How To Process Anci 835 For Bbsm

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1 July 2012 Subject: Changes for the Professional 837 and 835 Companion Document Dear software developer, A revised, updated copy of the ANSI ASC X12N 837 & 835 Professional Health Care Claim & Health Care Claim Payment/Advice (BCBSM EDI Professional 837/835 Companion Document) is now online at: The table below summarizes the changes to companion document. Section Description of Change Page Loop 2010BB NM109 Revised Payer Identifier for Medicare 8 If you have any questions regarding this information, please call our Electronic Data Interchange department at Sincerely, John Bialowicz Manager, ETP Contracting and Relations e-business Interchange Group 1

2 American National Standards Institute (ANSI) ASC X12N 837 (005010X222A1) Health Care Claim: Professional Published December 2010 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

3 Table of Contents Table of Contents... 1 Introduction... 2 ANSI ASC X12N Professional 837 (005010X222A1) Reporting Instruction Clarifications... 3 General Overview... 3 Maximums/Limitations... 3 Coordination of Benefits... 3 Reporting Commercial Payer IDs and Claim Office Numbers... 4 Professional Electronic Claim Exceptions... 4 ANSI ASC X12N Professional 835 (005010X221A1) Remittance Clarifications... 4 Blue Exchange... 4 Additional Information... 5 TA1 Interchange Acknowledgements Functional Acknowledgements... 5 Professional 837 and 835 Interchange Envelope and Functional Group Structure... 5 Data Clarifications for the Professional 837 (005010X222A1) Transaction Set... 6 Data Clarifications for the Professional 835 (005010X221A1) Transaction Set General EDI Terminology Grand River Page 1 of 13 Last revised 3 rd Qtr 2012

4 Introduction This document is the property of Blue Cross Blue Shield of Michigan and is for use solely in your capacity as a trading partner exchanging health care transactions with BCBSM. This document is intended for use as a companion to the HIPAA-mandated ANSI ASC X12N Professional 837 version X222 and 835 version X221 transaction set Technical Reports Type 3 (TR3) and the modifications implemented with the adopted Type 1 Errata (X12N/005010X222A1) and (X12N/005010X221A1). Specific payer instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the applicable HIPAA TR3s and the adopted Type 1 Errata published by Washington Publishing Company, companion documents, EDI User Guide, physician s manuals, and/or other billing guidelines published by our clearinghouse payers, including BCBSM. TR3s can be purchased from the Washington Publishing Company web site at Copyright (c) 2006, Data Interchange Standards Association on behalf of ASC X12.Format (c) 2006, Washington Publishing Company. All Rights Reserved. This document provides information related to specific elements within the ANSI ASC X12N 837 version X222A1 and 835 version X221A1 transactions, but does not change the definitions, data conditions, or use of a data elements or segments in the standards; add data elements or segments to the maximum defined data sets; use any codes or data elements that are either marked not used in the standard s implementation specification or are not in the standard s implementation specification(s); or change the meaning or intent of the HIPAA standards implementation specifications. 1 This document is incorporated by reference in the EDI Trading Partner Agreement. All instructions were written as known at the time of publication and are subject to change. Changes will be communicated in future letters and on the BCBSM web site: Appropriate steps must be taken before submitting production Addenda ANSI ASC X12N transactions, such as testing, completion of an EDI Trading Partner Agreement and demographic confirmation with our customer support staff. To begin this process, receive more information or ask questions, please call the EDI Help desk at Standards for Electronic Transactions, Federal Register, Vol 65, No. 160, August 17, 2000 pg Grand River Page 2 of 13 Last revised 3 rd Qtr 2012

5 ANSI ASC X12N Professional 837 (005010X222A1) Reporting Instruction Clarifications General Overview The BCBSM EDI clearinghouse accepts ANSI ASC X12N 837 version X222A1 professional transactions for BCBSM, Medicare Advantage 2, BCN 3, Blue Card, FEP, Medicare B, MDCH (Medicaid) and commercial carriers. Acceptance of 837 and return of 835 transactions will occur in batch mode and will not be accommodated in the real-time environment. BCBSM EDI may edit data submitted beyond the requirements defined in the HIPAA TR3. BCBSM EDI may reject interchanges, functional groups or transactions that do not follow all HIPAA TR3 and BCBSM Companion Document requirements. BCBSM EDI will reject an interchange that is submitted with a submitter identification number that is not authorized for electronic submission. BCBSM EDI will reject a file that is determined to be a duplicate of a previously submitted file. Medicare Advantage claims must be submitted as Medicare claims (following Medicare billing instructions) with the following exceptions: The Payer Identification Number, reported in NM109 of Loop 2010BB, must be equal to The Insured s Primary Identification Number, reported in NM109 of Loop 2010BA, must contain the BCBSM assigned contract number, together with alpha prefix, for the insured. BCN Advantage claims must be submitted as BCN claims, following BCN reporting instructions. Maximums/Limitations Report up to 100 claims per subscriber/patient combination. Submit a maximum of 5,000 claims per transaction set. Decimal data reported in data element 782 (Monetary Amount) is limited to a maximum length of 10 characters including reported or implied place for cents (implied value of 00 after the decimal point). Note: the decimal point and leading sign, if sent, are not part of the character count. Coordination of Benefits TR3 front matter Sections and provide examples and detailed information regarding claim balancing and allowed/approved amount calculations. 2 The term Medicare Advantage hereinafter incorporates by reference Medicare Plus Blue PPO, Medicare Plus Blue Group PPO and Medicare Plus Blue PFFS plans. 3 The term BCN hereinafter incorporates by reference BCN HMO, BCN Advantage, BCN Service Company, Healthy Blue Living SM, Personal Plus, BCN 65, OneBlue SM, Healthy Blue HMO HRA SM, BlueElect Self Referral Option SM, MyBlue Medigap SM, and BlueCaid Grand River Page 3 of 13 Last revised 3 rd Qtr 2012

6 Reporting Commercial Payer IDs and Claim Office Numbers In order to properly route commercial payer claims, the appropriate Payer ID must be reported in Loop 2010BB, NM109, and the corresponding Claim Office Number, when applicable, must be reported in Loop 2010BB, REF02 (Qualifier FY). Reference the EDI Commercial Payer Listing for payer identification and claims office numbers used in claims submitted through the BCBSM clearinghouse. The Commercial Payer Listing can be downloaded from If the Claim Office Number shown for a payer is blank or 0000, a REF02 segment should not be reported. If the Claim Office Number shown for a payer is NOCD, report NOCD in the REF02 segment (Qualifier FY). The Commercial Payer Listing also contains a column labeled Type : An X indicates that electronically submitted claims are printed and mailed to the payer. An E indicates that electronically submitted claims for that payer are processed electronically. A D in this column indicates that the claim is submitted directly to the payer by BCBSM EDI. If you have questions regarding which Payer ID or Claim Office number to report, contact the EDI Helpdesk at Professional Electronic Claim Exceptions Please note that for proper adjudication, BCBSM recommends hard copy claim submission for items on the list below BCBSM, FEP and BCN claims requiring hardcopy documentation BCBSM, FEP and BCN tertiary claims BCN status inquiry for secondary claims FEP COB and status inquiry claims BCBSM COB that are auto or employment related Commercial secondary or tertiary claims submitted for payers denoted as Print and Mail on the Commercial Payer Listing. See section Reporting Commercial Payer IDs and Claim Office Numbers above. ANSI ASC X12N Professional 835 (005010X221A1) Remittance Clarifications This document provides information pertaining to 835s for BCBSM, Medicare Advantage, BCN and NASCO (including FEP). One 835 transaction set reflects a single check or EFT transfer. Multiple claims can be referenced within one 835. The 835 may or may not contain responses for all services submitted within an individual claim and depends on how the claim is split by the adjudication system. Enveloping information only is provided for Medicare B (WPS). Blue Exchange 835 transactions for supplemental claims processed by other Blue Cross Blue Shield plans are available through BlueExchange. In order to receive these transactions, providers must register their NPI with the BCBSM EDI department Grand River Page 4 of 13 Last revised 3 rd Qtr 2012

