Provider EDI Reference Guide

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1 Provider EDI Reference Guide EDI Operations April 5, 2010 is a registered mark of Inc.

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3 Table of Contents Chapter 1 Introduction Supported EDI Transactions Real-Time Transaction Capability Real-Time Technical Connectivity Specifications Real-Time Claim Adjudication and Estimation General Requirements and Best Practices Chapter 2 General Information 19 2 Contact Information System Operating Hours Provider Data Services Audit Procedures Valid Characters in Text Data (AN, string data element type) Chapter 3 Security Features Confidentiality Authorized Release of Information Chapter 4 Authorization Process Where to Get Enrollment Forms to Request a Trading Partner ID Receiving 835 Transactions Generated from the Payment Cycle (Batch) Adding a New Provider to an Existing Trading Partner Deleting Providers from an Existing Trading Partner Reporting Changes in Status April 5,

4 Table of Contents 4.6 Out of State Providers Chapter 5 Testing Policy Web Based Transactional Testing Real-Time 837 Claim Estimation Demonstration Process.. 30 Chapter 6 Communications Dial-Up / Asynchronous File Transfer Dial-Up Command Prompt Option Internet Internet File Transfer Protocol (FTP) through edelivery Internet/Real-Time (HTTPS- Hypertext Terminal Protocol Secure) Chapter 7 Transmission Envelopes General Information Delimiters Data Detail and Explanation of Incoming ISA to ISA Interchange Control Header (Incoming) Data Detail and Explanation of Outgoing ISA from ISA Interchange Control Header (Outgoing) Outgoing Interchange Acknowledgment TA1 Segment Outgoing Functional Acknowledgment 997 Transaction Chapter 8 Professional Claim (837P) General Information and Guidelines for Submitting an 837P Patient with Coverage from Another Blue Cross Blue Shield Plan KHP Central Out-of-Area Claims First Priority Life Insurance Company (FPLIC) Out-of-Area Claims Independence Administrators Out-of-Area Claims April 5, 2010

5 Table of Contents Keystone Health Plan East (KHP East) Out-of-Area Claims Dental Services Data that is Not Used Transaction Size Suffix on s NAIC Code for Vision Claims Ambulance Claims Provider and Service Facility Location Identification Numbers Claim Submission Acknowledgment National Provider Identifier (NPI) Balancing Real-Time Claim Adjudication and Estimation Real-Time 837 Submission Limitations General Requirements and Best Practices Data Detail for 837P GS Functional Group Header REF Transmission Type Identification NM1 Submitter Name NM1 Receiver Name PRV Billing/Pay-to Provider Specialty Information N3 Billing Provider Address N4 Billing Provider City/State/Zip SBR Subscriber Information NM1 Subscriber Name NM1 Payer Name NM1 Patient Name CLM Claim Information DTP Date - Date Last Seen DTP Date - Admission PWK Claim Supplemental Information AMT Total Purchase Service Amount REF Mammography Certification Number CR2 Spinal Manipulation Information CRC Patient Condition Information - Vision PRV Referring Provider Specialty Information NM1 Rendering Provider Name April 5,

6 Table of Contents PRV Rendering Provider Specialty Information NM1 Service Facility Location N3 Service Facility Location Address N4 Service Facility Location City/State/Zip SBR Other Subscriber Information AMT COB Patient Paid Amount NM1 Other Payer Name SV1 Service Line AMT Sales Tax Amount PS1 Purchase Service Information LIN Drug Identification CTP Drug Pricing NM1 Rendering Provider Name PRV Rendering Provider Specialty Information REF Service Facility Location Secondary Identification PRV Referring Provider Specialty Information Chapter 9 Institutional Claim (837I) General Information and Guidelines for Submitting an 837I Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan KHP Central Out-of-Area Claims (Western Region) Data that is Not Used Transaction Size Number of Lines per Claim Suffix on s NAIC Code Standalone Major Medical Provider Identification Numbers Claim Submission Acknowledgment National Provider Identifier (NPI) Balancing Real Time Claim Adjudication and Estimation Real-Time 837 Submission Limitations General Requirements and Best Practices Data Detail for 837I April 5, 2010

7 Table of Contents GS Functional Group Header REF Transmission Type Identification NM1 Submitter Name NM1 Receiver Name PRV Billing/Pay-To Provider Specialty Information N3 Billing Provider Address N4 Billing Provider City/State/Zip SBR Subscriber Information NM1 Subscriber Name NM1 Payer Name NM1 Patient Name CLM Claim Information DTP Discharge Hour DTP Admission Date / Hour PWK Claim Supplemental Information CN1 Contract Information REF Original Reference Number (ICN/DCN) K3 File Information HI Principal Procedure Information HI Other Procedure Information HI Value Information NM1 Attending Physician, Operating Physician, and Other Provider Name PRV Attending Physician Specialty Information NM1 Service Facility Name N3 Service Facility Address N4 Service Facility City/State/Zip Code SBR Other Subscriber Information NM1 Other Payer Name LIN Drug Identification CTP Drug Pricing NM1 Attending Physician, Operating Physician, and Other Provider Name April 5,

