837 Professional Health Care Claim

Transcription

1 Companion Document 837P 837 Professional Health Care Claim Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional claims. The remaining sections of this appendix include tables that provide information about 837 Claim segments and data elements that require specific instructions to efficiently process through BlueCross BlueShield of Georgia (BCBSGa) systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide Health Care Claim: Professional, 837, ASC X12N 837 (004010X098), May 2000, and the subsequent Addenda (004010X098A1), October 2002, published by the Washington Publishing Co. EDI Transmission Structure Communications Transport Protocol Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Header (GS) Communications Session Interchange Control Wrap Functional Group 1 Wrap Functional Group 2 Wrap Transaction Set Transaction Set Transaction Set Transaction Set Transaction Set Header (ST) Detail Segment 1 Transaction Set Trailer (SE) Transaction Set Header (ST) Detail Segment 2 Transaction Set Trailer (SE) Functional Group Trailer (GE) Functional Group Header (GS) Transaction Set Header (ST) Detail Segment 1 Transaction Set Trailer (SE) Transaction Set Header (ST) Detail Segment 2 Transaction Set Trailer (SE) EDI Transaction Structure Envelope Envelope Envelope Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Header Detail Summary Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Functional Group Trailer (GE) Interchange Control Trailer (IEA) Communications Transport Protocol BlueCross BlueShield of Georgia Page 1 of 14

2 1 Uppercase Letters When entering alpha characters into the 837, use only UPPERCASE. As specified in the 837 IG, the basic character set includes uppercase letters, digits, space, and other special characters. For further information, see the 837 IG. 2 Delimiters When sending an ANSI ASC X12N transaction, BCBSGa uses the following delimiters to separate data elements or subelements and to terminate segments. Data Element Separator, Asterisk, (*) Sub-Element Separator, Colon, (:) Segment Terminator, Tilde (~) These delimiters are for illustration purposes only and are not specific recommendations or requirements. 3 Numeric s, Monetary Amounts and Unit Amounts BCBSGa accepts a line item charge amount equal to zero (000): 4 Coordination of Benefits SV102 Monetary Amount Line Item Charge Amount SV104 Quantity Service Unit Count Specific 837 data elements work together to coordinate benefits between BCBSGa and Medicare or other carriers. The tables in the section that follow (Loop 2320, 2330A, 2330B, and/or 2430), identify the data elements that pertain to Coordination of Benefits (COB) with Medicare (to-payer-to-payer COB model) and with other carriers (Payer-to--to-Payer COB model). BCBSGa recognizes submission of an 837 transaction to a sequential payer populated with data from the previous payer s 835 (Health Care Claim Payment/Advice). Based on the information provided and the level of policy, the claim will be adjudicated without the paper copy of the Explanation of Benefits from Medicare or the primary carrier. When more than one payer is involved on a claim, payer sequencing is as follows: If a secondary payer is indicated, then all the data elements from the primary payer must also be present. If a tertiary payer is involved, then all the data elements from the primary and secondary payers must also be present. If these data elements are omitted, BCBSGa will fail the particular claim. BlueCross BlueShield of Georgia Page 2 of 14

3 837 Professional Claim Header The 837 Claim Header identifies the start of a transaction, the specific transaction set, and its business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure ) relates the type of business data expected within each level. The following table indicates the specific values of the required header segments and data elements for BCBSGa processing. 837 Professional Health Care Claim Header IG Segment Loop ID 1000A Submitter Name P.67 NM1 Submitter Name Loop ID 1000B Receiver Name P.74 NM1 Receiver Name NM103 Receiver Name (Submitter Identifier) UPPERCASE EDI Assigned Sender ID. Equals the value entered in ISA06 and GS02. BCBSGA BCBSGA - BlueCross BlueShield of Georgia For professional claims, these values identify BCBSGa as the payer/receiver. 837 Professional Claim Detail The 837 Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant levels include: 1) Information Source (Billing/Pay-to ) 2) Subscriber (Can be the Patient when the Patient is the Subscriber) 3) Dependent (Patient when the Patient is not the Subscriber) BlueCross BlueShield of Georgia Page 3 of 14

