DCIPA Claims Submission Companion Guide for 837 Professional and 837 Institutional Claims

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1 VERSION 4010A1 DCIPA Claims 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 DCIPA Claims for Douglas County Individual Practice Association (DCIPA) The objectives of this document are: To clarify what information is needed by the DCIPA 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 Professional Claim Implementation Guide Versions X098A1 and 837 Institutional Claim Implementation Guide Version X096A1. In order to create a DCIPA HIPAA compliant transaction, you must first meet the requirements of the Implementation Guide and then incorporate the payer (DCIPA) 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. Version 3.0 Revision Date: 5/30/2008 ATRIO.EDI May 28, 2008

2 TABLE OF CONTENTS DCIPA 837 EDI Submissions... 1 Inbound Transactions Supported:... 1 Response Transactions Supported:... 1 Delimiters Supported... 1 File Submission Limits:... 1 Submission Gateways:... 2 DCIPA 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)... 4 Service Facility Scenario: (Institutional Claims)... 5 DCIPA 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 REF Transmission Type - 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 ATRIO.EDI May 28, 2008

3 NM1 -- Payer Name - Page N3 -- Payer Address - Page 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 ATRIO.EDI May 28, 2008

4 DCIPA 837 EDI Submissions DCIPA Claims Department receives and process ANSI ASC X12N compliant 837 Professional and 837 Institutional EDI files for Douglas County Individual Practice Association (DCIPA) thru the DCIPA.EDI System. DCIPA Claims processes all alpha characters in upper case. Do not use special characters. To properly process 837 transactions, DCIPA 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 (004010X098A1) 837 Institutional Health Care Claim ASC X12N 837 (004010X096A1) 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: 500 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 ABCT.EDI May 28,

5 Submission Gateways: DCIPA Secure Website: Douglas County Individual Practice Association (DCIPA) For DCIPA Website submission, call DCIPA Claims Department or or 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: ITSS Support at or After connectivity has been established the Trading Partner is assigned a UserAssignedID by the DCIPA.EDI/Support Unit. FTP Directory Structure Inbound Files: UserFTPDirectory\in Outbound Files: UserFTPDirectory\out FTP filename conventions/restrictions: DateTime_DP.UserAssignedID 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. ABCT.EDI May 28,

6 Testing Environment: Completion of the testing process must occur prior to electronic submission of production files. Assistance from the DCIPA.EDI/Support Unit 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 DCIPA.EDI System. Also, changes to the X12N formats may require additional testing. Trading Partner Testing Procedures: DCIPA s secure website: provides this companion guide as well as enrollment packages for download. These documents can also be request via from the DCIPA.EDI/Support Unit at 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, ITSS Support ( or will assist in setting up FTP protocol. The DCIPA.EDI/Support Unit will issue a UserAssignedID for submitted file name conventions after the connectivity has been established. The trading partner contacts DCIPA.EDI/Support Unit to arrange a testing schedule. The trading partner submits test files. The DCIPA.EDI/Support Unit representative evaluates the flow of test data through the DCIPA.EDI System. If the test files are completed successfully, the DCIPA.EDI/Support Unit contacts the trading partner that the trading partner is approved for production file submission thru the DCIPA.EDI System. If the test files are unsuccessful, the DCIPA.EDI/Support Unit 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. DCIPA.EDI 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. 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. ABCT.EDI May 28,

7 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. 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. ABCT.EDI May 28,

8 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). ABCT.EDI May 28,

9 DCIPA 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*DCIPAbbbbbbbbbb*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 15- byte requirement. ISA07 ISA08 ISA15 Interchange Receiver ID Interchange Receiver ID Usage Indicator R 2/2 ID ZZ R 15/15 AN DCIPA Enter DCIPA for DOUGLAS COUNTY IPA. Insert spaces after data to meet 15-byte requirement. 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*DCIPA* *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 Application Receiver's Code R 2/15 DCIPA Enter DCIPA for DOUGLAS COUNTY IPA. ABCT.EDI May 28,