7 Additional Information TA1 Interchange Acknowledgements Interchange Acknowledgements (TA1) are used to reply to an interchange or transmission, notify the sending trading partner of problems that were encountered in the interchange control structure, and verify the envelope information. TA1 acknowledgements are only provided when requested in the Interchange Control Header. Refer to Appendix A and B of the ANSI ASC X12N HIPAA TR3s for additional terminology, summaries and format information for the TA1 Interchange Acknowledgement. 999 Functional Acknowledgements Functional Acknowledgements (999) are used to facilitate control of EDI. Segments within the 999 are used to identify the acceptance or rejection of functional groups, transaction sets or segments. Data elements in error can also be identified. BCBSM will return 999 acknowledgements on a daily basis to verify receipt of files from trading partners. Refer to Appendix A and B of the ANSI ASC X12N HIPAA TR3s for additional terminology, summaries and format information for the 999 Functional Acknowledgement. Professional 837 and 835 Interchange Envelope and Functional Group Structure Trading partners should follow the Interchange Control Structure (ICS), Functional Group Structure (GS), Interchange Acknowledgement (TA1) and Functional Acknowledgement (999) guidelines for HIPAA that are located in the HIPAA TR3s in Appendices A and B. Trading partners should also follow the basic character set guidelines as set forth in the TR3. The following sections address specific information needed by BCBSM in order to process the ASC X12N/005010X222A1-Professional Health Care Claim Transaction. This information should be used in conjunction with the ASC X12N/005010X222A1 Professional Health Care TR3. Transaction Set Element Instruction Pg# Professional 837 Health Care Claim ISA05 Interchange ID Qualifier Report ZZ. C.4 Professional 837 Health Care Claim ISA06 Interchange Sender ID Report the EDI-assigned Billing Location Code of the C.4 submitter. Professional 837 Health Care Claim ISA07 Interchange ID Qualifier Report ZZ. C.5 Professional 837 Health Care Claim ISA08 Interchange Receiver ID Report C.5 Professional 837 Health Care Claim GS02 Application Sender s Code Report the EDI-assigned Billing Location Code of the C.7 submitter. Professional 837 Health Care Claim GS03 Application Receiver s Code Report C.7 Professional 837 Health Care Claim GS08 Version/Release/Industry ID Code Report X222A1 C.8 Professional 835 Health Care Claim Payment Advice ISA05 Interchange ID Qualifier ZZ will be returned from EDI. C.4 Professional 835 Health Care Claim Payment Advice ISA06 Interchange Sender ID will be returned from EDI. C Grand River Page 5 of 13 Last revised 3 rd Qtr 2012

8 Transaction Set Element Instruction Pg# Professional 835 Health Care Claim Payment Advice ISA07 Interchange ID Qualifier ZZ will be returned from EDI. C.4 Professional 835 Health Care Claim Payment Advice ISA08 Interchange Receiver ID The URI (Unique Receiver ID) designated by the provider C.5 based on source of payment will be returned. Professional 835 Health Care Claim Payment Advice GS02 Application Sender s Code One of the following application system identifiers will be C.7 returned for BCBSM-related 835 functional groups: Professional NASCO and FEP: BCBSM NASCO Professional BCBSM and MESSA: BCBSM LOCAL PRO Professional MOS: BCBSM MOS BCN: FACETSTHG Professional Master Medical: BCBSM MSTMD PRO Medicare (WPS): Medicare Advantage: MED ADVANTAGE Medicaid: D00111 Professional BCBSM and MESSA: BCBSM LOCAL SUB (pay subscriber claims). Professional 835 Health Care Claim Payment Advice GS03 Application Receiver s Code The same value as in ISA08 will be returned. C.7 Professional 835 Health Care Claim Payment Advice GS08 Version/Release/Industry ID Code Report X221A1 C.8 Data Clarifications for the Professional 837 (005010X222A1) Transaction Set Loop Segment/Element Instruction Industry/Element Name Pg# 1000A NM109 Report the BCBSM EDI-assigned billing location code of the submitter. Submitter Identifier B NM103 Report BCBSM as the receiver name. Receiver Name B NM109 Report as the receiver identification code for files directed to BCBSM as a clearinghouse Receiver Primary Identifier 80 or as a payer. 2000A PRV segment Required when adjudication is known to be impacted by the provider taxonomy (type) code and the billing provider is also the rendering provider. Billing Provider Specialty Information AA REF01, REF02 Cofinity EIN/SSN must match number on the Cofinity provider file. Qualifier and Billing Provider Tax Identification Number 2010AB N3, N4 All BCBSM, Medicare Advantage (including DME), BCN and FEP If reported, the Pay-to provider address will not be recognized/used. Payments will continue to be directed to the provider address indicated in corporate provider databases. Pay-To Address Pay-To Address City, State, Zip Code Grand River Page 6 of 13 Last revised 3 rd Qtr 2012

9 Loop Segment/Element Instruction Industry/Element Name Pg# 2000B SBR09 Claim Filing Indicator Codes determine the destination payer to whom the claim will be routed by the EDI Clearinghouse. The code must correspond to the destination payer ID reported in loop 2010BB. For proper claim routing and adjudication use only the following codes: Claim Filing Indicator Code BA NM109 Qualifier MI BL Blue Shield (including Blue Card claims) CI Commercial. HM Blue Care Network, BCN Advantage and BlueCaid MB Medicare B and Medicare Advantage (including DME). MC MDCH (Medicaid) TV Title V 11 State Medical Plan (Other Non-Federal) FI Federal Employee Program (FEP) Note: BCN Report BL for routine vision services. Medical vision and all other services for BCN members should be billed under HM (BCN). MDCH (Medicaid) In most cases, use MC. TV and 11 also accepted. If recipient qualifies for more than one program, or other Michigan Department of Community Health program not listed, use MC. All BCBSM (including Blue Card), BCN and Medicare Advantage Report the Subscriber Primary Identifier 123 subscriber s identification number, including alpha prefix, without embedded spaces or special characters. FEP Report R followed by eight digits. Medicare Report the patient s Medicare Health Insurance Claim Number (HICN), including alpha character(s) MDCH (Medicaid) Report the member ID number assigned by MDCH (Medicaid). Medicare and MDCH (Medicaid) For Indian Health Services, report the 3 digit tribe ID followed by the 7 digit residency code. These numbers are obtained from the authorizing service that referred the patient for services. Format as: Community 3 digits County 2 digits State 2 digits Commercial Either loop 2010BA/NM109 or 2010CA/NM109 must be present Grand River Page 7 of 13 Last revised 3 rd Qtr 2012

10 Loop Segment/Element Instruction Industry/Element Name Pg# 2010BB NM109 The Payer Identifier must correspond to the Claim Filing Indicator reported in SBR09 of Loop Payer Identifier 134 Qualifier PI 2000B. Payer If Claim Filing Indicator Equals: Report Payer ID: BCBSM (including Blue BL Card) FEP FI Medicare Advantage MB BCN/BCN HM Advantage/BlueCaid Medicare Advantage DME MB MADME (DMEnsions) Commercial CI See Reporting Commercial Payer IDs and Claim Office Numbers Medicare MB Medicare DMERC MB MDCH (Medicaid) MC TV 11 D CA NM103 BCBSM, BCN See additional instructions/description below. Patient Last Name CA NM104 BCBSM, BCN, MDCH and Medicare Patient first name must be at least one character. See Patient First Name 136 additional instructions/description below. 2010CA NM103 & NM104: Additional instructions. Description Correct Incorrect Names should not contain any special characters, other than a dash ABC-E ABC&% Names should not contain more than three spaces between the first and last character A<space>C<space>E<space>G A<space>C<space>E<space>G<space>I Name should not contain more than three dashes between the first and last character A-C-E-G A-C-E-G-I Names should not contain a combination of more than three dashes and spaces between the first and last A-C<space>E-G A-C<space>E-G<space>I character Name should not contain consecutive spaces A<space>C<space>E<space>G A<space><space>DE Name should not contain consecutive dashes A-C-E-G A DE Names should not contain a consecutive space and dash, in any combination A-C<space>E-G A<space>-DE Or A-<space>DE Grand River Page 8 of 13 Last revised 3 rd Qtr 2012

11 Loop Segment/Element Instruction Industry/Element Name Pg# 2300 REF Qualifier F REF02 Qualifier 9F 2300 HI Segment Diagnosis Code 2310A NM101 Qualifier DN Qualifier P3 BCBSM Report a qualifier of F8 in REF01 and the Document Control Number (DCN) of the BCBSM original claim in REF02 when loop 2300/CLM05-3 is 7 or 8 (Status Inquiry Claim). Medicare Advantage (including DMEnsions) Use a claim frequency code 1 or 7. If a claim frequency code 7 is used, report a qualifier of F8 in REF01 and an original claim DCN in the REF02. BCN If a claim frequency code 7 or 8 is submitted, report a qualifier of F8 in REF01 and the original claim reference number ICN/DCN (must start with an E, M, or 0 (zero) followed by 11 digits) in REF02. MDCH (Medicaid) Report a qualifier of F8 in REF01 and the 10 digit Claim Reference Number assigned by MDCH (Medicaid) to the last approved claim in REF02 when loop 2300/CLM05-3 is 7 or 8. BCBSM For Hearing Services, report the referral number assigned to the hearing evaluation date which is a prerequisite for receiving hearing benefits. The referral number assigned by BCBSM is HED CCYYMMDD when CCYYMMDD is the date of the hearing evaluation. All Payers Report diagnosis codes (without decimal points) to the highest specificity available. Use the diagnosis code pointer in loop 2400 to relate the diagnosis to specific service lines. BCBSM, Medicare Advantage (including DMEnsions), BCN and FEP Diagnosis codes will be validated for reported dates relating to the service. At this time, only one diagnosis code will be referenced per service line. Medicare Report up to eight diagnosis codes per claim. Medicare DMERC Only the first four diagnosis codes will be considered for claim processing on Medicare DMERC claims. MDCH (Medicaid) Report at least one diagnosis code on every claim. Commercial Some payers may only recognize up to four diagnosis codes. BCBSM and FEP: Report Qualifier DN for the referring/ordering physician in all cases when a patient was referred for services. This includes services ordered/referred by another physician or self-referral/no referral services. If more than one iteration of this loop is being reported DN is used to report the actual provider referring services Report Qualifier P3: when reporting the initial PPO network provider, in a second iteration of this loop for services that were performed by an out-ofnetwork provider (in order to avoid patient sanctions), or in a second iteration of this loop when reporting a Primary Care Provider in addition to the actual referring provider Original Reference Number/Payer Claim Control Number (ICN/DCN) Referral Number 193 Health Care Diagnosis Codes 226 Entity Identifier Code Grand River Page 9 of 13 Last revised 3 rd Qtr 2012

12 Loop Segment/Element Instruction Industry/Element Name Pg# 2310A NM108, NM109 BCBSM and FEP: Report the NPI of the referring/ordering physician in all cases when a patient was referred for services. This includes services ordered/referred by another physician or Identification Code Qualifier and Referring Provider 259 self-referral/no referral services. If the referring/ordering physician is not licensed in Michigan or Identifier the NPI is not known, repeat the NPI of the Billing provider from the 2010AA loop. BCBSM PPO: Report the NPI of the PPO Physician referring services in order to receive full payment on all out-of-panel referrals. If the referring/ordering physician is not licensed in Michigan or the NPI is not known, repeat the NPI of the Billing provider from the 2010AA loop. If the Billing NPI is used, this may impact adjudication. Report in either loop 2310A or 2420F. 2310B PRV segment Required when adjudication is known to be impacted by the provider taxonomy (type) code and the billing provider is not the rendering provider CAS BCBSM and BCN Report all prior payer adjustments at the service level to ensure proper processing of secondary claims SV103 All BCBSM (including Blue Card), BCN and Medicare Advantage: - The qualifier MJ, Qualifier MJ Minutes Minutes, is required for time-based anesthesia procedure codes without a time period in the Qualifier UN - Units code description. Anesthesia procedure codes with specified time periods including, but not limited to daily or 15 minutes must be reported using the qualifier UN, Units. Anesthesia procedure codes that are not time-based must use the qualifier UN, Units. 2420A PRV segment Required when adjudication is known to be impacted by the provider taxonomy (type) code and the billing provider is not the rendering provider and this code is different than reported at the claim level. 2420F NM101 Qualifier DN Qualifier P3 BCBSM and FEP: Report Qualifier DN for the referring/ordering physician in all cases when a patient was referred for services. This includes services ordered/referred by another physician or self-referral/no referral services. If more than one iteration of this loop is being reported DN is used to report the actual provider referring services Report Qualifier P3: when reporting the initial PPO network provider, in a second iteration of this loop for services that were performed by an out-ofnetwork provider (in order to avoid patient sanctions), or in a second iteration of this loop when reporting a Primary Care Provider in addition to the actual referring provider Rendering Provider Specialty Information 265 Claim Level Adjustments 299 Unit or Basis for Measurement Code Billing Provider Specialty Information Entity Identifier Code Grand River Page 10 of 13 Last revised 3 rd Qtr 2012

13 Loop Segment/Element Instruction Industry/Element Name Pg# 2420F NM108, NM109 BCBSM and FEP: Report the NPI of the referring/ordering physician in all cases when a patient was referred for services. This includes services ordered/referred by another physician or Identification Code Qualifier and Referring Provider 259 self-referral/no referral services. If the referring/ordering physician is not licensed in Michigan or Identifier the NPI is not known, repeat the NPI of the Billing provider from the 2010AA loop. BCBSM PPO: Report the NPI of the PPO Physician referring services. in order to receive full payment on all out-of-panel referrals. If the referring/ordering physician is not licensed in Michigan or the NPI is not known, repeat the NPI of the Billing provider from the 2010AA loop. If the Billing NPI is used, this may impact adjudication. Report in either loop 2310A or 2420F. Data Clarifications for the Professional 835 (005010X221A1) Transaction Set Loop Segment/Element Instruction Industry/Element Name Pg# TRN02 BCBSM and Medicare Advantage For remittance files containing all non-paid claims or a Trace Number 77 provider withhold adjustment, a unique generated check number will be returned. 1000A N102 BCBSM, MOS and NASCO BCBSM will be returned. Payer Name 87 Medicare Advantage Blue Cross Blue Shield Michigan will be returned. MESSA MESSA will be returned. BCN Blue Care Network of Michigan or BCN Service Company will be returned. BlueCaid BLUECAID will be returned 1000A N401 BCBSM, Medicare Advantage and NASCO Detroit will be returned. Payer City 90 MESSA East Lansing will be returned. BCN Southfield will be returned. 1000A N402 All BCBSM Payers, Medicare Advantage and BCN MI will be returned. Payer State A N403 BCBSM and NASCO will be returned. Payer Zip Code 91 Medicare Advantage will be returned. MESSA will be returned. BCN or will be returned. 1000A REF01, REF02 BCBSM REF01 will contain 2U and REF02 will contain Additional Payer ID 92 Medicare Advantage REF01 will contain 2U and REF02 will contain NASCO REF01 will contain 2U and REF02 will contain 710. MESSA Not used. BCN Not used CLP06 BCBSM, MESSA and Medicare Advantage Code values of 12 (Preferred Provider Organization (PPO) par arrangements) or 15 (Indemnity non-par arrangements) will be returned. NASCO Code values of HM (HMO), 12 (PPO), or 15 (Indemnity) will be returned. BCN HM will be returned. Claim Filing Indicator Code Grand River Page 11 of 13 Last revised 3 rd Qtr 2012

14 General EDI Terminology Addenda Refers to a version of the HIPAA mandated transaction sets which correct identified implementation issues noted in the original TR3s. ANSI X v5010 HIPAA standardized ANSI X12 transaction format for the claims remittance data. ANSI X v5010 HIPAA standardized ANSI X12 transaction format for the claims submission data. All lines of business use this transaction with the exception for retail pharmacy. BlueExchange A Blue Cross Blue Shield Association process through which non-claim HIPAA transactions for members from all other Blue Cross and/or Blue Shield plans can be accepted by a local host plan and routed to the home plan for processing. It also allows for receipt of 835 transactions for crossover remittances from other Blue Cross Blue Shield plans. CMS An acronym for Centers for Medicare and Medicaid Services. Data Segment Corresponds to a record in data processing terminology. Consists of logically related data elements in a defined sequence (defined by X12). Each segment begins with a segment identifier, which is not a data element and one or more related data elements, which are preceded by a data element separator. Each segment ends with a segment terminator. Data Element Corresponds to a field in data processing terminology. Each data element is an assigned unique reference number. Each element has a name, description, type, minimum length and maximum length. The length of an element is the number of character positions used, except as noted for numeric, decimal and binary elements. Data element types are: Nn Numeric (with an assumed number of decimal positions) R Decimal Real Number (including decimal or negative sign) ID Identifier AN Alphanumeric string DT Date TM Time Delimiter A character used to separate two data elements (or sub-elements) or to end a segment. They are specified in the interchange header segment (ISA). Once specified in the ISA, they should not be used in the data elsewhere other than as a separator or terminator. EDI An acronym for Electronic Data Interchange. Electronic Data Interchange the application-to-application transfer of key business information transacted in a standard format using a computer-to-computer communications link. There are typically 6 components used in order to do EDI. They are: an EDI file, a trading partner, an application file/form, translator (mapper), communications and value added network or value-added service provider. Errata - a list of errors with their corrections, inserted on a separate page of a published work Grand River Page 12 of 13 Last revised 3 rd Qtr 2012

15 Interface The point at which two systems connect to pass data. Loops Loops are groups of semantically related segments. Data segment loops may be unbounded or bounded. Routing Separation of data based on specific criteria for subsequent transfer to an internal or external system. TR3s Documents that provide standardized data requirements and content as the specifications for consistent implementation of a standard transaction set. HIPAA TR3s are published by the Washington Publishing Company on their web site: Trading partners Entities that exchange electronic data files. Agreements are sometimes made between the partners to define the parameters of the data exchange and simplify the implementation process. Translation Software Commercial computer software that with input instructions converts a standard format to an application format or an application format to a standard format. Most translation software products also compliance check standard format files and automatically create interchange/functional acknowledgements to identify receipt and translation status of a file. Some products also offer translation capability from any format to any format. X12 Transaction Set A transaction set is considered one business document which is composed of a transaction set header control segment, one or more data segments, and a transaction set trailer control segment. For example, one 837-transaction set is equivalent to one claim file. X12N An Accredited Standards Committee (ASC) commissioned by the American National Standards Institute (ANSI) to develop standards for Electronic Data Interchange (EDI). While X12 indicates EDI, the N identifies the Insurance Subcommittee that is responsible for developing EDI standards for the insurance industry. There is a special health care task group within this subcommittee responsible for the development of health care insurance transactions Grand River Page 13 of 13 Last revised 3 rd Qtr 2012