD Subscriber gender-- only required if subscriber is patient BB NM1 1 Hardcode 'PR' 2 Hardcode '2' If subscriber's gender is male, hardcode 'M'. Otherwise hardcode 'F' Insurance payer name of APS Health Care 3 Hardcode 'APS Health Care' 4 do not map 8 Hardcode 'PI' Enter APS's primary id of '54160' 9 Hardcode '54160' This 2000C loop is only to be filled out if patient is NOT the subscriber 2000C HL 1 Increment the number found in the precedin by 1 This indicates the parent hierarchical numbe 2 which this segment is subordinate 3 Hardcode '23' 4 Hardcode '0' 16

17 Input the relationship of the patient to the subscriber 2000C PAT CA NM1 1 Hardcode 'QC' 2 Hardcode '1' Code indicating patient's relationship to the subscriber. See the 837p Hipaa implementa guide for a list of codes that can be used Patient's last name only. Any suffix such as 'Jr' or 'III' goes in NM1 07 and not here at the end of the last name 3 Map patient's last name Patient's first name 4 Map patient's first name 5 Map patient's middle initial if known Prefix is not used. An example of a prefix would be Dr or Mrs Enter the suffix separately from the last name. An example of a suffix is 'Sr' or 'III' 7 Map patient's suffix if known 8 do not map 9 do not map Patient's street address 2010CA N3 1 Street address of patient Patient's city 2010CA N4 1 Patient's city of residence Patient's state 2 Patient's State 2-character code of residenc Patient's zip code 3 Patient's zip of residence 2010CA DMG 1 Hardcode 'D8' Enter patient's birthdate. 2 Map patient's birthdate CCYYMMDD If patient's gender is male, hardcode 'M'. Oth Patient gender 3 hardcode 'F' End of 2000C loop Claim number 2300 CLM 1 Map patient account number Total charge for this claim 2 Map total charge for this claim 3 do not map 4 do not map Where the service was performed 5-1 Facility Type Code 5-2 do not map 5-3 Hardcode '1' This tells whether the provider signature is on file with APS 6 Tells whether the provider accepts Medicare assignments 7 If the provider's signature is on file with APS else map 'N' If the provider accepts Medicare assignmen 'A'. If the provider only accepts Medicare assignments for Clinical Lab services, 'B'. If assignment is not accepted, map 'C'. If the p refuses to assign benefits, map 'P' 17

18 This provides information on whether the provider is to receive payment for this service or if the subscriber is receiving payment 8 This tells whether the patient allows medical information to be released as necessary 9 Input how the patient signature (if it is on file) was acquired 10 Only input this info if the claim is the result of an accident 11-1 If the provider is to receive payment, map 'Y map 'N' Hardcode 'Y' if provider has patient signed s allowing appropriate release of claim medica Hardcode 'N' if provider is not allowed to rele medical info If patient signature is on claim form, hardcod patient signature is on site at the provider si hardcode 'S' else if CLM 09 is 'N', do not ma If auto accident, hardcode 'AA'. If abuse, ha 'AB. If another party responsible, hardcode ' emergency-related, hardcode 'EM'. Else ma other accident 11-2 do not map 11-3 do not map If the claim is due to an auto accident, the 2 character state must be entered here do not map 13 do not map 14 do not map do not map 19 do not map 20 do not map 2300 HI 1-1 Hardcode 'BK' 2-character state or province code if 11-1 is accident) Primary diagnosis must be entered here 1-2 Map primary dx code 2-1 thru 8-1 Hardcode 'BF' There can be as many as 8 more secondary diagnosis codes entered for this claim 2-2 thru 8-2 Map other dx codes (up to 8 other dx codes 18

19 This rendering provider info applies to all service lines. Therefore, no rendering provider info should be provided at the service line level. However, if the rendering provider info is different for one or more of the service lines, then separate rendering provider information is to be given for each particular service line that has a different rendering provider than that listed here 2310B NM1 1 Hardcode '82' Rendering provider last name is entered here 3 2 If rendering provider name is an organizatio hardcode '2', otherwise hardcode '1' Map last name (or organization name) of ren provider Rendering provider first name is entered here 4 Map first name of rendering provider (do not NM1 03 is an organization name) 8 Hardcode '24' Rendering provider's EIN 9 Map rendering provider's EIN If APS is not the primary insurance, then the Other Subscriber loop must be filled out 2320 SBR 1 Hardcode 'P' Enter relationship of patient t o the other subscriber 2 Hardcode code that pertains to patient's rela to other subscriber (see 837p Imp Guide for 3 do not map Name of other insurer 4 Map other insured group name if known Insurance type (I.E. auto, commercial, etc) 5 8 do not map 9 Hardcode 'ZZ' 2320 AMT 1 Hardcode 'D' Hardcode insurance type code. If unknown, Hardcode 'OT' Enter amount paid by other insurance (zero is an acceptable value) -- COB Payer Paid Amt 2 Map amount paid by primary insurance 2320 AMT 1 Hardcode 'B6' Enter the maximum that the other subscriber will pay -- COB Allowed Amt 2 Map amount allowed by primary insurance 19

20 2320 OI 1 do not map 2 do not map This should be the same value found in CLM 08 and indicates whether the benefits are assigened to the provider or not 3 CLM 08 4 do not map This should be the same as CLM 09 and indicates whether the patient allows appropriate release of medical info as relates to this claim 6 CLM A NM1 1 Hardcode 'IL' 2 Hardcode '1' If APS is not the primary insurance, then the other subscriber name must be entered 3 Map last name of other subscriber providing insurance for patient 4 Map first name of other subscriber 8 Hardcode 'MI' Enter other subscriber's primary id # with the primary payer 9 Map subscriber's id # assigned by primary p 2330A NM1 1 Hardcode 'PR' 2 Hardcode '2' Other Payer's name 3 Map other payer org name 4 do not map 8 Hardcode 'PI' Enter the Other Payer's id 9 Map other payer's primary id End of the Other Subscriber loop Hardcode '1' and increment by 1 for each ad 2400 LX 1 service line 2400 SV1 1-1 Hardcode 'HC' Procedure code must be provided for each service line 1-2 Map procedure code If there are procedure modifier codes, they must be provided to APS 1-3 Map modifier code (if present) 20

21 1-4 Map additional modifier code (if present) 1-5 Map additional modifier code (if present) 1-6 Map additional modifier code (if present) Enter amount for this particular service line 2 Map amount for this service Enter unit of measure 3 hardcode 'F2' Quantity of units/minutes 4 Unit or minute count 8 do not map If this is as a result of an emergency, please indicate this to APS 9 Map 'Y' if this is emergency-related, else ma 2400 DTP 1 Hardcode '472' 2 otherwise hardcode 'D8' Enter date(s) this service was rendered 3 If statement date is a range then map this as CCYYMMDD-CCYYMMDD with the first dat beginning of the range and the second date the end of the date range, otherwise put sing statement date as CCYYMMDD Any rendering provider information is given in the service line if and only if it is different from the rendering provider named at the claim level 2420A NM1 1 Hardcode '82' 2 If rendering provider name is an organizatio hardcode '2', otherwise hardcode '1' Rendering provider last name is entered here 3 Rendering provider first name is entered here 4 Map last name (or organization name) of ren provider Map first name of rendering provider (do not NM1 03 is an organization name) 8 Hardcode '24' Rendering provider's EIN 9 Map rendering provider's EIN 21