835 Health Care Claim Payment/Advice Companion Guide

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1 835 Health Care Claim Payment/Advice Companion Guide HIPAA/V5010X221A1/835 Version: 1.2 Company: Blue Cross of Idaho Created: 07/18/2014

2 1.1 Disclaimer Blue Cross of Idaho (BCI) created this Companion Guide for the 835 Health Care Claim Payment Advice to use in conjunction with the 5010A1 version of the ANSI X12 Implementation Guide. This document is not a replacement for the ANSI X12 Implementation Guide, but an additional source of information created to assist providers and business partners of Blue Cross of Idaho. You can download a free copy of the latest ANSI X12 Implementation Guide at wpc-edi.com/content/view/533/377/. Blue Cross of Idaho ONLY provides remittances for Blue Cross of Idaho claims 1.2 Document Purpose The purpose of this companion guide is to describe those aspects of processing an electronic 835 Health Care Claims Payment Advice that are specific to Blue Cross of Idaho. This companion guide contains data clarifications derived from specific business rules that apply exclusively to claims processing done by Blue Cross of Idaho. In addition, this guide also includes useful information about sending and receiving data to and from Blue Cross of Idaho. Though Blue Cross of Idaho continually updates this document, the current version is always available on the website Scope The purpose of this companion guide is to describe those aspects of processing an electronic 835 Health Care Claims Payment Advice that are specific to Blue Cross of Idaho 2

3 Table of Contents Disclaimer.2 General Business Information..4 Business Rules..5 Business Rules..6 Trading Partner Information.7 3

4 General Business Information 2.1 Enrollment Information Any entity desiring to send or receive electronic transactions through the Blue Cross of Idaho EDI services must first be registered with Blue Cross of Idaho. Blue Cross of Idaho accepts one enrollment form for multiple transactions. If you are interested in registering with Blue Cross of Idaho, simply complete a copy of the Electronic Data Interchange (EDI) Enrollment Form available at and fax it to If you are a vendor, please select Vendor EDI Enrollment Form in the vendor column. Providers need to select EDI Enrollment Form from the provider column. 835 Remittances Advise Blue Cross of Idaho ONLY provides remittances for Blue Cross of Idaho claims. After Blue Cross of Idaho receives and processes your Electronic Claims Submission Enrollment Form, there are a number of tasks that must be completed: Receive your login and password information. Submit test files, assisted by a member of the Blue Cross of Idaho EDI Support Desk. Obtain permission to submit production data files. 2.2 EDI Support The Blue Cross of Idaho EDI Support Desk assists users with questions about electronic transactions. The Blue Cross of Idaho EDI Support Desk is available to all Idaho providers and vendors Monday through Friday from 8:00 a.m. to 5:00 p.m. MST at or Blue Cross of Idaho EDI Support Desk: Provides information on services offered Enrolls users for claims submission and data retrieval and vendors for 27x transactions Verifies receipt of electronic transmissions Provides technical assistance to users who are experiencing transmission difficulties 2.3 Working together Blue Cross of Idaho will only accept transactions from trading partners that completed the enrollment process and have a submitter ID on file. We will reject all other transactions. Blue Cross of Idaho complies with HIPAA regulations. Below are specific coding requirements used by Blue Cross of Idaho, remember the eligibility information returned by Blue Cross of Idaho is not a guarantee of claims payment. Blue Cross of Idaho responds to all eligibility requests with the coverage information available for the patient identified per the date provided. 4

5 3.1 Blue Cross of Idaho Business Rules Blue Cross of Idaho complies with HIPAA regulations. Blue Cross of Idaho s specific business rules regarding HIPAA Claims Adjustment Reason Codes (Loop 2110 / Segment CAS) and HIPAA Remittance Advice Remark Codes (Loop 2110 / Segment LQ02) are described below. Blue Cross of Idaho Business Rules Table HIPAA Claim Adjustment Reason Code HIPAA Remittance Advice Remark Code HIPAA Description N19 Procedure code incidental to primary procedure. 45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability). 3 MA Co-payment Amount MA67 Correction to a prior claim. 1 MA67 1 Deductible Amount MA67 Correction to a prior claim 95 Benefits adjusted. Plan procedures not followed. This change to be effective 4/1/200/: Plan procedures not followed B5 MA92 B5 Payment adjusted because coverage/program guidelines were not met or were exceeded. MA92 Missing plan information for other insurance Blue Cross of Idaho N19 is being used to indicate a procedure code is incidental to any other procedure code and should not be billed separately. 45 is being used to convey a Contractual Adjustment. This could apply to Per Diem, DRG, Fee Schedules, etc., per your contract. 3/MA67 combination is being used to inform the provider this claim is being adjusted due to an incorrect deductible on a prior claim. 1/MA67 combination is being used to inform the provider this claim is being adjusted due to an incorrect deductible on a prior claim. 95 is being used to inform the provider this claim was reprocessed to comply with the provider contract, member contract or other billing requirements. B5/MA92 is used when payment is being adjusted due to other plan s payment determination. The member s HOME plan is determining 5

6 B13 N381 B13 Previously paid. Payment for this claim/service may have been provided in a previous payment. N381 Consult our contractual agreement for restrictions/billing/payment information related to these charges. benefit payment. B13/N381 combination is being used to indicate Blue Cross has received a correction to a prior claim, yet payment has not been affected. N207 Missing/incomplete/invalid weight N207 is being used to inform the provider that the patient s weight, height, or frame information is missing, invalid, or incomplete. 96 N23 96 Non-covered charges(s). At least one Remark code must be provided (may be comprised of either the Remittance Advice Remark Code or NCPDP Reject Reason Code.) N23 Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions. 181 M Payment adjusted because this procedure code was invalid on the date of service. M51 Missing/incomplete/invalid procedure code(s). 23 N23 23 The impact of prior payer(s) adjudication including payments and/or adjustments. N23 Alert: Patient liability may be affected due to coordination of benefits with other carriers and/or maximum benefit provisions. 96/N23 combination is being used to inform the provider a portion of the calculated provider discount is subscriber liability. 181/M64 combination is being used to inform the provider a diagnosis or procedure code is not in effect or is incomplete for the date of service. 23/N23 combination is being used to inform the provider the member has an MOB policy and we will only pay up to our maximum allowance. Provider may bill member for the difference between actual charges and amounts we and the other carrier paid. 6

7 3.2 Federal Employee Program (FEP) The Operations Center in Washington DC processes Federal Employee Program (FEP) claims. Blue Cross of Idaho receives claim-processing data like payment, remittance messages and loop/segment information from FEP, which we forward to our trading partners. If you have questions regarding your FEP electronic remittance advice, go to FEPBLUE.org or wpcedi.com/hipaa/hipaa_40.asp. 4.1 Top 10 Claim Adjustment Reason Codes The Blue Cross of Idaho claim adjustment reason codes conforms to the three-digit standard and do not overlap industry standard codes. The following table contains Blue Cross of Idaho s 10 most common adjustment reasons. Top 10 Claim Adjustment Reason Codes Table Code Reason Code Description 18 Duplicate claim/service. 23 Payment adjusted due to the impact of prior payer(s) adjudication including payments and/or adjustments. This change to be effective 4/1/2008: The impact of prior payer(s) adjudication including payments and/or adjustments. 26 Expenses incurred prior to coverage 27 Expenses incurred after coverage terminated. 45 Charges exceed our fee schedule or maximum allowable amount. 50 These are non-covered services because this is not deemed a `medical necessity' by the payer. 109 Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor. 119 Benefit maximum for this time period or occurrence has been reached. 197 Payment adjusted for absence of precertification/authorization/notification. This change effective 4/1/2008: Precertification/authorization/notification absent. 204 This service/equipment/drug is not covered under the patient s current benefit plan. 5.1 Claim Filing Indicator Codes Blue Cross of Idaho complies with HIPAA regulations. Blue Cross of Idaho s HIPAA Claim Filing Indicator Codes are code values populated in the 2100 LOOP, Claim Payment Information, in the CLP segment CLP06. The codes identify the claim type. 7

8 Claim Filing Indicator codes Blue Cross of Idaho code Mapping 12 Preferred Provider Organization (PPO) - FEP and PPO 13 Point of Service (POS) Managed Care 15 Indemnity Insurance Traditional 16 Health Maintenance Organization (HMO) Medicare Risk Medicare Advantage Trading Partner Agreement EDI Trading Partner Agreements 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. 8

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