8 Table of Contents Chapter 10 Claim Acknowledgment (277) General Information and Guidelines for 277 Claim Acknowledgment Identifying the 837 in the 277 Claim Acknowledgment Front-End Editing: Level Types Text Format Options Timeframe for Batch 277 Claim Acknowledgment Specifications Real-Time Claim Acknowledgment Claim Adjudication Claim Estimation General Requirements and Best Practices Chapter 11 Claim Payment Advice (835) General Information and Guidelines for Missing Checks Administrative Checks Availability of Payment Cycle 835 Transactions (Batch) Private Business and Medicare Supplemental Major Medical Oral Surgery Unavailable Claim Data Claim Overpayment Refunds Institutional Claims Professional Claims Electronic Funds Transfer (EFT) Capitation Payments Member Identification Numbers Data that is Not Used National Provider Identifier (NPI) Provider Payments from Member Health Care Accounts Real-Time 835 Response Real-Time Response for Claim Adjudication Real-Time 835 Response for Claim Estimation General Requirements and Best Practices Data Detail for April 5, 2010

9 Table of Contents GS Functional Group Header BPR Financial Information REF Receiver Identification REF Additional Payer Identification N1 Payee Identification REF Payee Additional Identification LX Header Number CLP Claim Payment Information NM1 Service Provider Name REF Other Claim Related Identification SVC Service Payment Information PLB Provider Adjustment Chapter 12 Claim Status (276 & 277) General Instructions and Guidelines for 276 and General Instructions and Guidelines for General Description Dental Services Data that Is Not Used Minimum Requirements Situational Elements and Data Content Requests Per Transaction Mode Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan General Instructions and Guidelines for General Description of Claim Splits Customer Service Requests Maximum Claim Responses per Subscriber/Patient/Dependent Corrected Subscriber and Dependent Level National Provider Identifier Data Detail for GS Functional Group Header NM1 Payer Name NM1 Information Receiver Name April 5,

10 Table of Contents NM1 Provider Name NM1 Subscriber Name REF Payer Claim ID Number Data Detail for Claim Status Response (277) GS Functional Group Header NM1 Provider Name REF Payer Claim Identification Number Chapter 13 Eligibility Request-270 / Response General Instructions and Guidelines for 270 and Requirements Dental and Oral Surgery Inquiries Definition of Active Coverage Benefit Inquiries Allowable Time Frames for Inquiries Disclaimers Dates on the Incoming Range Dates on the Incoming Level of Detail on Outbound Specific Service Code Request Generic Service Code Request Real-Time Request (Left blank intentionally.) Data that is Not Used Requests Per Transaction Mode Date Ranges Submitted on the Minimum Amount of Data Required for Search Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan /271 Data Detail Instructions Data Detail for Eligibility Request (270) GS Functional Group Header BHT Beginning of Hierarchical Transaction NM1 Information Source Name NM1 Information Receiver Name April 5, 2010

11 Table of Contents NM1 Subscriber/Dependent Name REF Subscriber/Dependent Additional Identification PRV Provider Information EQ Subscriber/Dependent Eligibility or Benefit Inquiry Information164 III Subscriber/Dependent Eligibility or Benefit Inquiry Information Data Detail for Eligibility Response (271) GS Functional Group Header NM1 Information Receiver Name NM1 Subscriber/Dependent Name N3 Subscriber/Dependent Address N4 Subscriber/Dependent City, Street, Zip Code DTP Subscriber/Dependent Date REF Subscriber/Dependent Additional Information DTP Subscriber/Dependent Eligibility/Benefit Date MSG Message Text Chapter 14 Health Care Services Review (278) Request and Response General Information and Guidelines for Submitting a Real-Time Requests Data that is Not Used Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan Data Detail Instructions Data Detail for Services Review Request (278) GS Functional Group Header NM1 Utilization Management Organization (UMO) Name N3 Requester Address N4 Requester City/State/Zip Code PER Requester Contact Information HI Subscriber/Dependent Diagnosis PWK Additional Patient Information NM1 Subscriber/Dependent Name DMG Subscriber/Dependent Demographic Information April 5,

12 Table of Contents HL Service Provider Level N3 Service Provider Address N4 Service Provider City/State/Zip Code PER Service Provider Contact Information UM Health Care Services Review Information HI Procedures Data Detail for Services Review Response (278) GS Functional Group Header Appendix A Health Insurance Company 185 Appendix B Medi-CareFirst BlueCross BlueShield 187 Appendix C Provider Guide Changes for April 5, April 5, 2010

