EDI Claims Submission Guide

Transcription

1 EDI Claims Submissin Guide In supprt f Health Insurance Prtability and Accuntability Act (HIPAA) and its gal f administrative simplificatin, Cventry Health Care encurages physicians and medical prviders t submit claims electrnically. Electrnic claims submissin can have a significant, psitive impact n the prductivity and cash flw fr yur practice. Reduces Paperwrk and Csts assciated with printing and mailing paper claims. Reduces Time t receive a claim by eliminating mailing time. Reduces Delays due t incrrect claim infrmatin by returning errrs directly t yu thrugh the same electrnic channel. These claims can be crrected and re-submitted electrnically. Imprves Accuracy by decreasing the chance fr transcriptins errrs and missing/incrrect data. