HIPAA Transaction Standard Companion Guide For Availity Health Information Network Users

Transcription

1 HIPAA Transaction Standard Companion Guide For Availity Health Information Network Users Refers to the Technical Reports Type 3 Based on ASC X12 version X222A1 837 Health Care Claim Professional Companion Guide Version Number: 1.0 July 2011

2 Disclaimer Florida Health Care Plan, Inc. (FHCP) Companion Guide for EDI Transactions (Technical Reports, Type 3 (TR3) provides guidelines in submitting electronic batch transactions. Because the HIPAA ASC X12- TR3s require transmitters and receivers to make certain determinations /elections (e.g., whether, or to what extent, situational data elements apply), this Companion Guide documents those determinations, elections, assumptions or data issues that are permitted to be specific to FHCP business processes when implementing the HIPAA ASC X TR3s. This Companion Guide does not replace or cover all segments specified in the HIPAA ASC X12 TR3s. It does not attempt to amend any of the requirements of the TR3s, or impose any additional obligations on trading partners of FHCP that are not permitted to be imposed by the HIPAA Standards for Electronic Transactions. This Companion Guide provides information on FHCP specific codes relevant to FHCP business processes and rules and situations that are within the parameters of HIPAA. Readers of this Companion Guide should be acquainted with the HIPAA ASC X12 TR3s, their structure, and content. This Companion Guide provides supplemental information that exists between FHCP and its trading partners. Trading partners should refer to their Trading Partner Agreement for guidelines pertaining to Availity LLC, legal conditions surrounding the implementation of the electronic data interchange (EDI) transactions and code sets. However, trading partners should refer to this Companion Guide for Information on FHCP business rules or technical requirements regarding the implementation of HIPAA-compliant EDI transactions and code sets. Nothing contained in this Companion Guide is intended to amend, revoke, contradict or otherwise alter the terms and conditions of your applicable Trading Partner Agreement. If there is an inconsistency between the terms of this Companion Guide and the terms of your applicable Trading Partner Agreement, the terms of the Trading Partner Agreement will govern. If there is an inconsistency between the terms of this Companion Guide and any terms of the TR3, the relevant TR3 will govern with respect to HIPAA edits, and this Companion Guide will control with respect to business edits. FHCP 837 Professional Companion Guide Version: 1.0 2

3 Table of Contents DISCLAIMER... 2 I. INTRODUCTION... 5 What is HIPAA 5010?... 5 Purpose of the Technical Reports Type 3 Guides... 5 How to Obtain Copies of the Technical Reports Type 3 Guides... 5 Purpose of this 837 Companion Guide... 5 About Availity L.L.C. Patients. Not Paperwork Registration with Availity... 6 II. ASC X12 TRANSACTIONS SUPPORTED... 6 III. GENERAL INFORMATION... 7 EDI Technical Assistance... 7 Password Changes... 7 IV. EDI PROCESSING AND ACKNOWLEDGEMENTS... 7 EDI Processing Hours Functional Acknowledgement Transaction... 7 V. PAYER SPECIFIC REQUIREMENTS... 8 Common Definitions... 8 VI. CONTROL SEGMENTS & ENVELOPES... 9 Global Information... 9 Enveloping Information 837 Professional Claim Submission (Outbound to Payer) 11 Business Requirements VII. TIPS FOR SENDING COORDINATION OF BENEFITS INFORMATION VIII. TRANSACTIONAL TESTING PROCESSES FHCP 837 Professional Companion Guide Version: 1.0 3

4 IX. DIRECT CONNECT WITH FHCP X. TRADING PARTNER AGREEMENT FHCP 837 Professional Companion Guide Version: 1.0 4

5 837 Health Care Professional Claim Companion Guide (5010) I. Introduction What is HIPAA 5010? The Health Insurance Portability and Accountability Act (HIPAA) require that the health care industry in the United States comply with the electronic data interchange (EDI) standards as established by the secretary of Health and Human Services. The ASC X X212 is the established standard for Claim Status Inquiry and Response (276/277). Purpose of the Technical Reports Type 3 Guides The TR3 s, Technical Reports Type 3 Guide for the 837 Health Care Professional Claim transaction specifies in detail the required formats. It contains requirements for the use of specific segments and specific data elements within segments, and was written for all health care providers and other submitters. It is critical that your software vendor or IT staff review this document carefully and follow its requirements to send HIPAA-compliant files to FHCP via your vendor. How to Obtain Copies of the Technical Reports Type 3 Guides TR3 Guides for ASC X X222A1 Health Care Professional Claim (837 P) and all other HIPAA standard transactions are available electronically at Purpose of this 837 Companion Guide This Companion Guide was created for FHCP trading partners to describe the data content, business rules, and characteristics of the applicable transaction. FHCP 837 Professional Companion Guide Version: 1.0 5

6 About Availity L.L.C. Patients. Not Paperwork. Availity optimizes information exchange between multiple health care stakeholders through a single, secure network. The Availity Health Information Network encompasses administrative, financial, and clinical services, supporting both real-time and batch EDI via the web and through business to business (B2B) integration. For more information, including an online demonstration, please visit or call AVAILITY ( ). Registration with Availity In order to register, you ll need: 1. Basic information about your practice, including your Federal Tax ID/National Provider Identifier. 2. Someone with the legal authority (typically an owner or senior partner) to sign agreements for your organization. 3. An office manager or other employee who can oversee the Availity implementation and maintain user IDs and access. II. ASC X12 Transactions Supported FHCP processes the following ASCX X222A1 HIPAA transactions for Professional Claim Submissions FHCP 837 Professional Companion Guide Version: 1.0 6

7 III. General Information EDI Technical Assistance To request technical assistance from FHCP, please send an to Note: For support of EDI transactions through Availity, please visit or call AVAILITY ( ). Password Changes If a password change is necessary, please contact the Availity Health Information Network at Availity or IV. EDI Processing and Acknowledgements The purpose of this section is to outline FHCP processes for handling the initial processing of incoming files and the electronic acknowledgment generation process. EDI Processing Hours The 837 Health Care Professional Claim transaction files can be transmitted seven days per week, 24 hours per day. 997 Functional Acknowledgement Transaction If the file submission passes the ISA/IEA pre-screening above, it is then checked for ASC X12 syntax and HIPAA compliance errors. When the compliance check is complete, a 997 Acknowledgement will be sent to the trading partner informing them if the file has been accepted or rejected. If multiple transaction sets (ST-SE) FHCP 837 Professional Companion Guide Version: 1.0 7

8 are sent within a functional group (GSGE), the entire functional group (GS-GE) will be rejected when an ASC X12 or HIPAA compliance error is found. V. Payer Specific Requirements The purpose of this section is to delineate specific data requirements where multiple valid values are presented within the 5010 TR3. Common Definitions Interchange control header (ISA06) Interchange Sender ID (Mailbox ID) is individually assigned to each trading partner. Interchange control header (ISA08) Interchange Receiver ID is the FHCPL tax ID, Interchange control header (ISA15) Usage Indicator defines whether the transaction is a test (T) or production (P). Functional Group (GS02) Application Sender s code is individually assigned to each trading partner. FHCP 837 Professional Companion Guide Version: 1.0 8

9 VI. Control Segments & Envelopes Global Information Loop ID Segment & Element Name All Transactions FHCP requires a Trading Partner Agreement to be on file with Availity indicating all electronic transactions the Trading Partner intends to send or receive. All Segments Only loops, segments, and data elements valid for the 837 HIPAA-AS TR3 Guides ASC X X222 & ASC X X222A1 will be used for processing. Acknowledgments FHCP acknowledgements are created to communicate the status of transactions. It is imperative that they be retrieved on a daily basis. One file could result in multiple acknowledgements. ANSI X12: -997 Functional Acknowledgement 997 is available immediately after depositing file Negative Values Submission of any negative values in the 837 transaction will not be processed or forwarded. Date fields All dates submitted on an incoming 837 Health Care Professional Claim must be a valid calendar date in the appropriate FHCP 837 Professional Companion Guide Version: 1.0 9

10 Loop ID Segment & Element Name format based on the respective HIPAA-AS TR3 qualifier. Failure to do so may cause processing delays or rejection. Batch Transaction Processing Generally, Availity and FHCP Gateway accept transmissions 24 hours a day, 7 days a week. All transactions Health Care Professional Claims submitted with multiple patient events will be split into separate transactions and returned one at a time. All transactions B2B / EDI FHCP requests to remove - (dashes) from all Tax Ids, SSNs and Zip codes. All transactions FHCP requires that you do not submit any special characters in any text fields. Multiple Transmissions All Segments Any errors detected in a transaction set will result in the entire transaction set being rejected. All transactions 2010AA Billing Provider Loop 2310B Rendering Provider Loop PRV03 FHCP requires Provider Taxonomy Code to be submitted in PRV03. FHCP 837 Professional Companion Guide Version:

11 Enveloping Information 837 Professional Claim Submission (Outbound to Payer) Loop ID Segment & Element Name ISA All transactions utilize delimiters from the following list: >,*,~,^,,{ and :. Submitting delimiters not supported within this list may cause an interchange (transmission) to be rejected. Structure ISA Must submit Professional Claim data using the basic character set as defined in Appendix B of the ASC X X222 TR3. In addition to the basic character set, you may choose to submit lower case characters and the special character (@) from the extended character set. Any other characters submitted from the extended character set may cause the interchange (transmission) to be rejected by the Plan. Authorization Information Qualifier ISA01 FHCP requires 00 in this field. Authorization Information ISA02 FHCP requires 10 spaces in this field. Security Information Qualifier ISA03 FHCP requires 00 in this field. Security Information ISA04 FHCP requires 10 spaces in this field. FHCP 837 Professional Companion Guide Version:

12 Loop ID Segment & Element Name Interchange ID Qualifier ISA05 FHCP requires 01 in this field. Interchange Sender ID ISA06 FHCP requires submission of your individually assigned FHCP sender mailbox number in this field. Interchange ID Qualifier ISA07 FHCP requires ZZ in this field. Interchange Receiver ID ISA08 FHCP will only accept the submission of FHCP tax ID number in this field. Repetition Separator ISA11 FHCP only accepts { as repetition separator for all transactions. Submitting delimiters other than this may cause an Interchange (transmission) to be rejected. Interchange Usage Indicator ISA15 FHCP requires P in this field to indicate the data enclosed in this transaction is a production file. Component Element Separator` ISA16 : Delimiter FHCP requires the use of the above delimiter to separate component data elements within a composite data structure. Functional Group /Functional Group Trailer GS - GE ISA - IEA FHCP will only process one transaction type per GSGE (functional group). However, we will process multiple ST s within one (1) GS segment as long as they are all the same transaction type. FHCP 837 Professional Companion Guide Version:

13 Loop ID Segment & Element Name Functional Group Functional Identifier Code GS01 HC Health Care Claim Professional FHCP requires submission of the above value in this field. Functional Group Application Sender's Code GS02 FHCP requires the submission of the published Sender ID in this field. Functional Group Application Receiver's Code GS FHCP requires the submission of the above value in this field for 837 Professional Claim Submission, all others may cause rejection. Implementation Convention ST03 Must contain X222A1. Business Requirements Loop ID Segment & Element Name 1000A - Submitter Primary Identification Number Identification Code NM109 FHCP requires the submission of the Published Sender ID in this data element. 1000A Submitter EDI Contact Information Submitter Contact Name PER 02 Required when the contact name is different than the name contained in the Submitter Name segment of this loop and it is the first iteration of the Submitter EDI Contact Information Segment. FHCP 837 Professional Companion Guide Version:

14 Loop ID Segment & Element Name 1000B Receiver Name Last Name or Organization Name NM103 FHCP FHCP requests submission of above value in this field. 1000B Receiver Name Receiver Primary Identification Number NM FHCP requests submission of above value in this field. 2000B Subscriber Hierarchical Level Claim Filing Indicator Code SBR09 FHCP requires setting SBR09 to 16 (Health Maintenance Organization /Medicare Risk). 2010BA - Subscriber Name Identification Code Qualifier Subscriber Primary Identifier NM108 NM109 Member ID required and qualifier must be MI in NM108 for FHCP. FHCP requires submission of the ID number (#) in NM109 exactly as it appears on the FHCP ID card without using any embedded spaces (this includes any out of state Blue ID s )including any applicable alpha prefix or suffix. 2010BA - Subscriber Demographic Information Gender Code 2010CA - Patient Demographic Information Gender Code DMG03 F Female M Male FHCP requires that either the F or M gender code be submitted. If any other gender code is submitted, it will cause a reject. 2010BA Subscriber Address & City/ State/ Zip Code N3 N4 FHCP requires submission of the subscriber s address. FHCP 837 Professional Companion Guide Version:

15 Loop ID Segment & Element Name 2010BB Payer Name Payer Name NM103 FHCP FHCP requests submission of above value in this field. 2010BB Payer Name Qualifier Professional Payer ID NM108 NM109 PI Payer Identification Florida Health Care Plans ID FHCP requests submission of above value in this field. 2010BB Payer Name Identification Qualifier 2300 Claim Information / 2400 Service Line Number Monetary Amount Line Item Charge Amount REF01 CLM02 SV102 FHCP requests setting REF01 to G2 if utilized. The total claim charge amount must equal the sum of all submitted line items. Failure to do so will result in claim rejection. Note: If the whole dollar amounts are sent in monetary elements, do not include the decimal or trailing zero (E.g. $30 = 30). When indicating the dollars & cents, the decimal must be indicated (E.g. $30.12 = 30.12) Claim Information Claim Frequency Type Code CLM05-3 FHCP will accept applicable code(s) Note: When submitting the corrected claim, the original Number (ICN/DCN) also known as the Original Claim Number is required to be sent in loop 2300 REF. (REF01= F8 qualifier for Original Number, REF02 = Original Claim Number) Claim Information HI FHCP requires that you do not transmit the decimal points in the diagnosis codes. FHCP 837 Professional Companion Guide Version:

16 Loop ID Segment & Element Name Health Care Code Information The decimal point is assumed. 2310A Referring Provider Name Identification Qualifier REF01 FHCP requests Referring Provider name if applicable in this field. 2310B Rendering Provider Name Identification Qualifier REF01 FHCP requests Rendering Provider Name in this field. 2310C Service Facility Location Entity Identifier Code Identifier Code Qualifier Identification Code NM101 NM108 NM109 Billing Requirements for Blue Medicare Non- Participating Providers Providers who do not participate in the applicable Medicare network for the member, should bill as they would for a Medicare member and file the claim to FHCP. FHCP reimburses Medicare nonparticipating providers the prevailing Medicare rate (less the member s cost share) for the service area in which the service is rendered for Medicare members. Standard Medicare billing requirements apply including the following: Provider name and address Rendering zip code for professional claims Rendering zip code in the value code field for ambulance pick-up Weight and height, in proper format, in the value code fields for dialysis Services. NM101 Use 77 qualifier to indicate Service Location. NM108 - Use XX qualifier to indicate National Provider Identifier. NM109 Submit your office s NPI value FHCP 837 Professional Companion Guide Version:

17 Loop ID Segment & Element Name Service Facility Location City/State/Zip Postal Code N403 N403 Submit your office s 9-digit zip code 2310D Service Facility Location Name Identification Qualifier REF01 FHCP requests Service Facility Location Name in this field Other Subscriber Information Claim Filing Indicator Code SBR09 If MB is used in SBR09 to indicate Medicare Part B as the other payer, then send F8 (Original Number) in REF01 and Medicare ICN (Original Number) in REF Outpatient Adjudication Information MOA FHCP requests that this information be provided to facilitate claims processing. 2330B Other Payer Name NM108 FHCP requests the PI qualifier in this field Service Line Number Product/Service ID Qualifier SV101-1 HC FHCP requests submission of above value in this field as only HCPCS Procedure codes are accepted by FHCP at this time Professional Service Procedure Modifier(s) SV101-3 SV101-4 SV101-5 SV101-6 Please submit the appropriate modifiers in priority order. FHCP 837 Professional Companion Guide Version:

18 Loop ID Segment & Element Name 2410 Drug Identification Drug Identification Drug Quantity LIN CTP DME Providers LIN NDC must be submitted CTP Quantity must be submitted Drug Identification National Drug Code (NDC) LIN03 Must be eleven numeric digits in format. Other characters are not allowed. All loops with N403 Postal Code FHCP requires submission of 9 digit postal code. Coordination of Benefits (COB) Balancing Total Claim Charge Amount (CLM02) should be equal to sum of the service line charge amounts (sum of the SV102 s). FHCP 837 Professional Companion Guide Version:

19 Tips for Sending Coordination of Benefits Information VII. When Florida Health Care Plans (FHCP) is secondary, please remember to include coordination of benefits (COB) data on your claim as outlined below. All HIPAA mandated fields are required. The business requirements and corresponding 837 fields listed below are necessary to process COB information on FHCP claims. R =Required S=Situational 837 Fields Business Requirement S Loop 2320 CAS 01-19, as needed Submission of other insurance payment information requires claim adjustment group codes and associated monetary amounts. Please be sure to submit any differences between the paid and charge amounts in the CAS segments. FHCP requires the CAS segments and the AMT segments equal the charge amount. R Loop 2320 AMT 01 AMT 02 When FHCP is secondary, submit the primary insurer payment information to support correct processing of COB information AMT01 D is required 2320 AMT02 Sum of all Line level Payment Amount minus any Claim Level Adjustment amounts must balance to Claim level Payment Amount. R Loop 2430 CAS segments Loop 2430 SVD 02 When Medicare is primary and FHCP is secondary, FHCP requires: All line level adjustment reason codes & Payment amounts which must balance. FHCP 837 Professional Companion Guide Version:

20 VIII. Transactional Testing Processes All trading partners, clearing houses should be certified via Availity. It is recommended that the trading partner obtain HIPAA Certification from an approved testing and certification third party vendor, prior to testing. IX. Direct Connect with FHCP FHCP offers a Direct Connect alternative compared to traditional Clearinghouse to receive the 837 transaction. Each Direct Connect option is unique per provider and transactions are sent via a secured FTP. For questions regarding EDI submission, testing, enrollment, or setup please contact FHCP EDI support at: edisupport@fhcp.com or call X. Trading Partner Agreement Please contact Availity at Availity or www. Availity.com for your Trading Partner Agreement. FHCP 837 Professional Companion Guide Version: