EDI CLIENT COMPANION GUIDE

Transcription

2 Document Change History... 4 Purpose... 5 How to use this Guide EDI Implementation Life Cycle EDI Expectations MultiPlan Transaction Process Flow Process Description Process Flow Diagram MultiPlan File Validation Process EDI Validation Checks Load Validation Mapping & Syntax System Specific Validation Business Edits File Transfer and Protocols File Names Files Inbound to MultiPlan Files Outbound from MultiPlan FTP Setup Modes of Transfer Hosting File Mapping Information Files Inbound to MultiPlan Files Outbound From MultiPlan File Responses EDI Functional Acknowledgements ACK Outbound from MultiPlan ACK Inbound to MultiPlan Notifications Notice for MultiPlan File Loads Notice for MultiPlan File Extracts VERSION: 3.0 Page 2

3 8 Pre Go-Live Discussions Production Support Process Production Deployment Warranty Production Support APPENDICES TO MULTIPLAN COMPANION GUIDE Appendix A: Data Requirements for MultiPlan s In-Network processes Appendix B: Important Data Elements for MultiPlan Fee Negotiation Services Appendix C: Data Validation Edits for Viant/Beech Claims Processing Appendix D: Important Data Elements for NCN DIS Claims Processing Appendix E: Data isight State Regulations Considerations Appendix F: MultiPlan FTP Instructions Appendix G: MultiPlan Supported Modifier Codes Appendix H: Workers Comp and Auto Medical Considerations VERSION: 3.0 Page 3

4 Document Change History DATE CHANGED BY SECTION /DESCRIPTION 12/15/2014 Vidya B First Publication of Version /22/2015 Vidya B Section 6, Item 11 Workers Comp and Auto Medical mapping update VERSION: 3.0 Page 4

5 Purpose This Client Companion Guide is available for use by MultiPlan s electronic Trading Partners (also known as MultiPlan s EDI clients) and will provide information on Electronic Data Interchange (EDI) requirements and practices on a standard 837 implementation. Please note that we also offer real time repricing using Web Services for our clients but this information is not covered here and resides in a separate guide. This document is not a client specific EDI Guide and may contain information that is not applicable to a particular implementation. The EDI analyst assigned to the project will point out relevant information as necessary. The following information focuses on MultiPlan s business and system requirements only and is meant to be used as a supplement and not as a replacement to the following documents: X12N HealthCare Claim Implementation Guides published by Washington Publishing Company: 837P TR X222A1 and 837I TR X223A2 The information provided in this document defines what is considered as a standard end to end 837 (5010) implementation. It may be necessary to modify these conventions based on client requirements which will be addressed during the course of an implementation. VERSION: 3.0 Page 5

6 How to use this Guide This client companion guide is comprised of several major sections and a set of appendices. Each section builds on the preceding sections and follows the flow of execution during the project as much as possible. The MultiPlan implementation team and the Trading Partner will determine necessary steps to prepare for successful exchange of electronic transactions in the production environment. Section 1: EDI Implementation Life Cycle Section 2: EDI testing and claim expectations Section 3: MultiPlan transaction Process Flow Section4: File Validation Process Section 5: File transfer protocols (FTP) Section 6: File Mapping requirements (Inbound to MultiPlan from Client) Repricing results (Outbound from MultiPlan to Client) Section 7: File Responses Section 8: Pre Go-Live discussions Section 9: Production Support Process Section 10: Appendices VERSION: 3.0 Page 6

7 1 EDI Implementation Life Cycle This section clarifies the EDI portion in the life cycle of an implementation. Kickoff MultiPlan s Implementation team will usually schedule a kickoff call with the trading partner to initiate a project. Once the scope of the project and timelines are finalized, the EDI analyst will discuss key items from this EDI client Companion Guide including mapping information, acknowledgements, FTP setup, file names, testing process and common errors. FTP If a new FTP is to be setup, the analyst will confirm characteristics of the setup (Refer to Section 7) and relevant information such as PGP keys and file names is exchanged after the kickoff call. If an existing FTP is to be used, file names for new or existing files will be confirmed. Once FTP setup is complete, all files must be exchanged via the FTP server only. Unit Test Cycle The first cycle of testing is also known as a Unit Test where we will expect between professional & institutional claims from the client appropriately mapped with corresponding group indicators. MultiPlan s EDI analyst will process the file and return repricing results along with a thorough file and data integrity analysis. Any errors will be worked through with the involvement of all parties. The Trading partner will then process the repriced 837s and if applicable, generate test EOBs. Confirmation must be sent on whether these files loaded and processed successfully. Volume Test Cycle The second cycle of testing is also known as a Volume Test where we will expect between professional & institutional claims from the client appropriately mapped with corresponding group indicators. The same process as for the Unit test is then followed. Based on the results of the first two cycles and on the comfort level of the implementation team, further test cycles may be conducted. If any of these test cycles are considered a failure due to incorrect mapping or results, they will be repeated until success is achieved before proceeding to the next cycle. VERSION: 3.0 Page 7

8 Pre Go-Live Client Sign Off Once all end to end testing has been completed, a Go-Live date is agreed upon by MultiPlan and the Client teams. The client is then requested for an sign-off indicating that the testing and results were satisfactory and that they are ready to start preparing for the move to production on the predetermined date. A complete summary of the EDI setup is exchanged to verify the information that will be deployed into production. Monitoring Period MultiPlan s implementation team closely monitors client files for the first 30 days after Go-Live. This is called the warranty period where production status updates are exchanged and any issues are addressed by the implementing analyst. Post Go-Live Client Sign off After a few weeks of monitoring, the client is requested for an sign-off indicating that the transition to MultiPlan s production environment and subsequent file processing in production has been satisfactory. Transition to MultiPlan s EDI Support Process After the monitoring or warranty period, the implementing analyst transitions client details to the Daily EDI Production Support team who support all of MultiPlan s EDI clients after initial implementation. VERSION: 3.0 Page 8

9 2 EDI Expectations This section covers the guidelines and expectations of EDI exchanges during an end to end Implementation. Claim Adjustments cannot be handled via EDI at MultiPlan in TEST or PRODUCTION o Any second instance of a claim will be treated as a new claim o If desired, Adjustments to production claims can be handled by the client using MultiPlan s remote repricer MultiPlan cannot reconcile partial claims with each other in TEST or PRODUCTION o Each instance of a claim will be treated as a new claim MultiPlan cannot test claims with future dates of service. Testing during an EDI implementation will focus on FTP setup, data integrity, file mapping and ability of trading partner to process repriced claims. However, accuracy of repricing with respect to provider contracts and percentage of savings may not always be achieved within our TEST environment. The analyst will be able to confirm reason for unsuccessful processing of test claims after consulting with the appropriate repricing teams at MultiPlan. EDI Analysts will provide the results of a detailed file analysis for each test file. This will include information on data integrity and provider mapping. It is MultiPlan s expectation that clients will review this information and perform necessary changes or corrections in order to submit more accurate data for repricing. Pre Production EDI Testing will occur until all file issues inbound and outbound have been resolved and appropriate processes have been placed to avoid their occurrence in production. Most EDI Test files will be returned by MultiPlan within 3-5 business days once the files have been successfully received. Clients will be kept updated if any internal issues occur that delay processing of files. This turnaround time does not include file load or FTP issues where client involvement is required. Production turnaround times will be communicated by the client s Project Manager. VERSION: 3.0 Page 9

10 3 MultiPlan Transaction Process Flow 3.1 Process Description This section provides an explanation and a visual representation of MultiPlan s process flow for claims and corresponding transactions. Trading Partner or EDI Vendor chosen by Trading Partner prepares 837 transactions to be submitted to MultiPlan. Transactions are submitted at agreed upon FTP location for retrieval by MultiPlan processes. MultiPlan loads 837 files into EDI systems MultiPlan performs syntax and mapping validation at file level not claim level o If file passes validation, positive functional acknowledgement (997 or 999) is produced by MultiPlan and posted at FTP for retrieval by Trading Partner or Vendor o If file fails to load, EDI analysts will research and address error with Trading Partner No 997 or 999 is produced for files that fail load validation. MultiPlan requires a c-code (client code) to be attached to every claim that is submitted for repricing and performs validation on these values at claim level o If claim passes validation, it will move on to the next step o If claim fails validation, EDI analysts will research and address error with Trading Partner No 997 or 999 is produced for claims that fail c-code validation. MultiPlan performs repricing activities on claims including Provider matching, product matching and validation of required repricing data elements If Trading Partner has access to MultiPlan extenders, externals or aggregators, MultiPlan systems will act as a traffic cop and route claims to third parties for pricing based on network hierarchy and claim eligibility. o MultiPlan s process to package and transmit claims to and from third parties will be transparent to Trading Partner. Completed claims are extracted into 837 files by MultiPlan s extract process multiple times a day on a fixed schedule. MultiPlan posts 837s with repricing results to agreed upon FTP folders for retrieval by Trading Partner. Trading Partner or vendor chosen by Trading Partner loads MultiPlan s 997/999 and repriced 837 to load into their system for processing. Trading Partner or vendor chosen by Trading Partner posts 997 or 999 acknowledging MultiPlan s repriced files to FTP. MultiPlan loads 997s/999s and addresses any reported errors or missing acknowledgements with Trading Partner. VERSION: 3.0 Page 10

11 3.2 Process Flow Diagram VERSION: 3.0 Page 11

12 4 MultiPlan File Validation Process 4.1 EDI Validation Checks Load Validation Mapping & Syntax MultiPlan performs EDI HIPAA validation on inbound files for Level 1 compliance during the load process. All files should be mapped according to 5010 WPC TR3 documents guidelines. These checks are performed by MultiPlan only at File level and never at Claim level. Therefore if any mapping and syntax errors are encountered in a claim during the inbound process, the entire file will fail and will be addressed by the EDI Support team. Level 1 Validation consists of Transaction Format (X12) Syntax Integrity Compliance Checking comprising of the below items. ISA length (106 bytes, fixed length) Legal/valid separators and terminators X12 Standards Requirements Valid Loops/Segments Segment Order Data Element Attributes (i.e.; Mandatory, Min/Max Sizes, etc.) Numeric Validations X12 Syntax Validations X12 Rules System Specific Validation In addition to checking for ASC X12 and HIPAA compliance, MultiPlan applies system specific edits to each 837 transaction. Below is a list of non-x12 compliance check edits that will cause a transaction to fail or halt at MultiPlan. Empty (0 byte) files Duplicate client claim IDs within the same file o Duplicate claim IDs in separate files are acceptable Duplicate file names (Name of file same as a previously submitted file) File not named per agreed upon naming convention Incorrect or missing client group indicator o This check is done at claim level and will halt the affected claim for processing while other claims in the same file will process successfully. VERSION: 3.0 Page 12

13 4.1.3 Business Edits Sections 4.1 and 4.2 discuss edits that will cause a file or claim loading failure within MultiPlan s inbound interfaces. There are a few business edits that are further applied to 837 files based on the Trading Partner s access to products and networks. These edits will either cause a file failure or a low repricing percentage after successful load as indicated in each section. Appendix A lists important data requirements for accurate provider matching and repricing results within MultiPlan s In-Network processes Appendix B lists important data elements required for processing claims successfully by MultiPlan s Fee Negotiation Services Appendix C lists important data validation checks for processing claims successfully by MultiPlan s Viant or BEECH networks. Appendix D & E list important data elements required for processing claims successfully by MultiPlan s NCN Data isight networks VERSION: 3.0 Page 13

