Companion Guide 277 Health Care Claim Acknowledgement

Size: px
Start display at page:

Download "Companion Guide 277 Health Care Claim Acknowledgement"

Transcription

1 Companion Guide 277 Health Care Claim elease 1.0 X12N 277(Version 4040X167) Health Care Claim Implementation Guide Published November 2004

2 evision History Date elease Appendix name/ loop & segments Description 2 Published November 2004

3 TABLE OF CONTENT 1. INTODUCTION INTENDED AUDIENCE PUPOE OF THE COMPANION GUIDE GENEAL INFOMATION CONFIDENTIALITY, PIVACY AND ECUITY ECUITY TATEMENT CONTACT PIVACY CONTACT TANACTION CONTACT: POVIDE ELATION ETABLIHING CONNECTIVITY WITH NHP INITIATING EDI ETUP TADING PATNE ETUP TETING PODUCTION TECHNICAL PECIFICATION OF THE TANACTION...10 HEALTH CAE CLAIM ACKNOWLEDGEMENT.10 APPENDIX A EJECT EAON CODE...11 APPENDIX B TADING PATNE AGEEMENT...12 APPENDIX C - NHP PECIFIC 277 HEALTH CAE CLAIM ACKNOWLEDGEMENT MAP Published November 2004

4 1. Introduction 1.1 Intended Audience This companion guide is intended for the business and technical areas, within or on behalf of a provider organization, responsible for the testing and setup of electronic claims submissions to Neighborhood Health Plan. In addition, this information should be communicated to, and coordinated with, the provider's billing office in order to ensure that the required billing information is provided to its billing agent/submitter. This guide supports the submission of X12N 277 Health Care Claim (004040X167) 1.2 Purpose of the Companion Guide This document has been prepared as a Neighborhood Health Plan specific companion guide to the 277 Health Care Claim transaction sets. The primary purpose of the document is to assist the user with the acknowledgement of a valid 837 claims transaction and NHP s status of the file. 2. General Information 2.1 Confidentiality, Privacy and ecurity Maintaining the confidentiality of personal health information has been, and continues to be, one of NHP s guiding principles. NHP has a strict Confidentiality Policy with regard to safeguarding patient, employee, and health plan information. All staff are required to be familiar with, and comply with NHP s policy on the Confidentiality of Member Personal and Clinical Information to ensure that all member information is treated in a confidential and respectful manner. The policy permits use or disclosure of members medical or personal information only as necessary to conduct required business and perform care management, approved research, quality assurance and measurement activities when authorized to do so by a member or as required by law. In order to comply with our own internal policies and the provisions of the Health Insurance Portability and Accountability Act, 1996 (HIPAA), NHP has outlined specific requirements applicable to the electronic exchange of protected health information (PHI) including provisions for: Maintaining Confidentiality of Protected Information 4 Published November 2004

5 Confidentiality afeguards ecurity tandards eturn or Destruction of Protected Information Compliance with tate and Federal regulatory and statutory requirements equired disclosure Use of Business Associates Implementing trading partner agreements prior to receiving electronic files 2.2 ecurity tatement NHP has implemented a best practice approach to protecting the integrity and availability of protected health information. NHP is evaluating its current standards for the exchange of protected health information, electronic storage and/or transmission over telecommunications systems/networks based on the current HIPAA security regulations to determine whether updates or changes to established protocols will be needed. 3. Contacts 3.1 Privacy Contact For privacy questions please contact: Privacy Officer Neighborhood Health Plan 253 ummer treet Boston, MA or (Toll-free) and ask for Privacy Officer 5 Published November 2004

6 3.2 Transaction Contact: The NHP E-commerce department is the contact for all transaction-related questions. For user set up and to establish testing, please contact: E-commerce Neighborhood Health Plan 253 ummer treet Boston, Ma or (Toll-free) and ask for E-commerce Ecomm@nhp.org 3.3 Provider elations hould you need to have additional providers set up, please contact your Provider elations representative. 6 Published November 2004

7 4. Establishing Connectivity with NHP 4.1 Initiating EDI etup In order to receive a 277 Health Care Claim file from NHP, you would have had to submit an 837 Professional or Institutional file. 4.2 Trading Partner etup Providers wishing to receive electronic claims acknowledgements from NHP should contact the NHP E-Commerce Department via or telephone to initiate a setup request. A Trading Partner Agreement Amendment form (Appendix B) is required to initiate a trading partner change. If any of the information on the Authorization Form changes (i.e. request for U277 files), a new form must be completed and submitted to NHP s E-Commerce Department. NHP s E-Commerce Department will return an EDI authorization to the Trading Partner with all the necessary information to submit electronic transactions. The information will include: An assigned default user ID and password and a mailbox (folder) for file drop off and retrieval ubmitter (IA06) and the ubmitter Application ID (G02) Trading Partner ID NHP will return acceptance file for transmissions only from authorized Trading Partners who have signed an NHP Trading Partner Agreement. Claim submission files for providers who submit without a Trading Partner Agreement in place will be rejected with a 997 only. The NHP E- Commerce Coordinator will then contact you to establish a valid Trading Partner Agreement. ubmitters should include a script in their file pick up process that deletes the file from the server. (An archive copy of all files is stored and backed up daily by NHP. Eliminating the file from the server will improve overall performance.) 7 Published November 2004

8 4.3 Testing NHP will test this transaction with trading partners using data generated from submitted 837 transactions. If the trading partner is already in production with 837 claims submissions a 277 Health Care Claim file will be placed in their production OUT box for the corresponding production claims submitted. If the trading partner is submitting test 837 data then the resultant 277 Health Care Claim file will be placed in their test OUT box corresponding to the test 837 file that was submitted. 8 Published November 2004

9 4.4 Production NHP will monitor closely the first few production runs to ensure successful receipt of the file. NHP EEVE THE IGHT TO EQUIE E-TETING IF IT I DETEMINED THAT A UBMITTE I ECEIVING/GENEATING AN UNACCEPTABLE VOLUME OF EO O TYPE OF EO. 9 Published November 2004

10 5 Technical pecifications of the Transaction 277 Health Care Claim NHP uses a proprietary front-end processor. Files that are accepted by the NHP ANI Translator are not necessarily submitted to the claims adjudication system for processing. NHP will return a 277 Health Care Claim within twenty-four (24) hours of the file receipt but generally the file is available within two hours. This initial claims receipt will include an acknowledgement of claims accepted and or rejected. Initial Claims eceipt 277 esponse - TC01 valid codes are: A2 Claim has been received and forwarded to the claims adjudication system. A3 Claim has been rejected and has not been sent to the adjudication system. Please refer to Appendix A for a list of reject reasons. The submitter should review the 277 Health Care Claim to verify that all claims have been accepted and sent for processing or rejected. The 277 Health Care Claim is not a HIPAA-mandated transaction but is supported by NHP. At this level, NHP will pass good claims to the claims system and pass back claims that failed NHP business edits. Appendix C has a full listing of all Loops and egments used by NHP with the appropriate values. If your EDI file was rejected, and you are not sure why or how to correct it, it is important to contact the E-Commerce Department as soon as possible to ensure that your claim file is resubmitted before the filing limit expires. THE 277 HEALTH CAE CLAIM ACKNOWLEDGEMENT ELECTONIC FILE AND HUMAN EADABLE EPOT WILL BE ENT TO YOU OUT FOLDE FO ETIEVAL BY YOU. Your pick up file script should include a delete script in your file process. Delete the file out of your OUT mailbox after you have successfully retrieved it. THE UBMITTE HOULD EVIEW THE 277 HEALTH CAE CLAIM ACKNOWLEDGEMENT TO VEIFY THAT ALL BATCHE HAVE BEEN ACCEPTED AND ENT FO POCEING TO THE NHP ADJUDICATION YTEM. NHP will also offer the 276/277 claims status request response through NEHEN and NHPnet. NHP will work with clearing house trading partners to determine their readiness to accept a 276/277 request response. efer to NHP s Companion Guide for the 276/277 request response transaction. 10 Published November 2004

11 Appendix A eject eason Codes Description Error Code 21 Missing or invalid information. 33 ubscriber and subscriber id not found. 73 Payment made to entity, assignment of benefits not on file. 88 Entity not eligible for benefits for submitted dates of service. 121 ervice line number greater than maximum allowable for payer. (NHP will only accept one LIN segment per V1 segment.) 122 Missing/invalid data prevents payer from processing claim. 135 Entity's commercial provider id. 142 Entity's license/certification number. 153 Entity's id number. Identifier Code = HK (Insured/ubscriber) 158 Entity's date of birth Identifier Code = HK (Insured/ubscriber) 218 NDC number. 232 Admitting diagnosis. 251 Total anesthesia minutes. 254 Primary diagnosis code. 255 Diagnosis code. 258 Days/units for procedure/revenue code. 277 Paper claim. 448 Invalid billing combination. ee TC12 for details. This code should only be used to indicate an inconsistency between two or more data elements on the claim. A detailed explanation is required in TC12 when this code is used. (TC12 contains the correct ID Number to submit) 453 Procedure Code Modifier(s) for ervice(s) endered 454 Procedure code for services rendered. 455 evenue code for services rendered. 456 Covered Day(s) 465 Principal Procedure Code for ervice(s) endered 11 Published November 2004

12 Appendix B Trading Partner Agreement Amendment equest for Trading Partner Number etup for Filing Electronic Claims to Neighborhood Health Plan Please provide the following Information: Type of Account: New X Existing/evision to TPA Name of Person submitting this form: Phone Number: Address: Fax Number: Trading Partner/ubmitter Information: Practice Type: Community Health Center Clinic Hospital/Facility HealthCare Provider Office Clearing House Billing ervice* *Please Note: If a Billing ervice is going to submit transactions on your behalf, NHP needs an authorization on the provider s corporate letterhead, allowing NHP to release your financial/patient information. Health Care Provider Information: Name: Practice Tax ID Number Address: City: tate: Zip Contact Person Phone Number FAX address If Payee Information is Different from Provider Information: Name of Payee: Address: City: tate: Zip NHP Vendor ID Number Payee Tax ID Number 12 Published November 2004

13 13 Published November 2004

14 Claims Filing oftware Vendor Information: Vendor Name: Address: City: tate: Zip Vendor Contact Person Phone Number FAX Vendor address Type of transactions that you wish to be authorized for: Transaction With Addenda changes Claims Professional 837P version 4010A Claims Institutional 837I version 4010A emittance 835 version 4010A Claims tatus 276/277 version 4010A Eligibility 270/271 version 4010A eferral/authorizations 278 version 4010A Enrollments 834 version 4010A Premium Payments 820 version 4010A Unsolicited 277 version 4040 Communication Protocol Type: FTP/PPP NEHEN Other Protocol, Please contact e-commerce Department of NHP at I, agree that in reference to 45 C.F.. section Trading Partner Agreements of the HIPAA regulations, that we will not do any of the following: (a) Change the definition, data condition, or use of a data element or segment in a standard. (b) Add any data elements or segments to the maximum defined data set. (c) Use any code or data elements that are either marked "not used" in the standard s implementation specification or are not in the standard s implementation specification(s). (d) Change the meaning or intent of the standard s implementation specification(s). Print Name Print Title ignature Date 14 Published November 2004

15 Appendix C NHP-pecific 277 Map APPENDIX C - NHP PECIFIC U277 MAP =equires, =ituational, N=Not Used Loop or egment ANI U277 Field Name Allowable Data Values IG Page Field ize Min Max Business ule INTECHANGE CONTOL HEADE IA01 Auth Information Qualifier 00 No auth info present 03 Additional data information B3 2 2 IA02 Authorization Information B4 # 10 IA03 ecurity Info Qualifier 00 No info present B Password IA04 ecurity Information B4 # 10 IA05 Interchange ID Qualifier ZZ Mutually Defined B4 2 2 IA06 Interchange ender ID B4 # 15 IA07 Interchange ID Qualifier ZZ Mutually Defined B5 2 2 IA08 Interchange eceiver ID B5 # 15 IA09 Interchange Date YYMMDD B5 6 6 IA20 Interchange Time HHMM B5 4 4 IA11 epetition eparator B5 1 1 IA12 Interchange Control Version No B5 5 5 IA13 Interchange Control No. B6 9 9 IA14 Acknowledgment equested 0 No acknowledgement requested 1 requested B6 1 1 IA15 Usage Indicator P Production data T Test data IA16 Component Element eparator B6 1 1 B6 1 1 FUNCTIONAL GOUP HEADE G01 Functional ID Code HN Health Care Claim B8 2 2 tatus Notification (277) G02 Application ender's Code B G03 Application eceiver's B Code G04 Date Format: CCYYMMDD B Published November 2004

16 G05 Time Format HHMM (recommended), HHMM, HHMMD, HHMMDD B8 4 8 G06 Group Control No. B9 1 9 G07 esponsible Agency Code X Accredited B9 1 2 tandards Committee X 12 G08 Version/elease/Industry ID Code X167 B TANACTION ET HEADE T01 Transaction et Identifier Code T02 Transaction et Control Number T03 Implementation Convention eference 277 Health Care Claim tatus Notification X BEGINNING OF HIEACHICAL TANACTION BHT01 Hierarchical tructure Code BHT02 Transaction et Purpose Code 0085 Information ource, Information eceiver, Provider of ervice, Patient tatus BHT03 eference Identification BHT04 Transaction et Creation Format: CCYYMMDD Date BHT05 Time Format: HHMM or HHMM or HHMMD or HHMMDD. BHT06 Transaction Type Code TH eceipt Advice A INFOMATION OUCE LEVEL HL01 Hierarchical ID Number N HL02 Hierarchical Parent ID Number HL03 Hierarchical Level Code 20 Information ource HL04 Hierarchical Child Code 1 Additional subordinate HL Data egment in this Hierarchical tructure A INFOMATION OUCE NAME 16 Published November 2004

17 NM101 Entity ID Code P Payer NM102 Entity Type Qualifier 2 Non-Person Entity NM103 Name Last or Organization Name N NM104 Payer Name First N NM105 Payer Name Middle N NM106 Payer Name Prefix N NM107 Name uffix NM108 Payer Identification Code Qualifier PI Payer Identification NM109 Payer Identification Code N NM110 Entity elationship Code N NM111 Entity Identifier Code N NM112 Name Last or Organization Name A TANMIION ECEIPT CONTOL IDENTIFIE TN01 Trace Type Code 1 Current Transimission Trace Numbers TN02 eference Identification tart from 1 and incremental by 1 for every file. N TN03 Originating Company 42 # 10 Identifier N TN04 eference Identification A INFOMATION ECEIVE ECEIPT DATE DTP01 Date/Time Qualifier 050 eceived DTP02 Date Time Period Format D8 Date Expressed in Qualifier Format CCYYMMDD DTP03 Date Time Period A INFOMATION OUCE POCE DATE DTP01 Date/Time Qualifier 009 Process DTP02 Date Time Period Format Qualifier D8 Date Expressed in Format CCYYMMDD DTP03 Date Time Period Published November 2004

18 2000B INFOMATION ECEIVE LEVEL HL01 Hierarchical ID Number HL02 Hierarchical Parent ID Number Hierarchical Level Code 21 Information 2 HL03 eceiver 48 1 HL04 Hierarchical Child Code 1 Additional ubordinate HL Data egment in this Hierarchical tructure B INFOMATION ECEIVE NAME NM101 eceiver Entity ID Code 41 UBMITTE NM102 eceiver Entity Type Qualifier NM103 eceiver Name Last or Organization Name 1 Person 2 Non-Person Entity NM104 eceiver First Name NM105 eceiver Middle Name NM106 eceiver Name Prefix NM107 eceiver Name uffix NM108 eceiver Identification Code Qualifier NM109 eceiver Identification Code 46 Electronic Transmitter Identification Number (ETIN) N NM110 Entity elationship Code N NM111 Entity Identifier Code N NM112 Name Last or Organization Name B TANMIION ECEIPT CONTOL IDENTIFIE TN01 Trace Type Code 2 eferenced Transaction Trace Numbers TN02 eference Identification N TN03 Originating Company Identifier 53 # 10 N TN04 eference Identification Published November 2004