10 ST -- Transaction Set Header - 61 Usage: Required Segment Max Use within Transaction: 1 Loop ID: None Example: ST*837*987654~ ST01 Transaction R 3/3 ID 837 Code 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 REF Transmission Type - Page 64 Usage: Required Segment Max Use within Transaction: 1 Loop ID: None Example: REF* 87*004010X098A1 REF01 Reference R 2/3 ID 87 REF02 Billing Provider Additional R 1/30 AN Use X098A1 for Professional Use X096A1 for Institutional NM1 -- Submitter Name - Page 67 Usage: Required Segment Max Use within Loop: 1 Loop ID: 1000A Example: NM1*41*2*ABX SUBMITTER*****46*TP123456~ 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* DOUGLAS COUNTY IPA *****46*DCIPA~ ELEMENT NAME USE Min/Max Data Type Codes/Values ABCT.EDI May 28,

11 NM103 NM109 Receiver Name Receiver Primary R 1/35 AN DOUGLAS COUNTY IPA Enter DOUGLAS COUNTY IPA for DCIPA R 2/80 AN DCIPA Enter DCIPA for DOUGLAS COUNTY IPA 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." 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* ~ 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 by DCIPA.EDI 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 ABCT.EDI May 28,

12 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: DCIPA.EDI 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 Code R 1/2 ID 24 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) REF Pay-To-Provider Secondary - Page 101 Usage: Situational Segment Max Use within Loop: 8 Loop ID: 2010AA Example: REF*EI* ~ NOTE: DCIPA.EDI 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 Code R 1/35 ID MI NM109 Subscriber Primary R 2/80 AN Member Enter Member Medicaid ID for DCIPA NM1 -- Payer Name - Page 130 Usage: Required Segment Max Use within Loop: 1 Loop ID: 2010BB Example: NM1*PR*2* DOUGLAS COUNTY IPA *****PI*DCIPA~ ELEMENT NAME USE Min/Max Data Type NM103 Payer Name R 1/35 AN Codes/Values DOUGLAS COUNTY IPA Enter DOUGLAS COUNTY IPA for DCIPA ABCT.EDI May 28,

13 NM108 Code R 1/2 ID PI NM109 Payer R 2/80 AN DCIPA Or ATRIO Enter DCIPA for DOUGLAS COUNTY IPA N3 -- Payer Address - Page 134 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2010BB Example: N3*8113 W. HARVARD AVE. SUITE 206 ~ N301 Payer Address Line R 1/55 AN 8113 W. HARVARD AVE. SUITE 206 For DCIPA / DOUGLAS COUNTY IPA N4 -- Payer City/State/Zip - Page 135 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2010BB Example: N4*ROSEBURG*OR*97470~ For DCIPA OHP N401 Payer City Name R 2/30 AN ROSEBURG N402 Payer State Code R 2/2 ID OR 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~ 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) ABCT.EDI May 28,

14 NM1 --Rendering Provider Name-Page-290 Usage: Situational Segment Max Use within Loop: 1 Loop ID: 2310B Example: NM1*82*1*DOE*JOHN****XX* ~ ELEMENT NM108 NM109 NAME Code Subscriber Primary USE Data Codes/Values R 1/2 ID XX XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers R 2/80 AN Enter the Appropriate 10 Digit National Provider ID (NPI) 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~ 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~ ELEMENT SV101-1 SV102 NAME Product or Service ID Line Item Charge Amount USE Data Codes/Values R 2/2 ID HC R 1/18 R DCIPA.EDI 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* ~ ELEMENT NM108 NM109 NAME Code Subscriber Primary USE Data Codes/Values R 1/2 ID XX XX Health Care Financing Administration National Provider (NPI) for Healthcare Providers R 2/80 AN Enter the Appropriate 10 Digit National Provider ID (NPI) ABCT.EDI May 28,

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