14 5 File Transfer and Protocols This section is relevant if a new FTP connection is to be established or changes to existing FTP connection are to be made. MultiPlan s EDI team will collect information from the Trading Partner during the implementation for this setup. MultiPlan requires that all files follow a standard naming convention that is agreed upon by the Trading Partner and MultiPlan s implementation analyst. 5.1 File Names Files Inbound to MultiPlan Client file names must always follow a fixed naming convention and must be different from previously submitted 837 files (unless replacing a file that failed to load). It is preferred that 5010 files are named with a prefix of 5010_ MultiPlan requires the below information in inbound names File Skeleton: <ClientID>_<Date>_<Time>_<BillType>.<FileType> Client ID or Client Name Date Stamp Time Stamp Bill Type (such as - Hcfa/Ub, H/U, 837I/837P) Transaction Type (997, 999, 837) Files Outbound from MultiPlan Outbound files with repricing results from MultiPlan will always follow a fixed naming convention and will always be unique. MultiPlan offers the below tags within outbound file names <Clientname> <Date> in the format YYYYMMDD <Time> in the format HHMMSS (24 hour) <FileNum> - MultiPlan outbatch number (Not Optional; Currently 7 bytes) <X12Type> - 837I or 837P <Type> - Hcfa or Ub <Extension> - 837, 999 or 997 Common File Name format: <client>_<date>_<time>_<filenum>.<x12type>.837 VERSION: 3.0 Page 14

15 5.2 FTP Setup In order to ensure that PHI (Protected Health Information) data is transmitted in a safe and secure manner, MultiPlan requires that all file transmissions with a Trading Partner occur within the confines of a secure transfer protocol Modes of Transfer MultiPlan supports only the below two modes of FTP automated communication FTP Transmission with PGP Encryption MultiPlan s preferred method FTP over a Secure Shell (SSH) with PGP Encryption Clients may access MultiPlan s FTP server using a web browser if needed Hosting MultiPlan always prefers to host the FTP transfer server but can accommodate connecting to a client or vendor s FTP server in special cases. If MultiPlan is the transfer host: The Trading Partner must finalize file names as described in Section 5.1 The Trading Partner must specify which of the modes listed in Section will be used. If PGP, the Trading Partner must send a copy of their Public PGP Key to MultiPlan in order to complete FTP setup The analyst will complete the setup and send login information to the client. Appendix F contains a brief instruction manual to assist clients with this process. *Separate folder paths will be used for test and production files If Client is the transfer host: The Trading Partner must finalize file names as described in Section 5.1 The Trading Partner must specify which of the modes listed in Section will be used. MultiPlan requires all of the following information from the client o USERNAME: o PASSWORD: o HOST IP/ HOST NAME: o INPUT TEST DIRECTORY MULTIPLAN IS PULLING FROM: o OUTPUT TEST DIRECTORY MULTIPLAN IS PUSHING TO: o INPUT PROD DIRECTORY MULTIPLAN IS PULLING FROM: o OUTPUT PROD DIRECTORY MULTIPLAN IS PUSHING TO: o DELETE FILES AFTER PULLING YES/NO VERSION: 3.0 Page 15

16 6 File Mapping Information This section provides information on MultiPlan s mapping requirements for Client 837 files. 6.1 Files Inbound to MultiPlan MultiPlan is unable to accept Professional (HCFA) and Institutional claims (UB) in the same file. They must be sent in separate files. Clients are requested to always map per ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 for X12N/005010X223A2 and X12N/005010X222A1 published by the Washington Publishing Company; following information focuses on MultiPlan s business requirements and suggestions only. 1. Enveloping: (Professional & Institutional) Each 837 file can contain Only a single set of Interchange Control Header & Trailer (ISA/IEA) Only a single set of Group Control Header & Trailer (GS/GE) within an Interchange Multiple Transaction Sets (ST/SE) within a Group Multiple or single claims within a Group Files may contain claims for more than one product type or network access (Eg: PHCS Primary, MultiPlan Complementary, HEOS) within a file, except for Workers Comp and Auto Medical. 2. File Sender/Receiver ID: (Professional & Institutional) By default, MultiPlan anticipates that customers will use a ZZ qualified send/receive ID in the ISA segment and the same send/receive ID in the GS segment. The trading partnership will be set up this way unless requested otherwise. 3. MultiPlan assigned c-code: (Professional & Institutional) All Trading Partners are assigned one or more c-codes and corresponding account IDs for their client groups based on product and network access. This value is provided to the Trading Partner during an implementation by MultiPlan s Account Manager or Account Associate. It is expected that every claim that is sent to MultiPlan for repricing has a c-code or a predetermined unique group indicator attached to it. VERSION: 3.0 Page 16

17 This value may be mapped in any one of the below three locations as convenient. Loop 2000B, SBR Segment, Element 03. (Subscriber Loop) Loop 2010BB, NM1 Segment, Element 09. (Payer Name Loop) Loop 1000A, Segment NM1, Element 09. (Submitter Name Loop) o This choice assumes that every claim in the transaction set is mapped to this c-code. 4. Client Claim ID (Professional & Institutional) MultiPlan requires that every Client Claim that is submitted is identified by a unique ID or document control number (DCN). This value can be transmitted in one or both of the below locations Loop 2300, D9 qualified REF segment, Element 02 Loop F8 qualified REF segment, Element 02 If a claim has two unique identifiers, such as in the case of vendor mapping, MultiPlan encourages that both values are sent for each claim. 5. Provider Data: MultiPlan systems perform standard provider lookup and matching on all claims based on data mapped within inbound files in specific locations including Provider Name, Address (number, street, city, state, zip), TAX ID (TIN) and NPI. Complete and accurate information where available will greatly improve the rate of successful provider matching on a claim however incomplete information will not cause failures (unless not adhering to HIPAA mapping syntax). MultiPlan is unable to use any provider information if mapped at the service line level and always expects a one to one relationship between the billing provider, the rendering provider and a claim. 5.1 Professional Claims MultiPlan would like to receive provider information for a Professional claim in the following locations Billing provider name, address info mapped to loop 2010AA (NM1*85) Pay-to provider address info mapped to loop 2010AB (even if the same as Billing)(NM1*87) Rendering Provider Name and NPI mapped to loop 2310B (even if the same as Billing)(NM1*82) Service Facility Address mapped to Loop 2310C (even if the same as Billing)(NM1*77) VERSION: 3.0 Page 17

18 5.2 Institutional Claims MultiPlan would like to receive provider information for an Institutional claim in the following locations Billing provider name, address info mapped to loop 2010AA (NM1*85) Pay-to provider address info mapped to loop 2010AB (even if the same as Billing) (NM1*87) Service Facility name and address mapped to 2310E (even if the same as Billing) (NM1*77) 6. NPI, TIN: (Professional & Institutional) MultiPlan now uses NPI (National Provider Identifier) as part of the matching criteria in addition to Provider Name, Address & TIN during claim processing. It is expected that, whenever available, the NPI value is mapped for each provider in the file. When mapping NPI in loop 2010AA (billing provider), TIN mapping must also be included in the same loop in an EI qualified REF segment. 7. Diagnosis and Procedure codes: Institutional Claims ONLY DRG codes are extremely important on all claims, especially where the Type of Bill is IP (In-Patient). EG: 011x Hospital InPatient, 021x Skilled Nursing. Clients are expected to indicate whether Loop 2300 HI Segment ICD-9 or ICD-10 diagnosis codes are being sent to MultiPlan as follows: Description ICD-9 indicator (HI01-1) ICD-10 indicator (HI01-1) Principal diagnosis code BK ABK Admitting diagnosis code BJ ABJ Reason for visit PR APR External cause of injury BN ABN Other diagnosis information BF ABF VERSION: 3.0 Page 18

19 Notes: Multiple diagnosis codes may be permitted; please refer to the ANSI X12 Implementation Guide for specific information. Please do not transmit the decimal point for diagnosis codes. Please do not mix diagnosis code types within a claim (ICD-9s and ICD-10s). Clients should indicate whether Loop 2300 HI Segment ICD-9 or ICD-10 procedure codes are being sent as follows: Description ICD-9 indicator (HI01-1) ICD-10 indicator (HI01-1) Principal procedure code BR BBR Other procedure information BQ BBQ Procedure code modifiers should be mapped when applicable. A complete list of supported procedure modifier codes is included at the end of this guide in Appendix G. 8. Date Segments Institutional Claims ONLY Loop 2300, 435 qualified DTP segment: Clients are required to map the admission date for inpatient claims. Loop 2300, 434 qualified DTP segment: Clients are required to map the date range for the statement from and to dates. 9. Do Not Reprice Amounts: MultiPlan strongly encourages clients to send in denied, excluded or non-covered charge amounts in EDI files especially when claims may route to fee negotiation systems. This value is considered for the following products MPI, PHCS, HEOS, MPI Workers Comp, MPI Auto Medical, FNX and will be deducted from the total charge amount and the claim will be repriced based on the remaining balance. 9.1 Professional Claims Loop 2430 PI qualified CAS segment with qualifiers =B1, 96 or 150, Element 03 Eg. CAS*PI*B1* Institutional Claims Loop 2400 SV2 segment, element 07 VERSION: 3.0 Page 19

20 Loop 2430 PI qualified CAS segment with qualifiers =B1, 96 or 150, Element 03 Eg. CAS*PI*B1* MultiPlan Fee Negotiation Claims: (Professional & Institutional) In addition to preceding items, the following are important mapping requirements specific to MultiPlan Fee Negotiation HCFA and UB claims Appendix B contains a complete list of required data elements for successful Fee Negotiations 10.2 Patient Account Number. MultiPlan would like to receive Patient account number information in the Loop 2300 CLM segment in element 01 whenever available for fee negotiation claims Reasonable and Customary Amount. Clients may indicate a desired allowable amount on a claim for any given line item in the below location. This value may be considered by the fee negotiation systems as a benchmark during provider negotiations. CAS*PI*A7. Loop 2430, PI qualified CAS segment with an A7 qualifier, Element 03 Please note that this value is not considered when claims are repriced within the MultiPlan, PHCS or HEOS networks. 11. Workers Comp and Auto Medical Bills: In addition to preceding items, the following are important mapping requirements specific to MultiPlan and IHP Workers Compensation and Auto Medical bills. These bills will be successfully processed only when received from select states based on a list of MultiPlan launched states and states that maintain fee schedules or apply UCR methodologies; this will be shared with clients as part of the implementation. Appendix H contains a list of definitions for common Workers Compensation and Auto Medical Bill terms and the hierarchy by priority of states used in Claims Processing. Mapping Notes: Workers Comp bills, Auto Medical bills and Group Health claims must be sent in separate files. MultiPlan requires every line in the bill to have the appropriate amount (>=0) mapped. The bill will not process if any one line is missing this value. If the client submits a line-level target amount of $0, MPI will not reprice the line. VERSION: 3.0 Page 20

21 If a client submits a non-covered amount (either for a portion or the full amount of the billed charge), MPI will consider the non-covered amount during repricing. The client should also submit a target amount in this case. If a bill is determined to be for a Fee Schedule mandatory state and if the Fee Schedule amount segment is not present in the file, this bill will fail to process. MultiPlan requires that clients transmit the Accident (Juris) state for all Workers Comp and Auto Medical bill. This mapping should adhere to the following guidelines Professional Claims Clients may provide the following bill data on their Workers Comp and Auto Medical bills o o o o o Target amount Loop 2430 mapping; CAS segment, element 1 = PI, element 2 = W1, element 3 = monetary amount (i.e. CAS*PI*W1* ) Usual and Customary Amount Loop 2430 mapping; CAS segment, element 1 = PI, element 2 = A7, element 3 = monetary amount (i.e. CAS*PI*A7* ) Accident State (Juris State) Loop 2300 mapping; K3 segment, element 1 (i.e. K3*FLAG;ACST=xx) Bill Analysis State Loop 2300 mapping; K3 segment, element 1 (i.e. K3*FLAG;BAST=xx) Other State Loop 2300 mapping; CLM segment, element 11, sub-elements 01 & Institutional Claims Clients may provide the following bill data on their Workers Comp and Auto Medical bills o Target amount Loop 2430 mapping; CAS segment, element 1 = PI, element 2 = W1, element 3 = monetary amount (i.e. CAS*PI*W1* ) o Usual and Customary Amount Loop 2430 mapping; CAS segment, element 1 = PI, element 2 = A7, element 3 = monetary amount (i.e. CAS*PI*A7* ) o o o Accident State (Juris State) Loop 2300 mapping; K3 segment, element 1 (i.e. K3*FLAG;ACST=xx) Bill Analysis State Loop 2300 mapping; K3 segment, element 1 (i.e. K3*FLAG;BAST=xx) Other State Loop 2300 mapping; REF segment, element 2 with LU qualifier VERSION: 3.0 Page 21

22 6.2 Files Outbound From MultiPlan This section provides information that will assist Clients to prepare for processing MultiPlan s outbound repriced files. All data mapped in an inbound file to MultiPlan will be returned to the Trading Partner without modification or deletion with the exception of repricing segments outlined below. Any information mapped into MultiPlan s designated repricing segments will be overwritten on outbound files. 1. Enveloping: (Professional & Institutional) For priced claims files outbound from MultiPlan, the default file structure is a single ST/SE transaction set (containing multiple claims) in a single group (GS/GE) within a single interchange. If needed, arrangements can be made to have multiple ST/SE transaction sets, each containing a single claim in the repriced file outbound from MultiPlan. The only qualifier that MultiPlan EDI is able to return in ISA07 to a trading partner is ZZ. MultiPlan uses the ZZ qualified company tax ID ( ) in the ISA segment and the same value in the GS segment as a send/receive ID. Below is a list of default delimiter values that MultiPlan will populate in outbound repriced files. Delimiter Character Name Data Element Separator * Asterisk Sub-element Separator : Colon Segment Terminator ~ Tilde Repetition Separator ^ Caret 2. MultiPlan s Claim ID: (Professional & Institutional) Each inbound client claim is assigned a unique identifier by MultiPlan s repricing systems for easy reference. This value will be mandatorily returned in an outbound file to the Trading partner in the following location Loop 2300, 9A qualified REF Segment, Element Date Segment: (Professional & Institutional) The Repricer Received Date will be populated by MultiPlan in an outbound file to the Trading partner in the following location Loop 2300, 050 qualified DTP Segment, Element 02 VERSION: 3.0 Page 22

23 4. Repricing Network Code: (Professional & Institutional) Every claim that is processed at MultiPlan including those that are routed to external networks by MultiPlan receives a specific Repricing Network Code. This value is populated for both successful and unsuccessful claims and will be returned in an outbound file in the following locations. Loop 2300, HCP Segment, Element 04 Loop 2400, HCP Segment, Element 04 Loop 2300, CN1 Segment, Element 04; Element 01 will be 09 Please refer to the accompanying EOB/EOR document for your implementation for a list of possible network code values that you may receive. 5. Repricing Methodology: (Professional & Institutional) MultiPlan will map the repricing methodology for a claim and claim lines in the following location in outbound files. Loop 2300, HCP Segment, Element 01 Loop 2400, HCP Segment, Element 01 Following is the Code Set and interpretation for values that may be received. 00 Zero/Unsuccessful Pricing (Not Covered Under Contract) 01 Priced as Billed at 100% 10 Other Pricing 14 External Network Pricing 6. MultiPlan Allowed Amount(Professional & Institutional) The allowed amount obtained by MultiPlan or external networks is mapped in the following location Loop 2300, HCP Segment, Element 02 Loop 2400, HCP Segment, Element MultiPlan Savings Amount(Professional & Institutional) The savings amount obtained by MultiPlan or external networks is mapped in the following location Loop 2300, HCP Segment, Element 03 Loop 2400, HCP Segment, Element 03 VERSION: 3.0 Page 23

24 8. Non-Par Indicator(Professional & Institutional) If MultiPlan and MultiPlan s external Networks are unable to successfully reprice a claim, the outbound file will contain an indicator in the following location to enable clients to identify non-par claims easily. Loop 2300, HCP Segment, Element 13 Loop 2400, HCP Segment, Element 13 This value can either be a T1 or a T6 and is to be used in conjunction with the repricing reason codes. Please refer to the accompanying EOB/EOR document for your implementation for possible scenarios and values for HCP Claim Repricing Reason Code Outbound files from MultiPlan will be populated with a Repricing Reason Code for every claim (successful and unsuccessful) in the following locations. 9.1 Professional Claims Loop 2300, TPO qualified, NTE Segment (Billing Note), Element 02. Pre-existing MultiPlan clients who are currently receiving ADD instead of TPO in NTE01 in production professional files, will continue to do so. New clients will receive TPO only. 9.2 Institutional Claims Loop 2300, ADD qualified, NTE Segment (Billing Note), Element 02. These reason codes are populated in outbound EDI files depending on the category selected by MultiPlan s repricing engine. Further information on errors can be obtained by logging on to our remote repricing portal for Enterprice. Please refer to the accompanying EOB/EOR document for your implementation for a list of possible network code values that you may receive. 10. PHCS Product Code Claims that reprice against PHCS Primary or PHCS Healthy Directions will see a product ID in the following location Loop 2300, Segment K3, Element 01 VERSION: 3.0 Page 24

25 The possible values for this field are 101 = PHCS PPO 105 = Healthy Directions 7 File Responses 7.1 EDI Functional Acknowledgements MultiPlan uses the 999 ASC X12C/005010X231standard functional acknowledgement in response to client inbound 837 files. MultiPlan is also able to accommodate sending and receiving 997 responses for files ACK Outbound from MultiPlan If a Trading Partner requires it, MultiPlan can produce positive 997 or 999 functional acknowledgements in response to inbound 837 claim files submitted for repricing. These ACK files are produced only when MultiPlan s EDI systems successfully load inbound files. At this time, ACK files with error or reject reasons cannot be generated when a file fails to load. An EDI implementation analyst or EDI Support analyst will address file load failures with the client ACK Inbound to MultiPlan MultiPlan prefers that Trading Partners acknowledge all repriced 837 files outbound from MultiPlan with 997 or 999 functional acknowledgements. This information helps reconcile the acceptance of outbound transactions Notifications MultiPlan is also able to offer notifications to clients for files that load successfully into our system and for files that extract and are ready to be posted to the FTP for retrieval. If clients wish to receive these notices, MultiPlan will need the addresses or distributions to which these notifications are to be sent in production. Please note that MultiPlan is not able to receive and process any format of file response other than a 997 or Notice for MultiPlan File Loads An notice is produced by MultiPlan systems when a file successfully loads for processing. If a file fails to load, the implementation analyst or Support analyst will address the issue with the client. VERSION: 3.0 Page 25

26 One is generated per inbound file to MultiPlan and will contain information on the file including file name, number of claims, load date and total billed amount and will also contain an attachment with client claim IDs. Below is a Sample File Load Notification FILE LOAD NOTIFICATION: -----Original Message----- From: EDITEST11g P - Clients - Inbound [mailto:auto_edi_editest@multiplan.com] Sent: Thursday, February 21, :47 AM To: EDI; Balasubramanyn, Vidya Subject: EDITEST11g P Clients INBOUND Client : SampleClient_5010(123456V501). Client : SampleClient_5010 Machine Name : RCK-VMEDIEDI-01 Environment : PRODUCTION Hcfa Ub : H Alternate Account ID : V501** File Name : ABC_P Vhcfa.txt Number of Claims in the File : 3 Number of Claims Loaded : 3 Number of Claims Rejected : 0 Number of Lines in the File : 3 Number of Lines Loaded : 3 Number of Lines Rejected : 0 Total Billed Amount for Loaded Claims : 1, Load ID : Start Time : 2/21/ :47:19 End Time : 2/21/ :47:22 ** 10 digit MultiPlan Internal Trading Partner Identifier VERSION: 3.0 Page 26

27 Attachment to File Load Notification List of Claims accepted by Multiplan Input File Name : ABC_P Vhcfa.txt BPY M BPY M BPY M Number of Claims in the File : 3 Number of Claims Loaded : 3 Number of Claims Rejected : 0 Number of Lines in the File : 3 Number of Lines Loaded : 3 Number of Lines Rejected : 0 Total Billed Amount for Loaded Claims : 1, Load ID : Date : 2/21/2013 Time : 09:47: Notice for MultiPlan File Extracts An notice is produced by MultiPlan systems when an outbound file with repriced results successfully extracts and is ready to be posted to the FTP for retrieval by the client or vendor. One is generated per outbound file from MultiPlan and will contain information on the file including file name, number of claims, outbatch date and total billed amount and will also contain an attachment with client claim IDs. There will be a time delay of no more than 30 minutes from when these s are produced and when the file will be available at the FTP. Below is a Sample File Extract Notification VERSION: 3.0 Page 27

28 FILE EXTRACT NOTIFICATION: -----Original Message----- From: EDITEST11g I - Clients - Outbound [mailto:auto_edi_editest@multiplan.com] Sent: Monday, February 25, :43 AM To: EDI; clientname@client.com Subject: EDITEST11g I Clients OUTBOUND Client : SampleClient_5010(123456V501). Client : SampleClient_5010 Machine Name : RCK-VMEDIEDI-01 Environment : PRODUCTION Hcfa Ub : U Alternate Account ID : V501** Number of Claims : 3 Number of Lines : 3 Total Billed Amount : 4, Total Allowed Amount : 0.00 File Name : ABC_ub Out Batch Sequence : Start Time : 2/25/ :42:54 End Time : 2/25/ :42:57 Log File Path : \\rck-vmediedi- 02\DjEdiERoot\Logs\X12\837\2013\2013_02\2013_02_25\ Log File Name : X12_837I_CLIENTS_OUTBOUND_PROCESS_ _ log ** 10 digit MPI Internal Trading Partner identifier Attachment to File Extract Notification List of Claims sent by MultiPlan Outbound File Name : ABC_ub BPY M BPY M BPY M Number of Claims : 3 Number of Lines : 3 Total Billed Amount : 4, Total Allowed Amount : 0.00 Outbound Batch ID : Date : 2/25/2013 Time : 09:42:57 VERSION: 3.0 Page 28

29 8 Pre Go-Live Discussions Once testing has been completed to both the Trading Partner and MultiPlan implementation team s satisfaction, discussions will begin about moving setup into the production environment. A sign off must be obtained from both teams indicating that testing was successful and all teams are in a state of readiness to prepare for Production. At this time, MultiPlan s implementation team will confirm the below information with the client based on testing cycles. This is done via or using a Setup Summary Spreadsheet and will be discussed in the subsequent client call in detail. Go-Live date. o MultiPlan schedules Production changes ONLY on Mondays. o MultiPlan EDI requires one working week to complete production preparation o Testing sign-off must be sent before end of day Friday of the week prior to MultiPlan Production setup. o Example: For a Go-live on Monday Apr 22, Sign off must be received by EOD Apr 12. April Su M Tu W Th F Sa File Naming convention for Inbound & Outbound Files File Timings o MultiPlan is able to accept files for repricing anytime during the day multiple times o MultiPlan is able to offer one or more of the below outbound file schedules to clients M-F (EST) 5:00AM, 10:00AM, 3:00PM, 6:00PM, 11:30PM Clients commonly opt for the 5:00am EST run Exchange of acknowledgements FTP folder Paths for Production o Please refer to Appendix F Number and list of c-codes, product access Reiteration of File Failure reasons (Please refer to Section 3) VERSION: 3.0 Page 29

30 The above information cannot be changed after the completion of testing and before move to production. 9 Production Support Process Production Deployment MultiPlan s deployment window is on Mondays between 10am EST & noon EST. Once the client specific code has been successfully moved into production, the EDI analyst will send out a notification that MultiPlan is now ready to receive live claims for processing. Warranty EDI Analysts will closely monitor the client s claim processing in production for 30 days after scheduled Go-Live at which time they can be contacted with any questions, concerns or claim status queries. Any errors or issues during processing will be immediately brought to the client s attention for resolution during this time. A regular status update will also be sent out daily or on alternate days until a comfort level is reached by both parties. Production Support After the 30 day Warranty period, the analyst will hand over the support process to MultiPlan s EDI Production Support team who currently handle Daily Support for over 300 clients. All client specific details will be transitioned as the responsibility of the implementing analyst. This team can be contacted by ing EDI-SUPPORT@MULTIPLAN.COM with complete details of issue or query. All queries will be responded to within 1 business day while resolution may take longer depending on nature of issue. If the query needs to be triaged to another team at MultiPlan (such as Claims Operations or Fee Negotiations), the support team will forward appropriately and will inform the client. Please note that responses will be sent from an outgoing mailbox MP_EDI_SUPPORT@MultiPlan.com. Please add this to your safe address list and please reply all or include EDI-SUPPORT@MultiPlan.com in your response. Production Billing enquiries may be sent to Billing@MultiPlan.com with details of issue. VERSION: 3.0 Page 30

31 10 APPENDICES TO MULTIPLAN COMPANION GUIDE VERSION: 3.0 Page 31

32 Appendix A: Data Requirements for MultiPlan s In-Network processes REF: SECTION Below are the data elements that are required and need to be accurate in order for the results of testing to be correct and to mirror what will occur in production. The integrity of these values will affect both provider matching and repricing results within MultiPlan s systems. HCFA/ Professional claims: PROVIDER DATA 1. TIN -- (the actual TIN for the provider on the claim) 2. PROVIDER NAME For a PHYSICIAN claim: Rendering and Billing: Provider First Name Provider Last Name and/or Group name (if the group is contracted) For an ANCILLARY claim: Provider Name 3. ADDRESS Rendering and Billing address 4. NPI -- (the actual NPI of the provider on the claim) CLAIM DATA 5. Line Level claim details (CPT codes, units, modifiers, services, etc.) that match the type of provider on the claim VERSION: 3.0 Page 32

33 UB/Institutional claims PROVIDER DATA 6. TIN -- (the actual TIN for the provider on the claim) 7. PROVIDER NAME Facility Name 8. ADDRESS Service/Billing address 9. NPI -- (the actual NPI of the provider on the claim) CLAIM DATA 10. Type of Bill (e.g. 111, 112, 131, etc. This should be accurate for the provider as it affects pricing) 11. Line Level claim details (REV codes, units, services: ICD-9 s, procedure codes) that match the type of provider and type of bill on the claim 12. DRG codes VERSION: 3.0 Page 33

34 Appendix B: Important Data Elements for MultiPlan Fee Negotiation Services REF: SECTION The following is a list of data elements that are important for successful Fee Negotiation on MultiPlan claims. "Must Have" Data Elements from CMS1500/ HCFA Claim Forms "Should Have" Data Elements from CMS1500/ HCFA Claim Forms Block # Description Block # Description 1a Insured's ID # 1a Insured's ID # 2 Patient's Name 2 Patient's Name 3 Patient's Birth date 3 Patient's Birth date 4 Insured's Name 4 Insured's Name 11 Insured's Policy Group or FECA Number 11b 11c Employer's Name or School Name Insurance Plan Name or Program Name 21 ICD-9 Diagnosis Code 21 ICD-9 Diagnosis Code 24A Date(s) of Service 24A Date(s) of Service 24B Place of Service 24B Place of Service 24C Type of Service 24C Type of Service 24D Procedures, Services or Supplies [CPT & Modifier(s)] 24D Procedures, Services or Supplies [CPT & Modifier(s)] 24E Diagnosis Code (related to line item) 24E Diagnosis Code (related to line item) 24F Charges (per line item) 24F Charges (per line item) 24G Days or Units 24G Days or Units 25 Tax ID 25 Tax ID 26 Patient's Account No. 26 Patient's Account No. 28 Total Charges 28 Total Charges 31 Physician's Name 31 Physician's Name VERSION: 3.0 Page 34

35 32 Rendering Provider's Name, Address, Zip Code and Phone # 32 Rendering Provider's Name, Address, Zip Code and Phone # 33 Provider's Billing Name, Address, Zip Code and Phone # 33 Provider's Billing Name, Address, Zip Code and Phone # "Must Have" Data Elements from UB-92 / UB-04 Claim Forms "Should Have" Data Elements from UB-92 / UB-04 Claim Forms Block # Description Block # Description 1 Name and Address of Facility 1 Name and Address of Facility 3 Patient Control No. 3 Patient Control No. 5 Tax ID No. 5 Tax ID No. 4 Type of bill 4 Type of bill 6 Statement Covers Period (service dates) 6 Statement Covers Period (service dates) 12 Patient Name 12 Patient Name 14 Patient's Birthdate 14 Patient's Birthdate 15 Gender 15 Gender 17 Admission Date 17 Admission Date 19 Type 19 Type 20 Source 20 Source 22 UB Stat Code 22 UB Stat Code 42 Revenue Codes 42 Revenue Codes 43 Description 44 HCPCS/Rates 45 Service Dates 45 Service Dates 46 Service Units 46 Service Units 47 Total Charges 47 Total Charges 48 Non-Covered Charges VERSION: 3.0 Page 35

36 50 Payer 58 Insureds Name 58 Insureds Name 60 Insured's ID No. 60 Insured's ID No. 61 Group Name ICD-9 Diagnosis Code ICD-9 Diagnosis Code 78 DRG code 78 DRG code 80, 81A-E Procedure Code 80, 81A-E Procedure Code VERSION: 3.0 Page 36

37 Appendix C: Data Validation Edits for Viant/Beech Claims Processing REF: SECTION Claims for all Viant/ Beech, HMA, IHP and First Choice products will be validated against the following edits 1. Level 1: Transaction Format (X12) Syntax Integrity Compliance 2. Level 2: Level 1 plus HIPAA Implementation Guide Compliance 3. Level 2 plus balanced totals within the transaction set 4. Business Edits: Claims that pass above compliance checks will be validated against below Business Edits. They apply to both institutional and professional claims unless otherwise specifically noted Loop Field Edit Error # Error Message 2010AA Billing Provider Name N402 State must be a valid 2-characters US state or possession VE021 Billing Provider State must be a valid state 2010AA Billing Provider N AA N403 must be 5 or 9 characters in length; A hyphen (-) will be stripped out before the length is checked. VE002 Billing Zip Code must be 5 or 9 characters 2000B SBR03 SBR03 must be present. (Applies to Client or Client-Approved vendor) VE023 Employer Group Number is required 2000C Patient HL segment If 2000B SBR02 not = 18, 2000C HL segment must be present VE005 Patient information is required Institutional 2300 Claim Information DTP If 2300 DTP01 = 434 and DTP02 = D8, DTP03 must be less than or equal to current date. If 2300 DTP01 = 434 and DTP02 = RD8, the first date in DTP03 must be less than or equal to current date. VE006 Statement From Date cannot be greater than current date Institutional 2300 Claim Information DTP If 2300 DTP01 = 434 and DTP02 = RD8, the second date in DTP03 must be less than or equal to current date. VE007 Statement To Date cannot be greater than the current date Institutional 2300 Claim Information DTP If 2300 DTP01 = 434 and DTP02 = RD8, the second date in DTP03 must be greater than or equal to the first date in DTP03 VE008 Statement To Date must be greater than or equal to Statement From Date VERSION: 3.0 Page 37

38 Loop Field Edit Error # Error Message Institutional 2300 Claim Information DTP If this is an inpatient claim a DTP segment must be present with DTP01 = 435 VE009 Admission Date required on inpatient claim Institutional 2300 Claim Information DTP If 2300 DTP01 = 435, DTP03 must be less than or equal to current date VE010 Admission Date cannot be greater than current date 2300 Claim Information CLM 2300 CLM02 must be greater than zero VE012 Total Charges must be greater than zero Institutional 2300 Claim Information CLM 2300 CLM05-01 concatenated with CLM05-03 must be a valid Bill Type (See note below) VE013 Invalid Bill Type xxx (where xxx is the Bill Type value) 2310E Institutional Service Facility Name N402 State must be a valid 2-characters US state or possession VE022 Rendering Provider State must be a valid state 2310C Professional Service Facility Name N402 State must be a valid 2-characters US state or possession VE022 Rendering Provider State must be a valid state 2310E Institutional Service Facility Name N403 If 2310E N4 segment is present, 2310E N403 must be 5 or 9 characters in length VE015 Rendering Zip Code must be 5 or 9 characters 2310C Professional Service Facility Name N403 If 2310C N4 segment is present, 2310C N403 must be 5 or 9 characters in length VE015 Rendering Zip Code must be 5 or 9 characters 2400 Service Line DTP If 2400 DTP01 = 472 and DTP02 = D8, DTP03 must be less than or equal to current date If 2400 DTP01 = 472 and DTP02 = RD8, the first date in DTP03 must be less than or equal to current date 2400 Service Line DTP If 2400 DTP01 = 472 and DTP02 = RD8, the second date in DTP03 must be less than or equal to current date 2400 Service Line DTP If 2400 DTP01 = 472 and DTP02 = RD8, the second date in DTP03 must be greater than or equal to the first date in DTP03 VE018 Service From Date cannot be greater than the current date VE019 Service To Date cannot be greater than current date VE020 Service To Date must be greater than or equal to Service From Date VERSION: 3.0 Page 38