4 1 837 Claim Detail: Billing/Pay-to Hierarchical Level The first hierarchical level (HL) of the 837 Claim Detail, Billing/Pay-to HL, identifies the original entity who submitted the electronic claim/encounter to the destination payer. IG Segment Loop ID 2010AA Billing Name P.84 NM1 NM108 Billing ID Qualifier Name P.88 N3 N301 Billing Billing Address Address Line P.91 REF REF01 Billing ID Secondary Qualifier XX (Billing Primary ID) (Billing Street Address) REF02 1B EI SY Loop ID 2010AB Pay-To Name P.99 NM1 Pay-To Name NM108 ID Qualifier XX P.103 N3 Pay-To Address P.106 REF Pay-To Secondary Billing/Pay-to Hierarchical Level N301 Pay-To Address Line REF01 ID Qualifier REF02 (Billing Additional ID) (Pay-To Primary ID) (Pay-To Street Address) 1B EI SY (Billing Additional ID) XX - National Identifier 24 - Employer's Number 34 - Social Security Number NPI ('XX') for Non-Exempt providers Tax ID ('24') or SSN ('34') for Exempt providers Do not enter a post office address. Enter the physical address. 1B - Blue Shield Number EI - Employer's SY - Social Security Number 's Tax ID ('EI') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s XX - National Identifier 24 - Employer's Number 34 - Social Security Number NPI ('XX') for Non-Exempt providers Tax ID ('24') or SSN ('34') for Exempt providers Do not enter a post office address. Enter the physical address. 1B - Blue Shield Number EI - Employer's SY - Social Security Number 's Tax ID ('EI') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s BlueCross BlueShield of Georgia Page 4 of 14

5 2 837 Claim Detail Subscriber Hierarchical Level The second hierarchical level (HL) of the 837 Detail is the Subscriber HL. The following table indicates the specific values of the required Loop 2000B segments and data elements for BCBSGa processing. Subscriber Hierarchical Level IG Segment Loop ID 2000B Subscriber Level P.108 SBR SBR01 P, S, T Subscriber Payer Information Responsibility Sequence Number Loop ID 2010BA Subscriber Name P.117 NM1 Subscriber (Subscriber Identifier) Name This data element indicates whether this claim is Primary (P), Secondary (S), or Tertiary (T). If the value equals S or T, then either the data elements documented in this chart are required, or additional hard copy documentation may be required. ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Prefix Required. FEP contract numbers begin with 'R'. Suffix Not required. If you do include suffix, must also include matching demographic information (gender and date of birth). BlueCross BlueShield of Georgia Page 5 of 14

6 3 837 Claim Detail Patient Hierarchical Level The third hierarchical level (HL) of the 837 Claim Detail is the Patient HL. The following table indicates the specific values of the required segments and data elements for BCBSGa processing. IG Segment Loop ID 2010CA Patient Name P.157 NM1 Subscriber Name Loop ID 2300 Claim Information P.176 CLM CLM05-3 7, 8 Claim Information Claim Frequency Type CLM Related Causes P.194 DTP Date - Accident P.265 HI Health Care Diagnosis DTP03 Accident Date HI0X-2 Diagnosis Loop ID 2310B Rendering Name P.290 NM1 Rendering NM108 ID Qualifier XX Name P.296 REF Rendering Secondary Patient Hierarchical Level REF01 ID Qualifier REF02 (Patient Primary Identifier) (Rendering Primary ID) 1B EI SY (Rendering Additional Identifier) ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Prefix Required. FEP contract numbers begin with 'R'. Suffix Not required. If you do include suffix, must also include matching demographic information (gender and date of birth). If '7' (replacement) or '8' (void/cancel) then the Original Number (ICN/DCN) data segment (Loop 2300 REF02) is required and must contain BCBSGa's originally assigned claim number. If related causes code equals 'AA' (Auto Accident) or OA (Other Accident), 2300 DTP03 (Accident Date) is required. Required if 1) 2300 HI0X-2 (Diagnosis ) is accident-related or 2) 2300 CLM (related Causes code) equals 'AA (auto accident) or 'OA' (other accident). Refer to the latest ICD manual to verify if code is valid, or call EDI Services at (888) , Option 3. Decimal points are not allowed in diagnosis codes. Submit 4-digit diagnosis codes without decimals. If accident-related, 2300 DTP03 (Accident Date) is required. XX - National Identifier 24 - Employer's Number 34 - Social Security Number NPI ('XX') for Non-Exempt providers Tax ID ('24') or SSN ('34') for Exempt providers 1B - Blue Shield Number EI - Employer's SY - Social Security Number 's Tax ID ('EI') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s BlueCross BlueShield of Georgia Page 6 of 14

7 IG Segment Loop ID 2320 Other Subscriber Information P.318 SBR Other Subscriber Information SBR01 Payer Responsibility Sequence Number P S T P.332 AMT COB Payer Paid Amount CAS01 Claim Adjustment Group CAS02 Adjustment Reason CAS03 Adjustment Amount OA AMT01 D Amount Qualifier AMT02 (Payer Paid Monetary Amount Amount) AMT01 AAE Amount Qualifier For COB claims, enter data elements as noted for Loops 2320, 2330A, 2330B, and/or P.323 CAS Claim Level Adjustments (For Medicare Deductible Only) P.333 AMT COB Approved AMT02 Amount Monetary Amount P.334 AMT AMT01 COB Allowed Amount Qualifier Amount AMT02 Monetary Amount P.335 AMT COB Patient Responsibility Amount Patient Hierarchical Level P - Primary; S - Secondary; T - Tertiary Represents the other payers level of responsibility for payment of this claim. Use this segment to report Medicare deductible amounts only (not commercial). When reporting Medicare deductible, complete both this segment, 2320 CAS (Claim Level Adjustments) and 2430 CAS (Line Adjustment) as follows: For this segment, 2320 CAS (Claim Level Adjustments), total the line deductible amounts from the Medicare 835 Payment Advice or EOMB and report the combined amount. In 2430 CAS (Line Adjustment), report line level Medicare and commercial deductible amounts as well as coinsurance, copayment and non-covered amounts. AMT01 F2 Amount Qualifier AMT02 Monetary Amount Enter OA (Other Adjustment) 1 Enter 1 (Deductible Amount) (Approved Amount) B6 (Allowed Amount) (Other Payer Pat. Resp. Amount) Enter amount equal to the sum of the deductible for each claim line. D - Payor Amount Paid Represents total amount paid by Other Payer (835, Loop 1000B CLP04). AAE - Approved Amount Represents approved amount by Other Payer. Provide amount, if available. B6 - Allowed-Actual Represents allowed amount by Other Payer. Provide amount, if available. F2 - Patient Responsibility - Actual Represents Other Payer patient responsibility. Provide amount, if available (835, Loop 1000B CLP05). BlueCross BlueShield of Georgia Page 7 of 14

8 IG Segment P.337 AMT COB Discount Amount P.342 DMG Other Subscriber Demog. Information P.344 OI Other Insurance Coverage Information Patient Hierarchical Level AMT01 D8 Amount Qualifier AMT02 (Other Payer Monetary Amount Discount DMG01 Date Time Period Format Qualifier DMG02 Date Time Period DMG03 Other Insured Gender OI03 Yes/No Condition or Response Indicator OI04 Patient Signature Source OI06 Release of Information Loop ID 2330A Other Subscriber Name P.350 NM1 NM101 Other Entity Identifier Subscriber NM102 Name Entity Type Qualifier NM103, NM104 Name Last/Org. Name, Name First NM108 ID Qualifier Amount) D8 (Other Insured Birth Date) F M U N Y (Patient Signature Source ) (Release of Information ) IL For COB claims, enter data elements as noted for Loops 2320, 2330A, 2330B, and/or Loop ID 2320 Other Subscriber Information (Cont'd) Person (Other Subscriber Last & First Name) MI (Other Sub. Primary Member ID No.) D8 - Discount Amount Represents Other Payer discount amount. Provide amount, if available (835, AMT). D8 - Date expressed in format CCYYMMDD Represents other insured's date of birth. F - Female; M - Male; U - Unknown N - No; Y - Yes Indicates authorization of assignment of benefits (Loop 2300 CLM08). Required except when OI06 = N. Indicates Source of Patient's signature (Loop 2300 CLM10). Indicates authorization of release on file. If value does not equal 'N', OI04 must be populated (Loop 2300 CLM09). IL - Insured or Subscriber Represents the Other Subscriber's First and Last name. MI - Member Number Represents the Other Subscriber's ID No. as assigned by the Other Payer BlueCross BlueShield of Georgia Page 8 of 14

9 IG Segment For COB claims, enter data elements as noted for Loops 2320, 2330A, 2330B, and/or Loop ID 2330B Other Payer Name P.359 NM1 NM101 PR PR - Payer (Other) Other Payer Entity Identifier Name NM Non-Person Entity Entity Type Qualifier NM103 (Other Payer Represents the Other Payer Last or Name Last/Org. Name Org. Name) Organization Name NM108 PI PI - Payer ID Qualifier (Other Payer Primary ID No.) If Other Payer is a BCBS Plan, indicate Plan assigned by BCBS Association. P.366 DTP Required when Loop 2430 is not used & Other Payer has adjudicated the claim. Claim DTP Date Claim Paid Adjudication Date/Time Qualifier Date DTP02 D8 D8 - Date expressed in format CCYYMMDD Date Time Period Format Qualifier DTP03 Date Time Period (Other Payer Adjud. or Represents date the primary payer adjudicated the claim Payment Date) Loop ID 2400 Service Line P.398 LX Service Line LX01 Assigned No. See 837P IG Number of services cannot be greater than 50. P.400 SV1 Professional SV101-2 Procedure See 837P IG Enter the most recent, non-expired CPT or HCPCS. Service SV102 Line Item Chrge Amt See 837P IG Zero amount (000) is valid and acceptable for line charge. SV103 Unit or Basis for See 837P IG MJ - Minutes For anesthesia services, enter 'MJ'. Measurement SV104 Quantity See 837P IG For anesthesia services, value represents number of minutes. P.435 DTP Date - Service Date Patient Hierarchical Level DTP03 Service Date See 837P IG Electronic claims cannot span two calendar years. File charges for the previous year separately from the current year. Do not electronically file claims if the service date is more than one year old. P.488 NTE Line Note NTE02 Description (Line Note Text) For Medicare Private Fee for Service claims, submit the dates when the provider assumed/relinquished patient to/from postoperative care BlueCross BlueShield of Georgia Page 9 of 14

10 IG Segment Loop ID 2420A Rendering Name P.501 NM1 Rendering NM108 ID Qualifier XX Name ID (Rendering Prov Primary ID) P.507 REF Rendering Secondary Patient Hierarchical Level REF01 ID Qualifier REF02 1B EI SY (Rendering Additional Identifier) XX - National Identifier 24 - Employer's Number 34 - Social Security Number NPI ('XX') for Non-Exempt providers Tax ID ('24') or SSN ('34') for Exempt providers 1B - Blue Shield Number EI - Employer's SY - Social Security Number 's Tax ID ('EI') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s For COB claims, enter data elements as noted for Loops 2320, 2330A, 2330B, and/or Loop ID 2430 Line Adjudication Information Only use when service line adjustments reported. If not reported, enter claim adjud. date (Loop 2300). P.554 SVD SVD01 (Other Payer ID Matches Loop 2330B identifying Other Service Line ID ) Payer. Adjudication SVD02 Monetary Amt (Service Line Paid Amount) Represents paid amount by the Other Payer. SVD03-1 HC HC - HCPCS ID Qualifier SVD03-2 Prod/Serv ID (Procedure ) Represents procedure code. SVD ID Qualifier (Procedure Modifier) Represents procedure modifier, if applicable. SVD05 Quantity (Paid Service Unit Count) Represents paid units of service by the Other Payer. BlueCross BlueShield of Georgia Page 10 of 14

11 IG Segment Loop ID 2430 Line Adjudication Information (cont'd) Only use when service line adjustments reported. If not reported, enter claim adjud. date (Loop 2300). P.558 CAS Claim Level Use CAS segments to report Other Payer(s) service line level adjustments. DEDUCTIBLE Adjustment CAS01 Clm Adj Grp CAS02,5,8,11,14,17 Clm Adj Reas 1 OA - Other Adjustments 1 - Deductible Amount CAS03,6,9,12,15,18 Monetary Amount CAS01 Clm Adj Grp CAS02,5,8,11,14,17 Clm Adj Reas CAS03,6,9,12,15,18 Monetary Amount CAS01 Clm Adj Grp CAS02,5,8,11,14,17 Clm Adj Reas CAS03,6,9,12,15,18 Monetary Amount CAS01 Clm Adj Grp CAS02,5,8,11,14,17 Clm Adj Reas CAS03,6,9,12,15,18 Monetary Amount CAS01 Clm Adj Grp CAS02,5,8,11,14,17 Clm Adj Reas CAS03,6,9,12,15,18 Monetary Amount P.566 DTP Line Adjudication DTP01 Date Date Time Qualifier DTP03 Date Time Period Patient Hierarchical Level (Adjustment Amount) 2 (Adjustment Amount) 3 (Adjustment Amount) (Adjustment Rsn ) (Adjustment Amount) Represents the deductible as reported by the Other Payer. COINSURANCE 2 - Coinsurance Amount Represents the coinsurance as reported by the Other Payer. COPAYMENT 3 - Copayment Amount Represents the copayment amount as reported by the Other Payer. NON-COVERED CHARGES Enter the adjustment reason based on the Other Payer(s) Explanation of Benefits. Represents the non-covered amount as reported by Other Payer. CONTRACTUAL OBLIGATION (Adjustment Rsn Enter the adjustment reason based on the ) Other Payer(s) Explanation of Benefits. (Adjustment Represents the contractual obligation amount Amount) as reported by Other Payer. Enter the adjudication date at line level only if service line adjustments have been reported, otherwise report the adjudication date at claim level (Loop 2300) Claim Paid Date by Other Payer (Adjud. or Payment Date) OA - Other Adjustments OA - Other Adjustments PR - Patient Responsibility CO - Contractual Obligation Represents when Other Payer made payment and recognized for processing COB. BlueCross BlueShield of Georgia Page 11 of 14

12 Enveloping EDI envelopes control and track communications between you and BCBSGa. One envelope may contain many transaction sets grouped into functional groups. The envelope consists of the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 837 EDI Transaction Structure Interchange Control Header (ISA) Functional Group Header (GS) Transaction Set Header (ST) Envelope Envelope Envelope Header Detail Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA) BlueCross BlueShield of Georgia Page 12 of 14

13 837 Envelope Control Segments Inbound Health Care Claim Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. Containing authorization and security information, it clearly identifies the sender, receiver, date, time, and interchange control number. BCBSGa requests that all data entered in the ISA-IEA segment be in UPPERCASE. Segment 837 Professional Health Care Claim Interchange Control Header (ISA) ISA ISA No Authorization Information Present Interchange Auth Info Qualifier Control ISA02 (10 Spaces) Enter 10 positions. Header Authorization Info ISA03 Security Info Qualifier No Security Information Present ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Rec ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Cntrl No. (10 Spaces) Enter 10 positions. ZZ (Submitter ID) ZZ BCBSGA (YYMMDD) (HHMM) U ISA14 Ack Requested ISA15 Usage Indicator ISA16 (X) Component Element Separator ZZ - Mutually Defined Format - Fixed length of 15 positions, alphanumeric. Left-justified followed by spaces. Identical to GS02. ZZ - Mutually Defined BCBSGA - BlueCross BlueShield of Georgia Left-justified followed by spaces. must be a valid date in YYMMDD format. must be a valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Sender) Format - Fixed length 9 positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. Right-justified, filled with leading zeroes. Identical to IEA02. 0, No Acknowledgment Requested 1 - Interchange Acknowledgment Requested P, T Submitter ID must be approved to submit production data (P - Production Data; T - Test Data). X - 1 character contained in Basic or Extended Character set. must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). BlueCross BlueShield of Georgia Page 13 of 14

14 2 837 Health Care Claim Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. BCBSGa requests that all dat in the GS-GE segment be entered in UPPERCASE. Segment GS Functional Group Header GS01 Functional Identifier GS02 Application Sender's GS03 Application Receiver's GS04 Date GS05 Time GS06 Group Control Number GS07 Responsible Agency GS08 Version / Release / Industry Identifier 837 Professional Health Care Claim Functional Group Header (GS) HC HC - Health Care Claim (837) (Submitter ID) BCBSGA (CCYYMMDD) (HHMM) (Assigned by Sender) X X098A1 Format positions, alphanumeric. Left-justified with no trailing zeroes or spaces. Identical to ISA06. Routing of batched transactions to: BCBSGa - BlueCross BlueShield of Georgia must be a valid date in CCYYMMDD format. must be a valid time in HHMM format. Format positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. Left-justified with no trailing zeroes or spaces. Identical to GE02. X - Accredited Standards Committee X12 Operationally used to identify the transaction: X098A1-837 Professional Claim NOTE. Critical Batching and Editing Information. **Transactions must be batched in separate functional group by Application Receiver s (GS03). ***Group Control Number (GS06) may not be duplicated by submitter. Files containing duplicate or previously received group control numbers will be rejected. BlueCross BlueShield of Georgia Page 14 of 14

15 3 837 Health Care Claim Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Segment 837 Professional Health Care Claim Functional Group Trailer (GE) GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (Total Number of Transaction Sets in Functional Group or Transmission) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format positions, numeric. Left-justified with no trailing zeroes or spaces. Identical to GS Health Care Claim Interchange Control Trailer (IEA) The IEA segment is the ending, outmost level of the interchange control structure. It indicates and verifies the number of functional groups included with the interchange and the interchange control number (the same number indicated in the ISA segment). Segment 837 Professional Health Care Claim Interchange Control Trailer (IEA) IEA Interchange Control Trailer IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (Number of Functional Groups GS/GE Pairs in Interchange) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format - Fixed length 9 positions, numeric. Unique value greater than zero. Identical to ISA13. BlueCross BlueShield of Georgia Page 15 of 14