Assurant Health HIPAA Transaction Standard Companion Guide

Transcription

1 Assurant Health HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version Health Care Claim Payment/Advice CORE v5010 Master Companion Guide November Assurant, Inc. All rights reserved. 1

2 Disclosure Statement This document is subject to change. Changes will be posted to the Assurant Health website. See for updates Assurant, Inc. All rights reserved. 2

3 Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with Assurant Health. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N 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 X12N 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 Assurant, Inc. All rights reserved. 3

4 This page left intentionally blank Assurant, Inc. All rights reserved. 4

5 Table of Contents 1 INTRODUCTION... 6 SCOPE... 6 OVERVIEW... 6 REFERENCES GETTING STARTED... 6 WORKING WITH ASSURANT HEALTH COMMUNICATION WITH THE PAYER... 7 PROCESS FLOW... 7 TERMINLOGY CONTACT INFORMATION... 7 PROVIDER SERVICE NUMBER / CUSTOMER SERVICE... 7 EDI CUSTOMER SERVICE / TECHNICAL ASSISTANCE... 7 APPLICABLE WEBSITES/ CONTROL SEGMENTS/ENVELOPES... 8 ISA-IEA... 8 GS-GE... 9 ST-SE PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Transaction Limitations ACKNOWLEDGEMENTS AND/OR REPORTS TRADING PARTNER AGREEMENTS TRANSACTION SPECIFIC INFORMATION APPENDICES BUSINESS SCENARIOS TRANSACTION EXAMPLES FREQUENTLY ASKED QUESTIONS CHANGE SUMMARY Assurant, Inc. All rights reserved. 5

6 1 INTRODUCTION Federal regulations of the Patent Protection and Affordable Care Act (PPACA) require expanded support of the HIPAA Electronic Remittance Advice (ERA) transaction. SCOPE Providers, billing services and clearinghouses are advised to use the ASC X12N 835 (005010x221A1) Implementation Guide as a basis to send and/or receive Electronic Remittance Advice (ERA) and/or payments in the 835 format. This companion document should be used to clarify the CORE Business rules for 835 data content, transaction acknowledgment and delivery requirements. OVERVIEW The purpose of this document is to assist those responsible for testing and implementing electronic remittance transactions. This document provides information about Assurant Health s implementation of the Electronic Remittance Advice transaction (835) and supplements requirements specified in the ASC X12N 835 (005010x221A1) Implementation Guide. REFERENCES ASC X12N 835 (Version x221A1) Technical Report Type 3 guide for Health Care Remittance Advice: Assurant Health Companion Guide: CAQH/CORE Rules: 2 GETTING STARTED WORKING WITH ASSURANT HEALTH Providers who want to receive an 835 or payment by EFT must contact Change Healthcare (formerly known as Emdeon) to be set-up. If you would like your payments and remittances delivered electronically, please visit Change Healthcare s website for more information. Enrollment for these services is available at no additional cost. Enrollment can be completed online or by calling and selecting Option 1. If you encounter any errors, please contact the Assurant Health EDI Services group for technical assistance at ediserve@assurant.com Assurant, Inc. All rights reserved. 6

7 3 COMMUNICATION WITH THE PAYER PROCESS FLOW Figure 1: 835 Transaction Flow TERMINLOGY DFI Depository Financial Institution. DFI is a financial institution that accepts deposits and channels the money into lending activities. EFT Electronic Funds Transfer EFT is a way to electronically exchange or transfer money from one account to another. FDN Funds Deposit Notification 4 CONTACT INFORMATION PROVIDER SERVICE NUMBER / CUSTOMER SERVICE If you have questions regarding claim adjudication results, claim status, member eligibility or referral/authorization, contact the Assurant Health Customer Service department: Phone: EDI CUSTOMER SERVICE / TECHNICAL ASSISTANCE If the answers to questions you have are not found in this Companion Guide, please contact the Assurant Health EDI team: Phone: Assurant Help Desk ask to open a ticket with Assurant Health EDI Services group ediserve@assurant.com APPLICABLE WEBSITES/ Assurant Health Website: Assurant, Inc. All rights reserved. 7

8 5 CONTROL SEGMENTS/ENVELOPES Listed below are Assurant Health specific requirements for the exchange of a Health Care Remittance Advice (835) transaction. ISA-IEA The ISA segment terminator, which immediately follows the component separator, must consist of only one character code. The same character code must be used as the segment terminator for each segment in the ISA-IEA segment set. Page # Reference Name s Expected Value C.3 ISA Interchange Control All positions within each of the data Header elements must be filled. C.4 ISA01 Authorization Information Qualifier (zero zero) No Authorization Information Present (no meaningful information in ISA02) C.4 ISA02 Authorization Blank (fill with 10 spaces) Information C.4 ISA03 Security Information Qualifier No Authorization Information Present (no meaningful information in ISA04) C.4 ISA04 Security Information Blank (fill with 10 spaces) C.4 ISA05 Interchange ID Qualifier ZZ ZZ (Mutually Defined) C.4 ISA06 Interchange Sender ID , , This field will be filled with 15 characters and be left justified = Time Insurance Co = John Alden Life Co = Union Security Ins. Co. C.5 ISA07 Interchange ID Qualifier ZZ ZZ (Mutually Defined) C.5 ISA08 Interchange Receiver ID Vendor supplied ID. This field will be filled with 15 characters and be left justified. C.5 ISA09 Interchange Date Interchange Creation Date in YYMMDD format C.5 ISA10 Interchange Time Interchange Creation Time in HHMM format C.5 ISA11 Interchange Repetition Separator C.5 ISA12 Interchange Control Version Number C.5 ISA13 Interchange Control Number C.6 ISA14 Acknowledgement Requested ^ Assurant Health will utilize the carrot symbol ^ as the repetition separator Indicates version number Assigned by your software (usually sequential integer), no leading zeros allowed 0 or No Interchange Acknowledgment Requested 1 - Interchange Acknowledgment Requested C.6 ISA15 Usage Indicator P P - Production data C.6 ISA16 Component Element Separator > A : (Greater than symbol) will be sent in this field. C.10 IEA Interchange Control Trailer C.10 IEA01 Number of Included Count of the number of functional Functional Groups groups included in an interchange. C.10 IEA02 Interchange Control Control number assigned by the Number interchange sender that should be nine characters and be identical to the value in ISA Assurant, Inc. All rights reserved. 8

9 GS-GE Files must contain a single GS-GE per real time transaction. Page # Reference Name s Expected Value C.7 GS Functional Group All positions within each of the data Header elements must be filled. C.7 GS01 Functional Identifier HP HP Health Care Claim Payment/Advice C.7 GS02 Application Sender , , Same value as ISA = Time Insurance Co = John Alden Life Co = Union Security Ins. Co. C.7 GS03 Application Receiver Same value as ISA08. C.8 GS04 Date Functional Group Creation Date in CCYYMMDD format C.8 GS05 Time Functional Group Creation Time in HHMM format C.8 GS06 Group Control Number Unique number within interchange. Will begin with 0001, and will be identical to GE02. C.8 GS07 Responsible Agency X X - Accredited Standards Committee C.8 GS08 Version/Release/Industr y Identifier X221 A1 X12 Version and transaction number C.9 GE Functional Group Trailer C.9 GE01 Number of Transaction Sets Include C.9 GE02 Group Control Number 1 Total number of transaction sets included in the functional group. Unique number assigned by the sender that must be identical to GS06. ST-SE Each file can contain multiple 835 Remit Advices. Each 835 will be wrapped in a single ST-SE. Page # Referenc e Name s Expected Value 68 ST Transaction Set Header 68 ST01 Transaction Set Identifier ST02 Transaction Set Control Number Nine-digit number starting with 1 and increasing sequentially. Will match 68 ST03 Implementation Convention Reference X221 A1 the number in SE02. This element contains the same value as GS SE Transaction Set Trailer 228 SE01 Transaction Segment Count Total numbers of segments included in a transaction set (including the ST and SE segments) Assurant, Inc. All rights reserved. 9

10 6 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS Transaction Limitations Assurant Health supports the Electronic Remit Advice in batch mode only. 835s will have a ST/SE loop for each Remit Advice. 7 ACKNOWLEDGEMENTS AND/OR REPORTS For each 835 Electronic Remit Advice sent to Assurant Health, the following should be returned: 999 Implementation Acknowledgement if the 835 transaction contains HIPAA compliancy errors within the ST/SE segments. 8 TRADING PARTNER AGREEMENTS Providers who wish to receive an 835 or payment by EFT must contact Change Healthcare to be enrolled. If you would like your payments and remittances delivered electronically, please visit Change Healthcare s website for more information. Enrollment for these services is available at no additional cost. Enrollment can be completed online or by calling and selecting Option Assurant, Inc. All rights reserved. 10

11 9 TRANSACTION SPECIFIC INFORMATION This section attempts to explain the usage of 835 segments/elements in the context of EDI. Page # Loop Reference Name s Expected Value 69 BPR Financial Information 70 BPR01 Transaction Handling code H or I H Notification Only I Remittance Information Only 71 BPR02 Monetary Amount Negative Amounts are not allowed. Zero dollars not allowed for Check Payments. 71 BPR03 Credit/Debit Flag C Only Credit Flag is allowed. 72 BPR04 Payment Method 72 BPR05 Payment Format CHK, ACH, NON CCP CHK Check ACH Automated Clearing House NON Non Payment Data If ACH, then send CCP Cash Concentration / Disbursement plus Addenda (CCD+) (ACH) 73 BPR06 (DFI) ID Qualifier Number 01 or space If ACH, then send ABA Transit Routing Number. 73 BPR07 Payer s ABA Number If ACH, then send Payer s ABA number. 74 BPR08 Account Number Qualifier DA If ACH, then send DA. DA Demand Deposit 74 BPR09 Sender s Bank If ACH, then send. Account Number 74 BPR10 Originating Company Identifier , , If ACH, then send. Must be the Sender Federal Tax ID Number, preceded by a 1. Same as TRN = Time Insurance Co = John Alden Life Co = Union Security Ins. Co. 74 BPR11 Originating Company Supplemental If BPR10 is sent, then send. Same as TRN BPR12 (DFI) ID Qualifier Qualifier 01 If ACH, then send 01. ABA Transit Routing Number. 75 BPR13 (DFI) ID Number If ACH, then send. 76 BPR14 Account Number Qualifier DA If ACH, then send DA. DA Demand Deposit 76 BPR15 Account Number If ACH, then send. 76 BPR16 Check or EFT Effective Date in CCYYMMDD format 2015 Assurant, Inc. All rights reserved. 11

12 Page # Loop Reference Name s Expected Value 77 TRN Re-association Trace Number 77 TRN01 Trace Type Current Transaction Trace 77 TRN02 Check or EFT Trace Number 78 TRN03 Payer s Federal Tax ID 78 TRN04 Originating Company Supplemental , , Numbers This number must be unique within the sender/receiver relationship. The number is assigned by the sender. For example, if Payment is made by check; then this number should be the check number. Must be the Sender Federal Tax ID Number, preceded by a = Time Insurance Co = John Alden Life Co = Union Security Ins. Co. If ACH, then send. Same as BPR DTM Production Date 85 DTM01 Date Qualifier DTM02 Date Date 835 created in CCYYMMDD format A N1, N3, N4 Payer Identification Payer Name and Address 94 PER Payer Business Contact Info 95 PER01 CX CE - Payers claim office. 95 PER03 TE TE - Telephone number A PER Payer Technical Contact Info 97 PER01 BL BL - Technical Dept. 98 PER03 TE TE - Telephone number A PER Payer Web Site 100 PER01 IC IC - Information contact. 101 PER03 UR UR - URL B N1, N3, N4 Payee Identification Payer Name and Address 107 REF Payee Additional Identification 107 REF01 Payee Identification Qualifier TJ Payee Federal Tax ID Number LX Header Number CLP Claim Payment Info CAS Claim Adjustment 131 CAS01 Claim Adjustment Group CO, OA, PI, PR NM1 Patient Name 137 NM101 Entity Identifier QC QC Patient. 139 NM108 Identification Qualifier MI MI Member ID 2015 Assurant, Inc. All rights reserved. 12

13 Page # Loop Reference Name s Expected Value NM1 Insured Name 141 NM101 Entity Identifier IL IL Insured or Subscriber. 142 NM108 Identification Qualifier MI MI Member ID NM1 Service Provider Name 147 NM101 Entity Identifier Rendering Provider 149 NM108 Identification Qualifier XX XX NPI MIA Inpatient Adjudication Info REF Other Claim Related ID 169 REF01 Reference Identification Qualifier Employee identification number REF Rendering Provider ID * If available. 171 REF01 Reference Identification Qualifier 1A 1A Blue Cross provider number DTM Statement Dates 174 DTM01 Reference Identification Qualifier DTM Claim Received Date 177 DTM01 Reference Identification Qualifier AMT Claim Supplemental Info 182 AMT01 Amount Qualifier SVC Service Payment Info DTM Service Date 195 DTM01 Date/Time Qualifier CAS Service Adjustment 198 CAS01 Claim Adjustment Group REF Line Item Control Number 206 REF01 Reference Identification Qualifier REF Rendering Provider Info REF01 Reference Identification Qualifier AMT Service Supplemental Amount 211 AMT01 Amount Qualifier LQ Health Care Remark s PLB Provider Adjustment 232, Period start date. 233 Period end date Received date. AU, D8 150, 151, 472 CO, OA, PI, PR AU Coverage amount. D8 Discount amount. 150 Service period start. 151 Service period end. 472 Single day. CO Contractual Obligations OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility. * If available Assurant, Inc. All rights reserved. 13 6R HPI B6 6R Provider Control Number. This is the control number submitted on the 837 transaction. HPI Center for Medicare and Medicaid Services NPI B6 Allowed amount.

14 APPENDICES BUSINESS SCENARIOS Example 1 Electronic Remit Advice (835) with a Check Example 2 Electronic Remit Advice (835) with an EFT Example 3 Electronic Remit Advice (835) with no Check or EFT TRANSACTION EXAMPLES Example 1 Electronic Remit Advice (835) with a Check ISA*00* *00* *ZZ* *ZZ* *130702*1000*^*00501* *0*P*> GS*HP* * * *1000*3194*X*005010X221A1 ST*835* BPR*I*120.00*C*CHK************ TRN*1* * DTM*405* N1*PR*TIME INSURANCE COMPANY N3*501 W MICHIGAN N4*MILWAUKEE*WI*53203 PER*CX*Customer Service Desk*TE* PER*BL*ediserve@assurant.com*TE* PER*IC**UR* N1*PE*EXAMPLE TEST 1*XX* N3*EXAMPLE TEST 1 N4*XXXXXXXX*XX* REF*TJ* LX*1 CLP*XXXXXXXXXXXX*1*177.00*120.00**15* NM1*QC*1*EXAMPLE*TEST 1****MI*TI NM1*IL*1*EXAMPLE*TEST 1****MI*TI NM1*82*1*EXAMPLE*TEST 1****XX* REF*CE*XXXXXXX REF*28*TI REF*1A* DTM*232* DTM*233* DTM*050* AMT*AU* AMT*D8*57.00 SVC*HC>99396*177.00*120.00**1 DTM*472* CAS*CO*45*57.00 AMT*B6* SE*32* GE*1*3194 IEA*1* Assurant, Inc. All rights reserved. 14

15 Example 2 Electronic Remit Advice (835) with an EFT ISA*00* *00* *ZZ* *ZZ* *130702*1000*^*00501* *0*P*> GS*HP* * * *1000*3194*X*005010X221A1 ST*835* BPR*I*35.00*C*ACH*CCP*01* *DA* * *ICK *01*XXXXXX598*DA*XXXXXXX543* TRN*1* * *ICK DTM*405* N1*PR*TIME INSURANCE COMPANY N3*501 W MICHIGAN N4*MILWAUKEE*WI*53203 PER*CX*Customer Service Desk*TE* PER*BL*ediserve@assurant.com*TE* PER*IC**UR* N1*PE*EXAMPLE TEST 2*XX* N3*EXAMPLE TEST 2 N4*XXXXXXXX*XX* REF*TJ* LX*1 CLP*XXXXXXXXXX*1*35.00*35.00**15* NM1*QC*1*EXAMPLE*TEST 2****MI*TI NM1*IL*1*EXAMPLE*TEST 2****MI*TI NM1*82*1*EXAMPLE*TEST 2****XX* REF*28*TI REF*1A* DTM*232* DTM*233* DTM*050* AMT*AU*35.00 SE*26* GE*1*3194 IEA*1* Assurant, Inc. All rights reserved. 15

16 Example 3 Electronic Remit Advice (835) with no Check or EFT ISA*00* *00* *ZZ* *ZZ* *130702*1000*^*00501* *0*P*> GS*HP* * * *1000*3194*X*005010X221A1 ST*835* BPR*H*0*C*NON************ TRN*1* * DTM*405* N1*PR*TIME INSURANCE COMPANY N3*501 W MICHIGAN N4*MILWAUKEE*WI*53203 PER*CX*Customer Service Desk*TE* PER*BL*ediserve@assurant.com*TE* PER*IC**UR* N1*PE*EXAMPLE TEST 3*XX* N3*EXAMPLE TEST 3 N4*XXXXXXXX*XX* REF*TJ* LX*1 CLP*XXXXXXXXXX*1*193.00*0**15* NM1*QC*1*EXAMPLE*TEST 3****MI*TI NM1*82*1*EXAMPLE*TEST 3****XX* REF*CE*EXAMPLE TEST 3 REF*28*TI REF*1A* DTM*232* DTM*233* DTM*050* SVC*HC>99213*193.00*0**1 DTM*472* CAS*CO*95* REF*HPI* SE*29* GE*3*3194 IEA*1* Assurant, Inc. All rights reserved. 16

17 FREQUENTLY ASKED QUESTIONS Q. Why did I not receive my ERA? A. There are three possible answers to this question. a. There was no NPI sent on the 837 HIPAA Claims transaction. Assurant Health will not send an ERA 835 transaction if no NPI was passed even if the Provider is set-up to receive an 835. b. The policy is a Fixed Indemnity policy. Assurant Health will not send an ERA 835 transaction if the claim is for a Fixed Indemnity policy. c. The provider was not set-up to receive an ERA 835 transaction. Resolution: Visit website for more information. Enrollment for this service is available at no additional cost. Enrollment is available online or by calling and selecting Option 1. Q. Why did I receive my payment via check instead of EFT? A. The provider was not set-up to receive EFT. Resolution: Visit website for more information. Enrollment for this service is available at no additional cost. Enrollment is available online or by calling and selecting Option 1. Q. Who do I call for support if a problem arises? A. If the answers to questions you have are not found in this Companion Guide, please contact the Assurant Health EDI team: Phone: Assurant Help Desk ask to open a ticket with the Assurant Health EDI Services group CHANGE SUMMARY Version /11/2013 Initial draft Version 1.0 xx/xx/xx First published version 2015 Assurant, Inc. All rights reserved. 17