Phoenix Health Plans

Transcription

1 Phoenix Health Plans Health Care Payment/Advice (835) Standard Companion Guide Refers to the Implementation Guides Based on ASC X12N version: X221A1 Page 1

2 Disclosure Statement The following Phoenix Health Plans Companion Guide is intended to serve as a companion document to the corresponding ASC X12N/005010X221 Health Care Payment/Advice (835), its related Addenda (005010X221A1) and its related Errata (005010X221E1). The document further specifies the requirements to be used when preparing, submitting, receiving and processing electronic health care administrative data. The document supplements, but does not contradict, disagree, oppose, or otherwise modify the X221 in a manner that will make its implementation by users to be out of compliance. About Phoenix Health Plans Serving Arizona Families Since 1983 Phoenix Health Plan (PHP) is a contracted health plan with the Arizona Health Care Cost Containment System (AHCCCS). PHP services Maricopa county. Phoenix Health Plan (PHP) is committed to providing exceptional health care and customer service to our members in partnership with the Arizona Health Care Cost Containment System (AHCCCS). Effective for the January 2014 contract year Phoenix Health Plans will also incorporate the following: Phoenix Advantage (HMO) Serves our Medicare eligible Arizona neighbors in Coconino, Gila, Maricopa, Mohave, Pima, Pinal, Santa Cruz, and Yavapai counties. Phoenix Advantage Plus (HMO SNP) Serves our Arizona neighbors eligible for AHCCCS (the State of Arizona's Medicaid program) and Medicare in Maricopa county. Enroll in Phoenix Advantage Plus anytime if you're eligible for AHCCCS and Medicare. Phoenix Advantage Select (HMO) - New plan for 2014 Serves our Medicare eligible Arizona neighbors in Coconino, Gila, Maricopa, Mohave, Pima, Pinal, Santa Cruz, and Yavapai counties. Contact for Further Information on this Companion Guide Phoenix Health Plan 7878 North 16th Street, Suite 105 Phoenix, AZ Phone: phpedi@abrazohealth.com Page 2

3 Preface This Companion Guide to the v5010 ASC X12 Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Phoenix Health Plan. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12 Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12 Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. Page 3

4 EDITOR S NOTE: This page is blank because major sections of a book should begin on a right hand page. Page 4

5 Table of Contents 1. INTRODUCTION Scope Overview References Additional Information GETTING STARTED System Operating Hours Trading Partner Registration Certification and Testing Overview TESTING CONNECTIVITY Process flows Transmission Administrative Procedures Re-transmission procedures Communication Protocol Specifications Passwords CONTACT INFORMATION EDI Customer Service EDI Technical Assistance Applicable websites / CONTROL SEGMENTS/ENVELOPES ISA-IEA GS-GE ST-SE SPECIFIC BUSINESS RULES AND LIMITATIONS X221A1 Health Care Claim Payment/ Advice (835) ACKNOWLEDGEMENTS AND/OR REPORTS Report Inventory TRADING PARTNER AGREEMENTS TRANSACTION SPECIFIC INFORMATION X221A1 Health Care Claim Payment/ Advice (835) APPENDICES Page 5

6 1. Checklist Business Scenarios Transmission Examples Frequently Asked Questions Change Summary Page 6

7 1. Introduction The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the health insurance payers in the United States to comply with the electronic data interchange(edi) standards for health care as established by the Secretary of Health and Human Services(HHS). The ANSI X12N implementation guides have been established as the standards of compliance for electronic health care transactions. 1.1 Scope This section specifies the appropriate and recommended use of the Companion Guide. The standard adopted by HHS for electronic health care transactions is ANSI ASC X12N Version and is effective January 1, The unique version/release/industry identifier code for the 835 Health Care Payment/Advice transactions is X221A1. This Companion Guide assumes compliance with all loops, segments and data elements contained in the X221A1. This Companion Guide does NOT include any of the required loops, segments or data elements defined in the X221A1 with the exception of those loops, segments or data elements that require further clarification. 1.2 Overview This section specifies how to use the various sections of the document in combination with each other. This companion guide is to supplement the X12N implementation Guide and contains specific instructions related to the following: Data formats, content, codes, business rules, and characteristics of the electronic transaction; Technical requirements and transmission options; and Information on testing procedures that each trading partner must complete before transmitting electronic transactions The information in this document supersedes all previous communications about this electronic transaction. The following standards are in addition to those outlined in the provider manuals. Use this guide in conjunction with the information found in your provider manual. 1.3 References Providers, Trading Partners must use the ASC X12 National Implementation Guides adopted under the HIPAA Administrative Simplification Electronic Transaction rule. It is critical that your IT staff, or software vendor, review this document in its entirety and follow the stated requirements to exchange HIPAA-compliant files with us. The Implementation Guides for X12N and all other HIPAA standard transactions are available electronically at Additional Information The intended audience for this document is the technical and operational staff responsible for generating, receiving, and reviewing electronic health care transactions. Page 7

8 2. Getting Started 2.1 System Operating Hours EDI transactions are handled during regular business hours of Monday to Friday between 8am to 5pm MST, except during scheduled system maintenance periods. We strongly suggest that any test data transmission is done during our regular business hours. Trading Partners should exchange electronic health care transactions via secured transmission. After establishing a transmission method, each trading partner must successfully complete testing. Additional information is provided in the next section of this companion guide. After successful completion of testing, production transactions may be exchanged. 2.2 Trading Partner Registration An EDI trading partner is any entity (provider, billing service, clearinghouse, software vendor, etc.) that transmits electronic data to and receives electronic data from another entity. Trading partners are asked to complete a Business Associate Agreement, Non-Disclosure Agreement, Partner, Confidentiality Statement regardless of the trading partner type as defined below. Once the Agreements are received, the Trading Partner will be sent a user account for use when accessing the system for submission or retrieval of transactions. Trading partner is an entity engaged in the exchange or transmission of electronic transactions. Vendor is an entity that provides hardware, software and/or ongoing technical support for covered entities. In EDI, a vendor can be classified as a software vendor, billing or network service vendor or clearinghouse. Software vendor is an entity that creates software used by billing services, clearinghouses and providers/suppliers to conduct the exchange of electronic transactions. Billing service is a third party that prepares and/or submits claims for a provider. Clearinghouse is a third party that submits and/or exchanges electronic transactions on behalf of a provider. 2.3 Certification and Testing Overview Testing Policy We can set up a trial or test period for ERA upon request, but it is not mandatory. You may also need to test your posting software to ensure it is set up properly. The typical trial or test period will vary. During the trial or test period, you will continue to receive paper EOBs and checks. Complete deployment will depend on your comfort level and the amount of testing needed with your vendor. Page 8

9 3. Testing Before exchanging production transactions, each trading partner may complete testing if applicable. For any questions with testing process, criteria, schedule, the EDI department at Payment and Remittance Schedule 835s are available for retrieval each week. Retroactive Pay Cycles When a retro cycle produces a separate payment from the regular weekly claims run, no separate 835 transaction is produced. Production File-naming Convention 835 files have the following naming convention: F835(Vendor#)ccyyseq#.txt 4. Connectivity There are two types of communication methods for transferring data electronically. File Transfer Protocol (FTP) through a secure Internet connection. Hypertext Terminal Protocol Secure (HTTPS) through an Internet web service. 4.1 Process flows 4.2 Transmission Administrative Procedures Availability Regular Business hours (Monday to Friday 8am to 5pm MST) Downtime notification Trading partners will be notified using distribution in the case of any planned downtime or unexpected downtime. 4.3 Re-transmission procedures We do not have specific re-transmission procedures. Page 9

10 4.4 Communication Protocol Specifications FTP Secured File Transfer Protocol (FTP) is available for Trading Partners who submit or receive any HIPAA-compliant EDI transactions in batch mode. Secure FTP Server provides an FTP service over an encrypted data session during file exchanges. This service offers an Internet accessible environment to provide the ability to exchange files with customers, providers, and business partners using a simple FTP process in an encrypted and private manner. Any state of the art browser can be used to access our Secure FTP Server. Browsers must support strong encryption (128bit) and must allow cookies for session tracking purposes. Once the browser capabilities are confirmed, the following are the general guidelines for exchanging files. 1. Launch your web browser. 2. Connect to the FTP server at: port The server will prompt for an ID and Password. Use the ID/Password that was provided for accessing this service. Enter the ID, tab to password field and enter the password, then hit enter or click on OK. 4. The server will then place you in your individual file space on the FTP server. HTTPS(Internet) Providers secure site: Medicaid - Medicare Passwords EDI Specialist personnel will assign Logon IDs and Passwords to Trading Partners. EDI Transactions submitted by unauthorized Trading Partners will not be accepted by our 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. 5. Contact information 5.1 EDI Customer Service Contact information: (602) phpedi@abrazohealth.com Page 10

11 When contacting our EDI Specialists, have your vendor# and Logon ID available. These numbers facilitate the handling of your questions. EDI Specialists personnel are available for questions from 8:00 a.m. to 5:00 p.m. MST, Monday through Friday. 5.2 EDI Technical Assistance Contact information: (602) When contacting our EDI Specialists, have your vendor# and Logon ID available. These numbers facilitate the handling of your questions. EDI Specialists personnel are available for questions from 8:00 a.m. to 5:00 p.m. MST, Monday through Friday. 5.3 Applicable websites / This companion guide can be accessed online at: 6. Control Segments / Envelopes NOTE: The page numbers listed below in each of the tables represent the corresponding page number in the X12N 835 HIPAA Implementation Guide. X12N EDI Control Segments ISA Interchange Control Header Segment IEA Interchange Control Trailer Segment GS Functional Group Header Segment GE Functional Group Trailer Segment ST Transaction Set Header SE Transaction Set Trailer TA1 Interchange Acknowledgement 6.1 ISA Control header Communications transport protocol interchange control header segment. This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record. Segment Name Page in TR3 Comments ISA Interchange Control Header ISA01 Authorization Information Qualifier C.4 00 = No Authorization Information Present Page 11

12 ISA02 Authorization Information C.4 Value is 10 spaces as field is fixed length ISA03 Security Information Qualifier C.4 00 = No Security Information Present ISA04 Security Information C.4 Value is 10 spaces as field is fixed length ISA05 Interchange ID Qualifier C.4 ZZ ISA06 Interchange Sender ID C ISA07 Interchange ID Qualifier C.5 ZZ Segment Name Page in TR3 Comments ISA08 Interchange Receiver ID C.5 Varies per Provider ISA09 Interchange Date C.5 Format is YYMMDD ISA10 Interchange Time C.5 Format is HHMM ISA11 Interchange C.5 ^ Control Standards Identifier ISA12 Interchange C Control Version Number ISA13 Interchange Control Number C.5 Must be identical to Interchange ISA14 ISA15 ISA16 Acknowledgement Requested Interchange Usage Indicator Component Element Separator Trailer IEA02 C.6 0 = No Acknowledgement Requested C.6 P = Production Data T = Test Data C.6 : 6.1 IEA Control trailer Communications transport protocol interchange control trailer segment. This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record. Segment Name Page in TR3 Notes/Comments IEA Interchange Control Trailer IEA01 Number of Included Functional Groups C.10 Number of included Page 12

13 IEA GS-GE Interchange Control Number Functional Groups C.10 Must be identical to ISA13 GS Functional group header Communications transport protocol functional group header segment. This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record. Segment Name Page in TR3 Comments GS Functional Group Header GS01 Functional Identifier code C.7 HP Health Care Claim Payment/Advice (835) GS02 Application Sender's C Code GS03 Application Receiver's C.7 Varies per Provider Code GS04 Functional Group C.8 Format = CCYYMMDD Creation Date GS05 Functional Group C.8 Format = HHMM Creation Time GS06 Group Control Number C.8 Must be identical to GE02 GS07 Responsible Agency Code C.8 X = Accredited Standards Committee GS08 Version/Release/Industry Identifier Code X12 C X221A1 GE Functional group trailer Communications transport protocol functional group trailer segment. This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record. Segment Name Page in TR3 Notes/Comments GE Functional Group Trailer GE01 Number of Transaction Sets Included C.9 Number of included Transaction Sets GE02 Group Control Number C.9 Must be identical to the Page 13

14 value in GS ST-SE ST Transaction set header Communications transport protocol transaction set header segment. This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record. Segment Name Page in TR3 Notes/Comments ST ST01 ST02 ST03 Transaction Set Header Transaction Set Identifier Code Transaction Set Control Number Implementation Convention Reference SE Transaction set trailer Increment by 1 when multiple transaction sets are included. Must be identical to SE X221A1 Communications transport protocol transaction set trailer. This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments (including the beginning (ST) and ending (SE) segments). This segment may be thought of traditionally as the claim trailer record. Segment Name Page in TR3 Notes/Comments SE Transaction Set Trailer SE01 Transaction Segment Count 228 Number of segments included within the SE02 Transaction Set Control Number ST/SE segments 228 Must be identical to ST02 7. Specific Business Rules and Limitations Availability of Payment Cycle 835 Transactions(Batch) Payment Health Care Claim Payment/Advice(835) transactions are created on a weekly basis to correspond with our weekly payment cycles. The Health Care Claim Page 14

15 Payment/Advice(835) payment transaction files become available for retrieval after the payment cycle is complete. If a health Care Claim Payment/Advice (835) transaction was expected but not available for retrieval on the third day after the payment cycle was complete, contact the EDI Specialist for assistance. 8. Acknowledgments and Reports 8.1 Report Inventory No proprietary reports. 9. Trading Partner Agreements Trading Partner agreements are established at the time of the contract. TRADING PARTNERS EDI Trading Partner Agreements accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. For example, a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions 10. Transaction Specific Information This section describes how ASC X12 Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that is\are additional, over and above, the information in the TR3 s. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the IGs internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, composite or simple data element pertinent to 835 transactions. In addition to the row for each segment, one or more additional rows are used to describe the usage for composite and simple data elements and for any other information. Notes and comments will be placed at the deepest level of detail. For example, a note about a code value will be placed on a row specifically for that code value, not in a general note about the segment. The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides. Appendices 1. Implementation Checklist No Implementation Checklist. Page 15

16 2. Business Scenarios No Business Scenarios at this time. 3. Transmission Examples No examples at this time. 4. Frequently Asked Questions No FAQs at this time 5. Change Summary No Change Summary at this time Dec, 2013 Aug, 2013 Revised New Page 16