13 Chapter 1 Introduction 1 Introduction The addresses how Providers, or their business associates, conduct Professional Claim, Institutional Claim, Claim Acknowledgment, Claim Payment Advice, Claim Status, Eligibility, and Services Review HIPAA standard electronic transactions with. This guide also applies to the above referenced transactions that are being transmitted to by a clearinghouse. An Electronic Data Interchange (EDI) Trading Partner is defined as any customer (Provider, Billing Service, Software Vendor, Employer Group, Financial Institution, etc.) that transmits to, or receives electronic data from,. s EDI transaction system supports transactions adopted under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) as well as additional supporting transactions as described in this guide. EDI Operations supports transactions for multiple payers; each transaction chapter lists the supported payers for that transaction. While EDI Operations will accept HIPAA compliant transactions from any covered entity, HIPAA security requirements dictate that proper procedure be established in order to secure access to data. As a result, has a process in place to establish an Electronic Trading Partner relationship. That process has two aspects: A Trading Partner Agreement must be submitted which establishes the legal relationship and requirements. This is separate from a participating provider agreement. Once the agreement is received, the Trading Partner will be sent a logon ID and password combination for use when accessing s EDI system for submission or retrieval of transactions. This ID is also used within EDI Interchanges as the ID of the Trading Partner. Maintenance of the ID and password by the Trading Partner is detailed in the security section of this document. April 5,

14 Chapter 1 Introduction Supported EDI Transactions 1.1 Supported EDI Transactions will be supporting the following EDI Transactions: Provider Transactions 270 Transaction Eligibility/Benefit Inquiry 271 Transaction Eligibility or Benefit Information (response to 270) 276 Transaction Claim Status Request 277 Transaction Claim Status Notification (response to 276) 278 Transaction Two implementations of this transaction: Services Review Request for Review (Referral/Authorization Request) Services Review Response to Request for Review 837 Transaction Three implementations of this transaction: Institutional Professional Dental NOTE: Dental transactions (837Ds) for products must be sent to s dental associate, United Concordia Companies Inc (UCCI). To receive authorization to submit EDI transactions to UCCI, you must contact Dental Electronic Services at (800) Transaction Claim Payment/Advice (Electronic Remittance) 14 April 5, 2010

15 Chapter 1 Introduction Real-Time Transaction Capability Employer/Sponsor Transactions 834 Transaction Benefit Enrollment and Maintenance 820 Transaction Premium Payment Acknowledgment Transactions TA1 Segment Interchange Acknowledgment 997 Transaction Functional Group Acknowledgment 277 Acknowledgment Claim Acknowledgment to the 837 (Provider Transaction) 1.2 Real-Time Transaction Capability supports all of the EDI transactions listed in Section 1.1 in batch mode. Additionally, supports all of the Provider Transactions listed in Section 1.1 in real-time mode. The Acknowledgment Transactions listed in Section 1.1 are also used in real-time mode Real-Time Technical Connectivity Specifications maintains separate specifications detailing the technical internet connectivity requirements for 's real-time processes. These connectivity specifications are located in the Resources section under EDI Reference Guides at the following site: https://www.highmark.com/edi/resources/guides/index.shtml For connectivity specifications related to the Request and Response Inquiry transactions (270/271, 276/277 and 278), see the 'Real-Time Inquiry Connectivity Specifications'. For connectivity specifications related to Claim Adjudication and Claim Estimation processes (837/835), including a complete 'Transaction Flow' diagram, see the 'Real-Time Claim Adjudication and Estimation Connectivity Specifications'. April 5,

16 Chapter 1 Introduction Real-Time Transaction Capability Real-Time Claim Adjudication and Estimation Effective November 7, 2008, implemented real-time capability for claim adjudication and claim estimation. Both processes leverage the 837 and 835 transactions for these business functions, as well as the 277 Claim Acknowledgment for specific situations. Real-Time Adjudication - allows providers to submit a claim (837) that is adjudicated in real-time and receive a response (835) at the point of service. This capability allows providers to accurately identify and collect member responsibility based on the finalized claim adjudication results. Real-Time Estimation - allows providers to submit a claim (837) for a proposed service and receive a response (835) in real-time. The response 835 estimates the member responsibility based on the current point in time and the data submitted for the proposed service. This capability allows providers to identify potential member responsibility and set patient financial expectations prior to a service. For transaction specific information related to real-time claim adjudication and claim estimation capability, see Chapters: 8 - Professional Claim (837P) 9 - Institutional Claim (837I) 10 - Claim Acknowledgment (277) 11 - Claim Payment Advice (835) General Requirements and Best Practices Trading Partners must use the ASC X12 National Implementation Guides adopted under the HIPAA Administrative Simplification Electronic Transaction rule and 's EDI Reference guidelines for development of the EDI transactions used in the real-time processes. These documents may be accessed through 's EDI Trading Partner Portal: https://www.highmark.com/edi/resources/guides/index.shtml Trading Partners must use the most current national standard code lists applicable to the EDI transactions. The code lists may be accessed at the Washington Publishing Company website: 16 April 5, 2010

17 Chapter 1 Introduction Real-Time Transaction Capability The applicable code lists and their respective X12 transactions are as follows: Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Claim Status Category Codes and Claim Status Codes (277 Claim Acknowledgement) Provider Taxonomy Codes (837) April 5,

18 Chapter 1 Introduction Real-Time Transaction Capability 18 April 5, 2010

19 Chapter 2 General Information Contact Information 2 General Information EDI specifications, including this reference guide, can be accessed online at: https://www.highmark.com/edi/resources/guides/index.shtml Contact Information Contact information for EDI Operations: Address: EDI Operations P.O. Box Camp Hill, PA or TELEPHONE NUMBER: ADDRESS: (717) or (800) When contacting EDI Operations have your Trading Partner Number and Logon ID available. These numbers facilitate the handling of your questions. Inquiries pertaining to Private Business Medical/Surgical or Dental claims should be directed to the appropriate Customer Service Department listed below: Central Region (866) Western Region (866) Eastern Region (866) FEP (866) Dental (Commercial Products) (800) Dental (TriCare Dental Programs) (800) Clarity Vision (717) Special (866) April 5,

20 Chapter 2 General Information System Operating Hours EDI Operations personnel are available for questions from 8:00 a.m. to 5:00 p.m. ET, Monday through Friday. 2.1 System Operating Hours is available to handle EDI transactions 24 hours a day seven days a week, except during scheduled system maintenance periods. We strongly suggest that EDI Trading Partners transmit any test data during the hours that EDI Operations support is available. 2.2 Provider Data Services To obtain the status of a provider s application for participation with any provider network, please contact Provider Data Services at (866) (option 6). Also, use this number to update provider data currently on file with. Note that this number only serves networks; provider data for other payers mentioned in this guide for EDI transactions must be communicated as established by those other payers. 2.3 Audit Procedures The Trading Partner ensures that input documents and medical records are available for every automated claim for audit purposes. may require access to the records at any time. The Trading Partner s automated claim input documents must be kept on file for a period of seven years after date of service for auditing purposes. Microfilm/microfiche copies of Trading Partner documents are acceptable. The Trading Partner, not his billing agent, is held accountable for accurate records. The audit consists of verifying a sample of automated claim input against medical records. Retention of records may also be checked. Compliance to reporting requirements is sample checked to ensure proper coding technique is employed. Signature on file records may also be verified. In accordance with the Trading Partner Agreement, may request, and the Trading Partner is obligated to provide, access to the records at any time. 20 April 5, 2010

21 Chapter 2 General Information Valid Characters in Text Data (AN, string data element type) 2.4 Valid Characters in Text Data (AN, string data element type) For data elements that are type AN, "string", can accept characters from the basic and extended character sets with the following exceptions: Character Name Hex value! Exclamation point (21) > Greater than (3E) ^ Caret (5E) Pipe (7C) ~ Tilde (7E) These five characters are used by for delimiters on outgoing transactions and control characters for internal processing and therefore would cause problems if encountered in the transaction data. As described in the X12 standards organization's Application Control Structure document (X12.6), a string data element is a sequence of characters from the basic or extended character sets and contains at least one non-space character. The significant characters shall be left justified. Leading spaces, when they occur, are presumed to be significant characters. In the actual data stream trailing spaces should be suppressed. The representation for this data element type is AN. April 5,

22 Chapter 2 General Information Valid Characters in Text Data (AN, string data element type) 22 April 5, 2010

23 Chapter 3 Security Features Confidentiality 3 Security Features EDI Operations personnel will assign Logon IDs and Passwords to Trading Partners. EDI Transactions submitted by unauthorized Trading Partners will not be accepted by our EDI Operations system. Trading Partners should protect password privacy by limiting knowledge of the password to key personnel. Passwords should be changed regularly; upon initial usage and then periodically throughout the year. Also, the password should be changed if there are personnel changes in the Trading Partner office, or at any time the Trading Partner deems necessary. Password requirements include: Password must be 8 characters in length. Password must contain a combination of both numeric and alpha characters. Password cannot contain the Logon ID. Password must be changed periodically. 3.1 Confidentiality and its Trading Partners will comply with the privacy standards for all EDI transactions as outlined in the EDI Trading Partner Agreement. 3.2 Authorized Release of Information When contacting EDI Operations concerning any EDI transactions, you will be asked to confirm your Trading Partner information. April 5,

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