FMH Benefit Services, Inc.

Transcription

1 FMH Benefit Services, Inc. HIPAA Transaction Electronic Data Interchange (EDI) Implementation Guide For Health Care Providers Version Number: 2.0 Issued: October 28, 2003 FMH Benefit Services, Inc. a division of

2 HIPAA Transaction Electronic Data Interchange (EDI) Implementation Guide For Health Care Providers 1. Introduction Purpose of this Guide Getting Started Working with FMH Benefit Services, Inc FMH Benefit Services, Inc. Contact Information Registering with a Clearinghouse Health Care Claims Registering with FMH Benefit Services, Inc Certification and Testing Overview Connectivity with FMH Benefit Services, Inc Hours of Availability for Real Time Transactions Contingency Plan FMH Benefit Services, Inc. Specific Business Rules Eligibility and Claim Inquiry Transaction Use... 7 October 2003 Version 2.0 2

3 1. Introduction The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires that the Secretary of the Department of Health and Human Services (HHS) adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. These electronic transactions are referred to as Electronic Data Interchange or EDI. On October 16, 2003, FMH Benefit Services, Inc. will be prepared to exchange HIPAA compliant EDI transactions with Health Care Providers. 2. Purpose of this Guide This HIPAA EDI Implementation Guide contains the information and procedures Health Care Providers need to understand and follow in order to exchange EDI transactions with FMH Benefit Services, Inc. These transactions could include: Eligibility for a Health Plan Request and Response ASC 12N 270/271 Health Care Claim Status Request and Response ASC 12N 276/277 Referral Certification and Authorization Request and Response ASC 12N 278 Benefit Enrollment and Maintenance ASC 12N 834 Health Care Remittance Advice ASC 12N 835 Health Care Claim: Dental ASC 12N 837 Health Care Claim: Professional ASC 12N 837 Health Care Claim: Institutional ASC 12N 837 Retail Pharmacy Claims NCPDP 5.1 This Guide is intended to convey information that is within the framework and structure of the 12N and NCPDP Version 5.1 Implementation Guides and not to contradict or exceed them. 3. Getting Started 3.1- Working with FMH Benefit Services, Inc. FMH Benefit Services, Inc. will conduct EDI transactions with any Health Care Provider or their agents that otherwise would legitimately conduct non-electronic transactions with FMH Benefit Services, Inc. Some transactions will be routed through a clearinghouse while others will be transmitted directly with FMH Benefit Services, Inc. Some of the transactions routed through a clearinghouse require registration with the clearinghouse. Refer to section 3.3 Registering with a Clearinghouse for a list of these transactions. Registration with FMH Benefit Services, Inc. is required for all transactions that are transmitted directly with FMH Benefit Services, Inc. Refer to section 3.5 Registering with FMH Benefit Services, Inc. for a list of these transactions. October 2003 Version 2.0 3

4 3.2 - FMH Benefit Services, Inc. Contact Information Electronic Data Interchange (EDI) help desk requests focus solely on the generation, processing, and/or transmission of a HIPAA standard transaction. EDI help desk will not focus on transaction results such as claim payment, member maintenance, or member eligibility. Please contact WebMd Customer Solutions at (800) for information on the following HIPAAA standard transactions. 270/271 Health Care Eligibility Benefit Inquiry and Response 276/277 Health Care Claim Status Request and Response 837 Health Care Claim: Professional 837 Health Care Claim: Institutional 837 Health Care Claim: Dental 835 Health Care Claim: Remit Advice Please contact SSI at (251) for information on the following HIPAAA standard transactions. 837 Health Care Claim: Professional 837 Health Care Claim: Institutional Please contact FMH Benefit Service, Inc. EDI help desk for information on the following HIPAA standard transactions: 278 Health Care Services Review Request for Review and Response 834 Benefit Enrollment and Maintenance Please contact FMH Benefit Services, Inc. customer service for information on Non-EDI requests: Such as claim payment and remittance advice, member maintenance, or member eligibility. Non-EDI customer service and assistance requests will not focus on the generation, processing and/or transmission of a HIPAA standard transaction. Contact Info Phone Address FMH EDI Help Desk (800) x1028 hipaa@f-m-h.com FMH Non-EDI (800) questions@f-m-h.com SSI (251) x WebMD (800) October 2003 Version 2.0 4

5 3.3 - Registering with a Clearinghouse The clearinghouse to be used to exchange specific EDI transactions is dependent on the payer ID assigned to your patient. Please refer to the patient s medical ID card to locate the appropriate payer ID and contact information. SSI WebMD Payer ID Payer IDs 37129, 48116, Real Time Transactions: Eligibility Inquiry (270/271) Claim Status Inquiry (276/277) Batch Transactions: Professional Claim Submission (837) Institutional Claim Submission (837) Dental Claim Submission (837) Remittance Advise (835) Contact Information: Phone (251) Web address Registration with the clearinghouse is required before you can begin to exchange the following EDI transactions. Eligibility for a Health Plan Request and Response (270/271) Health Care Claim Status Request and Response (276/277) Health Care Claim Professional (837) Health Care Claim Institutional (837) Health Care Claim Dental (837) Health Care Remittance Advice (835) October 2003 Version 2.0 5

6 3.4 - Health Care Claims The following claim transactions are sent to FMH Benefit Services, Inc. through the clearinghouse. Health Care Claim Professional, Institutional and Dental (837) Registering with FMH Benefit Services, Inc. Registration with FMH Benefit Services, Inc. is required before you can begin to exchange the following EDI transactions directly with FMH Benefit Services, Inc. Referral Certification and Authorization Request and Response (278) Benefit Enrollment and Maintenance (834) Retail Pharmacy Claims (NCPDP version 5.1) Contact the FMH Benefit Services, Inc. EDI Help Desk to register before you begin to exchange these transactions with FMH Benefit Services, Inc Certification and Testing Overview FMH Benefit Services, Inc. recommends but does not require that each Provider certify their EDI transactions prior to production use. However, FMH Benefit Services, Inc. will obtain 3 rd party certification of its outbound transactions prior to production use. Providers that wish to test EDI transactions that are exchanged with FMH Benefit Services, Inc. through the clearinghouse, may do so by contacting the clearinghouse. Providers that wish to test EDI transactions exchanged directly with FMH Benefit Services, Inc. may do so by contacting the FMH Benefit Services, Inc., EDI Help Desk. 4. Connectivity with FMH Benefit Services, Inc. 4.1 Hours of Availability for Real Time Transactions For payer ids 37129, 48116, and 48117, FMH Benefit Services, Inc., will respond to the following real time transactions 7 days a week, 24 hours a day: Eligibility for a Health Plan Request and Response (270/271) Health Care Claim Status Request and Response (276/277) October 2003 Version 2.0 6

7 4.2 Contingency Plan If the Clearinghouses are not ready to handle the online transactions by October 16, 2003, FMH Benefit Services, Inc. will support direct connections in the interim. Should this occur, contact the FMH Benefit Services, Inc. EDI HelpDesk. Refer to section 3.2 for contact information. 5. FMH Benefit Services, Inc. Specific Business Rules 5.1 Eligibility and Claim Inquiry Transaction Use Eligibility and claim inquiries are supported to enable a Provider to establish eligibility prior to claim submission. Eligibility and claim data may not be requested by a Provider not involved in provision of health care services to a purported FMH Benefit Services, Inc. patient, unless the Provider has been approached by the purported FMH Benefit Services, Inc. patient or other Provider to provide health care services to that individual. Searches of eligibility and claim data of possible beneficiaries who are not currently receiving services, or for whom a Provider has not been approached to furnish services is prohibited. The ratio of claims to eligibility inquiries per Provider will be monitored. Providers will be contacted if their ratio suggests possible overuse of eligibility and claim inquiries. Providers that are determined to have abused their query privileges may lose eligibility query for 1 year after the date of determination of abuse. October 2003 Version 2.0 7