19 2200B INFOMATION ECEIVE TATU INFOMATION TC01 HEALTH CAE CLAIM TATU TC01-1 TC01-2 TC01-3 TC * * Category Code A2 Good tatus Code 19 Good Entity Identifier Code Code List Qualifier Code 65 Health Care tatus Code TC02 Date TC03 Action Code WQ Accept TC04 Monetary Amount um of clm02 N TC05 Monetary Amount N TC06 Date N TC07 Payment Method Code N TC08 Date N TC09 Check Number TC010 HEALTH CAE CLAIM TATU TC10-1 TC * * Industry Code Industry Code TC10 Entity Identifier Code TC10 Code List Qualifier Code 65 Health Care Claim tatus Code TC11 HEALTH CAE CLAIM TATU 60 * * TC11-1 TC11-2 TC11-3 TC11-4 Industry Code Third tatus Code Industry Code Entity Identifier Code Code List Qualifier Code 65 Health Care Claim tatus Code N TC12 Free-Form Message Text B INFOMATION ECEIVE UBMIION ACKNOWLEDGEMENT TOTAL ACCEPTED QUANTITY QTY01 Quantity Qualifier 90 Acknowledged Quantity Published November 2004

20 QTY02 Quantity Total number of good claims N QTY03 COMPOITE UNIT OF 64 MEAUE N QTY04 Free-Form Message Text B INFOMATION ECEIVE UBMIION ACKNOWLEDGEMENT TOTAL EJECTED QUANTITY QTY01 Quantity Qualifier AA Unacknowledged Quantity QTY02 Quantity Total number of bad claims N QTY03 COMPOITE UNIT OF 66 MEAUE N QTY04 Free-Form Message Text B INFOMATION ECEIVE UBMIION ACKNOWLEDGEMENT TOTAL ACCEPT AMOUNT AMT01 Amount Quantity Qualifier YU In Process AMT02 Monetary Amount um of clm02 of good claims. N AMT03 Credit/Debit Flag Code B INFOMATION ECEIVE UBMIION ACKNOWLEDGEMENT TOTAL EJECTED AMOUNT AMT01 Amount Quantity Qualifier YY eturned AMT02 Monetary Amount um of clm02 of bad claims. N AMT03 Credit/Debit Flag Code C BILLING/PAY-TO-POVIDE OF EVICE LEVEL HL01 Hierarchical ID Number HL02 Hierarchical Parent ID Number HL03 Hierarchical Level Code 19 Provider of ervice HL04 Hierarchical Child Code 1 Additional ubordinate HL Data egment in this Hierarchical tructure 2100C BILLING POVIDE NAME NM101 Provider Entity ID Code 85 Billing Provider NM102 Provider Entity Type Qualifier NM103 Provider Last or Organization Name 1 Person 2 Non-Person Entity If AB NM102 is empty set NM102 = AA NM102 else set NM102 = AB NM If NM102 = AA NM102 NM103 = AA NM103 else NM103 = AB NM Published November 2004

21 NM104 Provider First Name If NM102 = AA NM102 NM104 = AA NM104 else NM104 = AB NM104 NM105 Provider Middle Name If NM102 = AA NM102 NM105 = AA NM105 else NM105 = AB NM105 NM106 Provider Name Prefix If NM102 = AA NM102 NM106 = AA NM106else NM106 = AB NM106 NM107 Provider Name uffix If NM102 = AA NM102 NM107 = AA NM107 else NM107 = AB NM107 NM108 Provider Identification Code Qualifier 24 Employer's Identification Number 34 ocial ecurity Number If NM102 = AA NM102 NM108 = AA NM108 else NM108 = AB NM108 NM109 Provider Identification Code If NM102 = AA NM102 NM109 = AA NM109 else NM109 = AB NM109 N NM110 Entity elationship Code N NM111 Entity Identifier Code N NM112 Name Last or Organization Name C POVIDE OF EVICE INFOMATION TACE IDENTIFIE TN01 Trace Type Code 1 Current Transaction Trace Numbers TN02 eference Identification N TN03 Originating Company 78 # 10 Identifier N TN04 eference Identification C BILLING POVIDE TATU INFOMATION TC01 HEALTH CAE CLAIM TATU 79 * * 21 Published November 2004

22 TC01-1 TC01-2 TC01-3 TC01-4 Category Code A2 Good tatus Code 19 Good Entity Identifier Code Code List Qualifier Code 65 Health Care Claim tatus Code N TC02 Date TC03 Action Code WQ Accept TC04 Monetary Amount um of clm02 of each HL. N TC05 Monetary Amount N TC06 Date N TC07 Payment Method Code N TC08 Date N TC09 Check Number TC10 HEALTH CAE CLAIM TATU 83 * * TC10-1 TC10-2 TC10-3 TC10-4 Industry Code Industry Code Entity Identifier Code Code List Qualifier Code TC11 HEALTH CAE CLAIM TATU TC11-1 TC11-2 TC11-3 TC Health Care Claim tatus Code * * Industry Code Third tatus Code Industry Code Entity Identifier Code Code List Qualifier Code 65 Health Care Claim tatus Code N TC12 Free-Form Message Text C POVIDE ECONDAY IDENTIFIE EF01 eference Identification Qualifier EF02 eference Identification Get the vendor no from tblhostclaim table. N EF03 Description N EF04 EFEENCE 87 * * IDENTIFIE 22 Published November 2004

23 2200C TOTAL ACCEPTED QUANTITY QTY01 Quantity Qualifier QA Quantity Approved QTY02 Quantity Total number of good claims. N QTY03 COMPOITE UNIT OF MEAUE 90 N QTY04 Free-Form Message Text C TOTAL EJECTED QUANTITY QTY01 Quantity Qualifier QC Quantity Disapproved QTY02 Quantity Total number of bad claims. N QTY03 COMPOITE UNIT OF MEAUE 92 N QTY04 Free-Form Message Text C TOTAL ACCEPT AMOUNT AMT01 Amount Quantity Qualifier YU In Process AMT02 Monetary Amount um of 837 clm02 of good claims of each HL. N AMT03 Credit/Debit Flag Code C TOTAL EJECTED AMOUNT AMT01 Amount Quantity Qualifier YY eturned AMT02 Monetary Amount um of 837 clm02 of bad claims of each HL. N AMT03 Credit/Debit Flag Code D PATIENT LEVEL HL01 Hierarchical ID Number HL02 Hierarchical Parent ID Number HL03 Hierarchical Level Code PT Patient HL04 Hierarchical Child Code 0 No ubordinate HL egment in this Hierarchical tructure D PATIENT NAME NM101 ubscriber Entity ID Code QC Patient NM102 ubscriber Entity Type 1 Person Qualifier NM103 ubscriber Last Name If CA NM103 is empty set NM103 = BA NM103 else set NM103 = CA NM Published November 2004

24 NM104 ubscriber First Name If NM103 = BA NM103 NM104 = BA NM104 else NM104 = CA NM104 NM105 ubscriber Middle Name If NM103 = BA NM103 NM105 = BA NM105 else NM105 = CA NM105 N NM106 ubscriber Name Prefix NM107 ubscriber Name uffix If NM103 = BA NM103 NM107 = BA NM107 else NM107 = CA NM107 NM108 ubscriber Identification Code Qualifier NM109 ubscriber Identification Code MI Member ID Number If NM103 = BA NM103 NM109 = BA NM109 else NM109 = CA NM109 N NM110 Entity elationship Code N NM111 Entity Identifier Code N NM112 Name Last or Organization Name D PATIENT ACCOUNT NUMBE TN01 Trace Type Code 2 eferenced Transaction Trace Numbers TN02 eference Identification/Trace Number N TN03 Originating Company Identifier # 10 TN04 eference Identification D CLAIM LEVEL TATU INFOMATION TC01 HEALTH CAE CLAIM TATU TC * * Category Code A2 Good Published November 2004

25 TC01-2 TC01-3 TC01-4 tatus Code Entity Identifier Code Code List Qualifier Code 65 Health Care Claim tatus Code TC02 Date ystem Date TC03 Action Code WQ Accepted TC04 Total Claim Charge Amount N TC05 Claim Payment Amount N TC06 Payment Date N TC07 Payment Method Code N TC08 Check Issue Date N TC09 Check Number TC010 HEALTH CAE CLAIM TATU 105 * * TC10-1 TC10-2 TC10-3 TC10-4 Industry Code Industry Code Entity Identifier Code Code List Qualifier Code TC11 HEALTH CAE CLAIM TATU TC11-1 TC Health Care tatus Code * * Industry Code Industry Code TC11-3 TC11-4 Entity Identifier Code Code List Qualifier Code 65 Health Care tatus Code TC12 Free-Form Message Text D INFOMATION OUCE CONTOL IDENTIFICATION NUMBE EF01 eference Identification Qualifier 1K Payer's Claim Number EF02 eference Identification N EF03 Description N EF04 EFEENCE IDENTIFIE 109 * * 2200D CLAIM IDENTIFIE NUMBE FO CLEAINGHOUE AND OTHE TANMIION INTEMEDIAIE 25 Published November 2004

26 EF01 eference Identification Qualifier D9 Claim Number If EF01 = D9 EF01 = D9 EF02 eference Identification If EF01 = D9 EF02 = EF02 N EF03 Description N EF04 EFEENCE 111 * * IDENTIFIE 2200D INTITUITUIONAL BILL TYPE IDENTIFICATION EF01 eference Identification Qualifier BLT Billing Type EF02 eference Identification Bill Type Identifier The first two characters of the 837I 2300 clm05_01and the third character of the 837I 2300 clm05_03. N EF03 Description N EF04 EFEENCE 113 * * IDENTIFIE 2200D CLAIM LEVEL EVICE DATE DTP01 Claim Date/Time Qualifier 232 Claim tetement Period tart DTP02 Claim Date Time Period Format Qualifier D8 ange of Dates Expressed om Format CCYYMMDD- CCYYMMDD DTP03 Claim Date Time Period ervice period date expressed as CCYYMMDD- CCYYMMDD Institutional Claims use the tatement Dates Loop 2300 DTP01=434. This date can be a single date DTP02=D8 which means the To and From date are the same or it can be a range DTP02=D8 in which the To and From date will be listed. Professional Claims use the ervice Date Loop 2400 DTP01=472. This date can be a single date DTP02=D8 which means the To and From date are the same or it can be a range DTP02=D8 in which the To and From date will be listed. 2220D EVICE LINE INFOMATION 26 Published November 2004

27 VC01-1 Product/ervice ID Qualifier For Institutional:If 837I 2400 V is empty VC01-1 = "NU"Else VC01-1 = 837I 2400 V VC01-2 Product/ervice ID For Institutional: If 837I 2400 V is empty VC01-2 = 837I 2400 V Else VC01-2 = 837I 2400 V VC01-3 VC01-4 VC01-5 VC01-6 Procedure Modifier Procedure Modifier Procedure Modifier Procedure Modifier N VC01- Description VC02 ervice Line Monetary Amount N VC03 ervice Line Monetary Amount VC04 ervice Line Product/ervice ID N VC05 ervice Line Quantity N VC06 ervice Line Composite 118 Medical Procedure Identifier VC07 ervice Line Quantity D EVICE LINE LEVEL TATU INFOMATION TC01-1 Category Code A3 - Bad TC01-2 tatus Code TC01-3 Entity Identifier Code Published November 2004

28 TC01-4 Code List Qualifier Code 65 Health Care Claim tatus Code N TC02 Date TC03 Action Code U eject N TC04 Total Claim Charge Amount Line Charge Amount N TC05 Claim Payment Amount N TC06 Payment Date N TC07 Payment Method Code N TC08 Check Issue Date N TC09 Check Number TC10 HEALTH CAE CLAIM TATU 121 * * TC10-1 TC10-2 Industry Code econd Claim tatus Cat Code Industry Code TC10-3 TC10-4 Entity Identifier Code Code List Qualifier Code TC11 HEALTH CAE CLAIM TATU TC11-1 TC11-2 TC11-3 TC Health Care Claim tatus Code * * Industry Code Industry Code Entity Identifier Code Code List Qualifier Code 65 Health Care Claim tatus Code TC12 Free-Form Message Text D EVICE LINE ITEM IDENTIFICATION EF01 eference Identification Qualifier FJ Line Item Control Number EF02 Line Item Control Number Provider submitted line ID Number N EF03 Description N EF04 EFEENCE 125 * * IDENTIFIE 28 Published November 2004

29 2220D EVICE LINE DATE DTP01 ervice Line Date/Time Qualifier DTP02 Date Time Period Format Qualifier DTP03 ervice Line Date Time Period TANACTION ET TAILE E01 Transaction egment Count E02 Transaction et Control Number FUNCTIONAL GOUP TAILE GE01 Number of Transactions ent 472 ervice D8 ange of Dates expressed in format CCYYMMDD - CCYYMMDD B GE02 Group Control No. B INTECHANGE CONTOL TAILE IEA01 Number of Functional Groups B7 1 5 IEA02 Interchange Control No. B Published November 2004

Beacon Health Strategies

Beacon Health Strategies Beacon Health trategies 837P Health Care Claim Companion Guide and 837I Health Care Claim Companion Guide For use with AC X12N 837 Health Care Professional and Institutional Transactions et Implementation

More information

HIPAA 835 Companion Document

HIPAA 835 Companion Document HIPAA 835 Companion Document For use with the AC X12N 835(004010X091) and (004010X091A1) Health Care Claim Payment/Advice Transaction et Implementation Guide and Addenda And the National Provider May 2007

More information

837 Health Care Claim Companion Guide Professional and Institutional. Version 1.14 November 24, 2010

837 Health Care Claim Companion Guide Professional and Institutional. Version 1.14 November 24, 2010 837 Health Care Claim Companion Guide Professional and Institutional Version 1.14 November 24, 2010 Page 1 Version 1.14 November 24, 2010 TABLE OF CONTENTS VESION CHANGELOG 3 INTODUCTION 4 PUPOSE 4 SPECIAL

More information

4010A1 5010 Min. Max.

4010A1 5010 Min. Max. IA INTERCHANGE CONTROL HEADER 1 R 1 IA Authorization Information Qualifier ID 2-2 R 00, 03 IA01 INTERCHANGE CONTROL HEADER 1 R 1 Authorization Information Qualifier ID 2-2 R 00, 03 IA01 IA02 Authorization

More information

837I Health Care Claims Institutional

837I Health Care Claims Institutional 837 I Health Care Claim Institutional For Independence Administrators - 1 Disclaimer This Independence Administrators (hereinafter referred to as IA ) Companion Guide to EDI Transactions (the Companion

More information

837 Professional EDI Specifications & Companion Guide

837 Professional EDI Specifications & Companion Guide APS Healthcare, Inc. Helping People Lead Healthier Lives sm Information Technology Division 8403 Colesville Rd. Silver Spring, MD 20910 837 Professional EDI Specifications & Companion Guide The purpose

More information

How To Use An Electronic Data Exchange (Edi)

How To Use An Electronic Data Exchange (Edi) Electronic Data Interchange Companion Document HIPAA...3 Getting Started with EDI...4 When You Are Set Up for EDI...4 When You Are Ready to Go Live...5 Specifications for 837P Transactions...6 Transaction

More information

837 Health Care Claim: Institutional Companion Guide. HIPAA version 5010

837 Health Care Claim: Institutional Companion Guide. HIPAA version 5010 837 Health Care Claim: Institutional Companion Guide HIPAA version 5010 Version 1.6.3 Status: Published October 28, 2015 Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue

More information

837 Professional Health Care Claim

837 Professional Health Care Claim Companion Document 837P 837 Professional Health Care Claim Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional claims.

More information

Geisinger Health Plan

Geisinger Health Plan Geisinger Health Plan HIPAA Transaction Companion Guide 276/277 Health Care Claim Status Request and Response ASC X12 version 005010X212 1 Disclosure Statement Geisinger Health Plan and Geisinger Indemnity

More information

Purpose of the 270/271 Health Care Eligibility Benefit Inquiry and Response

Purpose of the 270/271 Health Care Eligibility Benefit Inquiry and Response Oklahoma Medicaid Management Information System Interface Specifications 270/271 Health Care Eligibility Benefit Inquiry and Response HIPAA Guidelines for Electronic Transactions - Companion Document The

More information

837P Health Care Claim Professional

837P Health Care Claim Professional 837P Health Care Claim Professional Revision summary Revision Number Date Summary of Changes 6.0 5/27/04 Verbiage changes throughout the companion guide 7.0 06/29/04 Updated to include the appropriate

More information

HIPAA ELECTRONIC CLAIM SUBMISSION REQUIREMENTS: CMS 1500 TO ANSI 837 5010 CROSSWALK

HIPAA ELECTRONIC CLAIM SUBMISSION REQUIREMENTS: CMS 1500 TO ANSI 837 5010 CROSSWALK HIPAA ELECTONIC CLAIM UBMIION EQUIEMENT: CM 1500 TO ANI 837 5010 COWALK The CM-1500 (02-12) claim form is being revised to accommodate cross-walking to the 5010 version. WP has created the following crossreference

More information

Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERAL EMPLOYEE PROGRAM (FEP) Dental Claims

Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERAL EMPLOYEE PROGRAM (FEP) Dental Claims Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERAL EMPLOYEE PROGRAM (FEP) Dental Claims HIPAA Transaction Companion Document Guide Refers to the X12N Implementation Guide: 005010X224A2:

More information

HIPAA EDI Companion Guide for 835 Electronic Remittance Advice

HIPAA EDI Companion Guide for 835 Electronic Remittance Advice HIPAA EDI Companion Guide for 835 Electronic Remittance Advice ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) Version 005010X221A1 Companion Guide Version: 2.0 Disclosure

More information

Administrative Services of Kansas

Administrative Services of Kansas Administrative Services of Kansas ANSI X12N 837D V4010A1 Health Care Claim Companion Guide - Dental, INC BlueCross BlueShield of Western New York BlueShield of Northeastern New York Last Updated March

More information

835 Claim Payment/Advice

835 Claim Payment/Advice Companion Document 835 835 Claim Payment/Advice Basic Instructions This section provides information to help you prepare for the ANSI ASC X12 Claim Payment/Advice (835) transaction. The remaining sections

More information

837 I Health Care Claim Institutional

837 I Health Care Claim Institutional 837 I Health Care Claim Institutional Revision Number Date Summary of Changes 6.0 5/27/04 Verbiage changes throughout the companion guide 7.0 06/29/04 Updated to include the appropriate AmeriHealth qualifier

More information

Companion Guide Benefit Enrollment and Maintenance 834

Companion Guide Benefit Enrollment and Maintenance 834 Companion Guide Benefit Enrollment and Maintenance 834 Release 1.0 X12N 834 (Version 4010) X12N 834 (Version 4010)Healthcare Services Review Benefit Enrollment and Maintenance Implementation Guide Published

More information

HIPAA X 12 Transaction Standards

HIPAA X 12 Transaction Standards HIPAA X 12 Transaction Standards Companion Guide 837 Professional/ Institutional Health Care Claim Version 5010 Trading Partner Companion Guide Information and Considerations 837P/837I June 11, 2012 Centene

More information

Health Care Claim: Dental (837)

Health Care Claim: Dental (837) Health Care Claim: Dental (837) Standard Companion Guide Transaction Information November 2, 2015 Version 2.2 Express permission to use ASC X12 copyrighted materials within this document has been granted.

More information

837 I Health Care Claim HIPAA 5010A2 Institutional

837 I Health Care Claim HIPAA 5010A2 Institutional 837 I Health Care Claim HIPAA 5010A2 Institutional Revision Number Date Summary of Changes 1.0 5/20/11 Original 1.1 6/14/11 Added within the timeframes required by applicable law to page 32. Minor edits

More information

BLUE CROSS AND BLUE SHIELD OF LOUISIANA DENTAL CLAIMS COMPANION GUIDE

BLUE CROSS AND BLUE SHIELD OF LOUISIANA DENTAL CLAIMS COMPANION GUIDE BLUE CROSS AND BLUE SHIELD OF LOUISIANA CLAIMS Table of Contents I. Introduction... 3 II. General Specifications... 4 III. Enveloping Specifications... 5 IV. Loop and Data Element Specifications... 7 V.

More information

Health Plan of San Joaquin

Health Plan of San Joaquin Health Plan of San Joaquin HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 CORE v5010 Companion Guide September 2015 September 2015 005010

More information

306 276-277 HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE

306 276-277 HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE Handbook for Electronic Processing Chapter 300 Requirements for Electronic Processing 306 276-277 HEALTH CARE CLAIM STATUS REQUEST AND RESPONSE 306.1 GENERAL INFORMATION Introduction This chapter contains

More information

DEPARTMENT OF HEALTH & MENTAL HYGIENE MEDICAL CARE PROGRAM

DEPARTMENT OF HEALTH & MENTAL HYGIENE MEDICAL CARE PROGRAM DEPARTMENT OF HEALTH & MENTAL HYGIENE MEDICAL CARE PROGRAM COMPANION GUIDE FOR 270/271 - HEALTH CARE ELIGIBILITY BENEFIT INQUIRY AND RESPONSE VERSION 005010X279A1 January 1, 2013 Draft Version 2 Disclosure

More information

Neighborhood Health Plan

Neighborhood Health Plan Neighborhood Health Plan HIPAA Transaction Standard Companion Guide (835, 005010X221A1) Refers to the Technical Report Type 3 based on X12 version 005010A1 Companion Guide Version Number 1.0 1 Contents

More information

HIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 3.0

HIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 3.0 HIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 3.0 ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides, Version

More information

CMS. Standard Companion Guide Transaction Information

CMS. Standard Companion Guide Transaction Information CMS Standard Companion Guide Transaction Information Instructions related to the 837 Health Care Claim: Professionals based on ASC X Technical Report Type 3 (TR3), version 00500A Companion Guide Version

More information

276-277. HIPAA Transaction Standard Companion Guide. Refers to the Implementation Guides Based on ASC X12 version 005010. CORE v5010 Companion Guide

276-277. HIPAA Transaction Standard Companion Guide. Refers to the Implementation Guides Based on ASC X12 version 005010. CORE v5010 Companion Guide Gold Coast Health Plan CORE Companion Guide 276-277 HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 CORE v5010 Companion Guide August 2015

More information

Sanford Health Plan. Electronic Remittance Advice 835 Transaction Companion Guide Trading Partner Information

Sanford Health Plan. Electronic Remittance Advice 835 Transaction Companion Guide Trading Partner Information Sanford Health Plan Electronic Remittance Advice 835 Transaction Companion Guide Trading Partner Information Instructions related to Transactions based on ASC X12 Implementation Guides, version 005010

More information

Florida Blue Health Plan

Florida Blue Health Plan FLORIDA BLUE HEALTH PLAN COMPANION GUIDE Florida Blue Health Plan ANSI 276/277- Health Care Claim Status Inquiry and Response Standard Companion Guide Refers to the Technical Report Type Three () of 005010X212A1

More information

278 HEALTH CARE SERVICES REVIEW REQUEST AND RESPONSE COMPANION GUIDE

278 HEALTH CARE SERVICES REVIEW REQUEST AND RESPONSE COMPANION GUIDE 278 HEALTH CARE SERVICES REVIEW REQUEST AND RESPONSE COMPANION GUIDE OCTOBER 19, 2012 A S C X 1 2 N 2 7 8 (0 0 5 0 1 X 217) VERSION 3.0 TABLE OF CONTENTS 1.0 Overview 3 2.0 Introduction 4 3.0 Data Exchange

More information

How To Write A Health Care Exchange Transaction

How To Write A Health Care Exchange Transaction 837 PROFESSIONAL CLAIMS AND ENCOUNTERS TRANSACTION COMPANION GUIDE JULY 23, 2015 A S C X 1 2 N 8 3 7 (0 0 5 0 10 X 222A1) VERSION 4.0 TABLE OF CONTENTS 1.0 Overview 3 2.0 Introduction 4 3.0 Data Exchange

More information

Your Choice. Page 1 of 10 Release 4 (May 2015) WEB-BSC-0043-15

Your Choice. Page 1 of 10 Release 4 (May 2015) WEB-BSC-0043-15 EDI User Guide for non-employer group trading partners 5010 I. Getting Started BlueChoice HealthPlan Medicaid is a strong proponent of EDI transactions because they significantly increase administrative

More information

Blue Cross and Blue Shield of Illinois (BCBSIL)

Blue Cross and Blue Shield of Illinois (BCBSIL) Blue Cross and Blue Shield of Illinois (BCBSIL) HIPAA Transaction Standard Companion Guide 270/271 Health Care Eligibility Benefit Inquiry and Response Version 1.0 BCBSIL December 2012 A Division of Health

More information

XEROX EDI GATEWAY, INC.

XEROX EDI GATEWAY, INC. XEROX EDI GATEWAY, INC. HEALTH CARE CLAIM PAYMENT/ADVICE COLORADO MEDICAL ASSISTANCE PROGRAM DEPARTMENT OF HEALTH CARE POLICY AND FINANCING (DHCPF) COMPANION GUIDE May 16 2014 2013 Xerox Corporation. All

More information

HIPAA ASC X12N Version 5010. Inbound 837 Transactions. Companion Document

HIPAA ASC X12N Version 5010. Inbound 837 Transactions. Companion Document HIPAA ASC X12N Version 5010 Inbound 837 Transactions Companion Document Version 1.2 Release Date: April 1, 2014 Purpose This document has been prepared as a PerformCare companion document to the ASC X12N

More information

APEX BENEFITS SERVICES COMPANION GUIDE 837 Institutional Health Care Claims. HIPAA Transaction Companion Guide 837 Institutional Health Care Claim

APEX BENEFITS SERVICES COMPANION GUIDE 837 Institutional Health Care Claims. HIPAA Transaction Companion Guide 837 Institutional Health Care Claim HIPAA Transaction Companion Guide 837 Institutional Health Care Claim Refers to the Implementation Guides Based on X12 version 004010 Addendum Companion Guide Version Number: 1.3 May 23, 2007 Disclaimer

More information

Geisinger Health Plan

Geisinger Health Plan Geisinger Health Plan HIPAA Transaction Companion Guide 270/271 - Eligibility, Coverage or Benefit Inquiry and Response ASC X12 version 005010X279 Document Version Number: 1.10 Revised January 09, 2014

More information

ANSI ASC X12N 837P Health Care Encounter Professional

ANSI ASC X12N 837P Health Care Encounter Professional ANSI ASC X12N 837P Health Care Encounter Professional Managed Organization (MTO) COMPANION GUIDE July 23, 2014 Version 3.0 Page 1 of 15 Table of Contents 837P MTO TABLE OF CONTENTS... 2 1. INTRODUCTION...

More information

National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096)

National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096) National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096) DMC Managed Care Claims - Electronic Data Interchange

More information

Trading Partner guidelines for 837 5010 professional and institutional submissions. To be added to HN 837 companion guides.

Trading Partner guidelines for 837 5010 professional and institutional submissions. To be added to HN 837 companion guides. Health Net Trading Partner guidelines for 837 5010 professional and institutional submissions. To be added to HN 837 companion guides. Items covered by this document ST / SE Standards ISA / GS Standards

More information

276/277 HIPAA Transaction Companion Guide HIPAA/V005010X212 VERSION: 1.0 DATE: 02/05/2014

276/277 HIPAA Transaction Companion Guide HIPAA/V005010X212 VERSION: 1.0 DATE: 02/05/2014 276/277 HIPAA Transaction Companion Guide HIPAA/V005010X212 VERSION: 1.0 DATE: 02/05/2014 www.aetnaseniorproducts.com 1 Disclosure Statement This material contains confidential, proprietary information.

More information

837 Professional Health Care Claim Encounter. Section 1 837P Professional Health Care Claim Encounter: Basic Instructions

837 Professional Health Care Claim Encounter. Section 1 837P Professional Health Care Claim Encounter: Basic Instructions Companion Document 837P This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained

More information

HIPAA X 12 Transaction Standards

HIPAA X 12 Transaction Standards HIPAA X 12 Transaction Standards Companion Guide 837 Professional/ Institutional Health Care Claim Version 5010 Trading Partner Companion Guide Information and Considerations 837P/837I April 2016 1 Overview

More information

Florida Blue Health Plan

Florida Blue Health Plan FLORIDA BLUE HEALTH PLAN COMPANION GUIDE Florida Blue Health Plan ANSI 270/271- Health Care Eligibility and Benefit Inquiry and Response Standard Companion Guide Refers to the Technical Report Type Three

More information

276/277 Health Care Claim Status Request and Response Transactions

276/277 Health Care Claim Status Request and Response Transactions 276/277 Health Care Claim Status Request and Response Transactions IBC/KHPE 276/277 Trading Partner Companion Guide V4.0 Rev. 12..06-1 - Disclaimer This Independence Blue Cross and Keystone Health Plan

More information

5010 Gap Analysis for Dental Claims. Based on ASC X12 837 v5010 TR3 X224A2 Version 2.0 August 2010

5010 Gap Analysis for Dental Claims. Based on ASC X12 837 v5010 TR3 X224A2 Version 2.0 August 2010 5010 Gap Analysis for Dental Claims Based on ASC X12 837 v5010 TR3 X224A2 Version 2.0 August 2010 This information is provided by Emdeon for education and awareness use only. Even though Emdeon believes

More information

Claim Status Request and Response Transaction Companion Guide

Claim Status Request and Response Transaction Companion Guide Claim Status Request and Response Transaction Companion Guide Version 1.2 Jan. 2015 Connecticut Medical Assistance Program Disclaimer: The information contained in this companion guide is subject to change.

More information

Horizon Blue Cross and Blue Shield of New Jersey

Horizon Blue Cross and Blue Shield of New Jersey Horizon Blue Cross and Blue Shield of New Jersey Companion Guide for Transaction and Communications/Connectivity Information Instructions related to Transactions based on ASC X12 Implementation Guides,

More information

276/277 Health Care Claim Status Request and Response Transactions

276/277 Health Care Claim Status Request and Response Transactions 276/277 Health Care Claim Status Request and Response Transactions AmeriHealth 276/277 Companion Guide V4.0 Rev. 12.18.06-1 - Disclaimer This AmeriHealth (hereinafter referred to as AH) Companion Guide

More information

Xerox EDI Direct Claims Gateway Communication Document for ASC X12N 837 Health Care Claim Transaction Submission

Xerox EDI Direct Claims Gateway Communication Document for ASC X12N 837 Health Care Claim Transaction Submission Xerox EDI Direct Claims Gateway Communication Document for ASC X12N 837 Health Care Claim Transaction Submission Supporting Institutional, Professional and Dental Transactions for Select Payers Updated

More information

HP SYSTEMS UNIT. Companion Guide: Electronic Data Interchange Reports and Acknowledgements

HP SYSTEMS UNIT. Companion Guide: Electronic Data Interchange Reports and Acknowledgements HP SYSTEMS UNIT I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Companion Guide: Electronic Data Interchange Reports and Acknowledgements L I B R A R Y R E F E R E N C E N U M B E R : CLEL1 0

More information

837 5010 Professional Implementation Guide

837 5010 Professional Implementation Guide 625 State Street Schenectady, NY 12305 MVP Health Care 837 5010 Professional Implementation Guide ASC X12N Version 005010X222A1 Health Care Claim: Professional Guide Version 4.0 September 13, 2011 TABLE

More information

HIPAA Transaction Standard Companion Guide 834 Eligibility Enrollment and Maintenance

HIPAA Transaction Standard Companion Guide 834 Eligibility Enrollment and Maintenance HIPAA Transaction Standard Companion Guide 834 Eligibility Enrollment and Maintenance Refers to the Implementation Guides Based on X12 version 005010 Errata Companion Guide Version Number: 2.1 June 21,

More information

Workers Compensation Companion Guide 837 Requirements and Attachment Options

Workers Compensation Companion Guide 837 Requirements and Attachment Options Workers Compensation Companion Guide 837 Requirements and Attachment Options Revision History Date Version Description Author SME 2/25/2010 1.0 Workers Companion Guide Scott Codon 3/12/2010 1.0 Updated

More information

Arkansas Blue Cross Blue Shield EDI Report User Guide. May 15, 2013

Arkansas Blue Cross Blue Shield EDI Report User Guide. May 15, 2013 Arkansas Blue Cross Blue Shield EDI Report User Guide May 15, 2013 Table of Contents Table of Contents...1 Overview...2 Levels of Editing...3 Report Analysis...4 1. Analyzing the Interchange Acknowledgment

More information

Introduction. Companion Guide to X12 Transactions version 5010

Introduction. Companion Guide to X12 Transactions version 5010 Introduction Companion Guide to X12 Transactions version 5010 Introduction: Table of Contents Table of Contents: Introduction Overview... 1 Purpose... 1 Content... 1 Document Structure... 1 Term Usage...

More information

Blue Cross and Blue Shield of Texas (BCBSTX)

Blue Cross and Blue Shield of Texas (BCBSTX) Blue Cross and Blue Shield of Texas (BCBSTX) 835 Electronic Remittance Advice (ERA) Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 Version 1.0 BCBSTX January 2014 A

More information

HIPAA X 12 Transaction Standards

HIPAA X 12 Transaction Standards HIPAA X 12 Transaction Standards Companion Guide 837 Professional/ Institutional Health Care Claim Version 5010 Trading Partner Companion Guide Information and Considerations 837P/837I October 25, 2011

More information

Oregon Workers Compensation Division Electronic Billing and Payment Companion Guide. Release 1.0 January 1, 2015

Oregon Workers Compensation Division Electronic Billing and Payment Companion Guide. Release 1.0 January 1, 2015 Oregon Workers Compensation Division Electronic Billing and Payment Companion Guide Release 1.0 January 1, 2015 i Purpose of the Electronic Billing and Remittance Advice Guide This guide has been created

More information

Standard Companion Guide Transaction Information

Standard Companion Guide Transaction Information Standard Companion Guide Transaction Information Instructions Related to 837 Health Care Institutional & Professional Claims Transactions Based on ASC X12 Implementation Guides, Version 005010 ASC X12N

More information

835 Health Care Payment/ Remittance Advice Companion Guide

835 Health Care Payment/ Remittance Advice Companion Guide 835 Health Care Payment/ Remittance Advice Companion Guide Version 1.6 April 23, 2007 Page 1 Version 1.6 April 23, 2007 TABLE OF CONTENTS VERSION CHANGE LOG 3 INTRODUCTION 4 PURPOSE 4 SPECIAL CONSIDERATIONS

More information

997 MUST be sent to Safeway to confirm receipt of 824 transmission. This is unrelated to EDI syntax errors as reported on 997.

997 MUST be sent to Safeway to confirm receipt of 824 transmission. This is unrelated to EDI syntax errors as reported on 997. This document defines Safeway Inc. s guidelines of EDI Transaction Set 824, Application Advice, VICS Version 004010. It does not vary from the X12/UCS/VICS standards. Only segments and elements that are

More information

810 Invoice ANSI X.12 Version 5010

810 Invoice ANSI X.12 Version 5010 810 Invoice SI X.12 Version 5010 *** HEADE AEA *** SEG SEGMENT EQ MAX LOOP NAME DES USE EPEAT ISA Interchange Control Header M 1 GS Functional Group Header M 1 ST Transaction Set Header M 1 BIG Beginning

More information

HIPAA - ASC X12N Outbound EDI 835 Electronic Remittance Advice Transaction

HIPAA - ASC X12N Outbound EDI 835 Electronic Remittance Advice Transaction HIPAA - ASC X12N Outbound EDI 835 Electronic Remittance Advice Transaction HIPAA Transaction Companion Guide Refers to the X12N Implementation Guide ANSI Version 4010 X091A1 Version 1.0 Date: November13,

More information

HIPAA TRANSACTION 837 INSTITUTIONAL STANDARD COMPANION GUIDE

HIPAA TRANSACTION 837 INSTITUTIONAL STANDARD COMPANION GUIDE HIPAA TRANSACTION 837 INSTITUTIONAL STANDARD COMPANION GUIDE Refers to the Implementation Guides Based on X12 version 004010 A1 and version 005010 Companion Guide Version Number: 1.3 January 29, 2014 TABLE

More information

Georgia State Board of Workers Compensation Electronic Billing and Payment National Companion Guide (Based on ASC X12 005010 and NCPDP D.

Georgia State Board of Workers Compensation Electronic Billing and Payment National Companion Guide (Based on ASC X12 005010 and NCPDP D. Georgia State Board of Workers Compensation Electronic Billing and Payment National Companion Guide (Based on ASC X12 005010 and NCPDP D.0) Release 2.0 September 10, 2012 Purpose of the Electronic Billing

More information

Title 40 LABOR AND EMPLOYMENT Part I. Workers' Compensation Administration Subpart 1. General Administration Chapter 3. Electronic Billing

Title 40 LABOR AND EMPLOYMENT Part I. Workers' Compensation Administration Subpart 1. General Administration Chapter 3. Electronic Billing NOTICE OF INTENT Louisiana Workforce Commission Office of Workers' Compensation Electronic Medical Billing and Payment Companion Guide (LAC 40:I:305,306) Notice is hereby given, in accordance with R.S.

More information

DCIPA Claims Submission Companion Guide for 837 Professional and 837 Institutional Claims

DCIPA Claims Submission Companion Guide for 837 Professional and 837 Institutional Claims VERSION 4010A1 DCIPA Claims Submission Companion Guide for 837 Professional and 837 Institutional Claims This companion guide for the ANSI ASC X12N 837 Professional and Institutional Claim transaction

More information

North Carolina Workers Compensation Electronic Billing and Payment Companion Guide

North Carolina Workers Compensation Electronic Billing and Payment Companion Guide North Carolina Workers Compensation Electronic Billing and Payment Companion Guide Based on ASC X12 005010 and NCPDP D.0 Release 2.0 February 21, 2014 Important Note The International Association of Industrial

More information

837 Professional Health Care Claim. Section 1 837P Professional Health Care Claim: Basic Instructions

837 Professional Health Care Claim. Section 1 837P Professional Health Care Claim: Basic Instructions Companion Document 837P This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained

More information

UPMC HEALTH PLAN. HIPAA EDI Companion Guide For 837 Institutional Claims File

UPMC HEALTH PLAN. HIPAA EDI Companion Guide For 837 Institutional Claims File UPMC HEALTH PLAN HIPAA EDI Companion Guide For 837 Institutional Claims File Companion Guide Version: 0.1 Refers to the Implementation Guide Based on X12 Version 005010X223A1 ~ 1 ~ Overview Batch File

More information

835 Dental Health Care Claim Payment / Advice. Section 1 835D DentalHealth Care Claim Payment / Advice: Basic Instructions

835 Dental Health Care Claim Payment / Advice. Section 1 835D DentalHealth Care Claim Payment / Advice: Basic Instructions Companion Document 835D 835 Dental Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and

More information

How To Submit 837 Claims To A Health Plan

How To Submit 837 Claims To A Health Plan UPMC HEALTH PLAN HIPAA EDI Companion Guide For 837 Professional Claims File Companion Guide Version: 0.1 Refers to the Implementation Guide Based on X12 Version 005010X222A1 ~ 1 ~ Overview Batch File Submissions

More information

835 Health Care Claim Payment / Advice

835 Health Care Claim Payment / Advice Companion Document 835 835 Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not

More information

837 Health Care Claim : Institutional

837 Health Care Claim : Institutional 837 Health Care Claim : Institutional HIPAA/V5010X223A2/837: 837 Health Care Claim : Institutional Version: 1.0 Final Company: Blue Cross of Northeastern PA Publication: 1/12/2012 Table of Contents 837

More information

UnitedHealthcare West. HIPAA Transaction Standard Companion Guide

UnitedHealthcare West. HIPAA Transaction Standard Companion Guide UnitedHealthcare West HIPAA Transaction Standard Companion Guide Refers to the Technical Report Type 3 (TR3) Implementation Guides Based on ASC X12 Version 005010X223A2 Health Care Claim: Institutional

More information

Communications and Connectivity

Communications and Connectivity Chapter V Communications and Connectivity Trading partners are responsible for the purchase of communication protocol packages and access support for the dial-up process to the Enterprise EDI Gateway/Clearinghouse.

More information

UPMC HEALTH PLAN. HIPAA EDI Companion Guide

UPMC HEALTH PLAN. HIPAA EDI Companion Guide UPMC HEALTH PLAN HIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 1.2 Refers to the Implementation Guide Based on X12 Version 005010X279A1 ~ 1 ~ Disclosure

More information

835 Health Care Remittance Advice

835 Health Care Remittance Advice 835 Health Care Remittance Advice Independence Administrators is an independent licensee of the Blue Cross and Blue Shield Association IA 835 Health Care Remittance Advice V3.0 Rev. 07/25/2011-1 - Disclaimer

More information

HIPAA Transaction Standard Companion Guide

HIPAA Transaction Standard Companion Guide HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 Companion Guide Version Number: 2.6 August 2015 August 2015 005010 1 Disclosure Statement

More information

WPS Health Solutions

WPS Health Solutions WPS Health Solutions HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010220A1 Companion Guide Version Number: 1.0 October 2015 1 Preface This

More information

837P Professional Health Care Claim

837P Professional Health Care Claim Section 3B 837P Professional Health Care Claim Companion Document Basic Instructions This section provides information to understand before submitting the ANSI ASC X12N 837 Health Care transaction for

More information

Geisinger Health Plan

Geisinger Health Plan Geisinger Health Plan Companion Guide for the 820 Payroll Deducted and Other Group Premium Payment for Insurance Products Refers to the Implementation Guides Based on X12 version 004010A1 Version Number:

More information

(Delaware business only) HIPAA Transaction Standard Companion Guide

(Delaware business only) HIPAA Transaction Standard Companion Guide AmeriHealth (Delaware business only) HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 Implementation Guides, version 005010 February 2014 February 2014 005010

More information

EDI Support Frequently Asked Questions

EDI Support Frequently Asked Questions EDI Support Frequently Asked Questions Last revised May 17, 2011. This Frequently Asked Question list is intended for providers or billing staff who may or may not have a technical background. General

More information

Subject: Changes for the 834 Benefit Enrollment and Maintenance Companion Document

Subject: Changes for the 834 Benefit Enrollment and Maintenance Companion Document August 31, 2015 Subject: Changes for the 834 Benefit Enrollment and Maintenance Companion Document The table below summarizes recent changes to the ANSI ASC X12N 834 (005010X220A1) Benefit Enrollment and

More information

Instructions related to Transactions based on ASC X12 Implementation Guides, version 5010. October 2010 005010 1

Instructions related to Transactions based on ASC X12 Implementation Guides, version 5010. October 2010 005010 1 999 New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation

More information

MEDICAID MISSISSIPPI PRE ENROLLMENT INSTRUCTIONS 77032

MEDICAID MISSISSIPPI PRE ENROLLMENT INSTRUCTIONS 77032 MEDICAID MISSISSIPPI PRE ENROLLMENT INSTRUCTIONS 77032 HOW LONG DOES PRE ENROLLMENT TAKE? Standard processing time is 1 2 weeks. WHAT FORM(S) SHOULD I COMPLETE? EDI Provider Agreement and Enrollment Form

More information

Real Time Transactions - 5010 Companion Guide

Real Time Transactions - 5010 Companion Guide Real Time Transactions - 5010 Companion Guide Health Care Eligibility Benefit Inquiry and Response ASC X12N-005010X279A1 270/271 Health Care Claim Status Request and Response ASC X12N-005010X212A1 276/277

More information

emedny New York State Department Of Companion Guide Version Number: 1.2 May 22, 2014 Health Insurance Programs (OHIP)

emedny New York State Department Of Companion Guide Version Number: 1.2 May 22, 2014 Health Insurance Programs (OHIP) New York State Department of Health (NYS DOH) Office of Health Insurance Programs (OHIP) New York State Department New of Health York (NYS State DOH) Office of Health Insurance Department Programs (OHIP)

More information

Alameda Alliance for Health

Alameda Alliance for Health Alameda Alliance for Health HIPAA Transaction Standard Companion Guide Refers to the Implementation Guides Based on ASC X12 version 005010 CORE v5010 Companion Guide October 2015 October 2015 005010 Version

More information

SCAN HEALTH PLAN. 837-I Companion Guide

SCAN HEALTH PLAN. 837-I Companion Guide SCAN HEALTH PLAN Standard Companion Guide Transaction Instructions related to the 837 Health Care Claim: Institutional Transaction based on ASC X12 Technical Report Type 3 (TR3), Version 005010X223A2 837P

More information

HIPAA TRANSACTION 837 PROFESSIONAL STANDARD COMPANION GUIDE

HIPAA TRANSACTION 837 PROFESSIONAL STANDARD COMPANION GUIDE HIPAA TRANSACTION 837 PROFESSIONAL STANDARD COMPANION GUIDE Refers to the Implementation Guides Based on X12 version 004010 A1 and version 005010 Companion Guide Version Number: 1.2 October 1, 2010 TABLE

More information

835 Health Care Claim Payment / Advice

835 Health Care Claim Payment / Advice Companion Document 835 835 Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not

More information

835 Transaction Companion Guide Healthcare Claim Payment/Advice. Version 004010X91A1 (Addendum)

835 Transaction Companion Guide Healthcare Claim Payment/Advice. Version 004010X91A1 (Addendum) 835 Transaction Companion Guide Healthcare Claim Payment/Advice Version 004010X91A1 (Addendum) 0308 Preface This Companion Guide to the ASC X12N Implementation Guides adopted under HIPAA clarifies and

More information

X12_820_4010A1_V4 P-13075 (09/10)

X12_820_4010A1_V4 P-13075 (09/10) Companion Document to HIPAA Implementation Guide: X12 820 Payroll Deducted and Other Group Premium Payment for Insurance Products X12_820_4010A1_V4 P-13075 (09/10) Companion Document Audience Companion

More information

Connectivity and Communications

Connectivity and Communications Chapter 5 Connectivity and Communications This chapter provides information to establish an electronic communications session with Anthem and to submit and receive files. Important: Do not send duplicate

More information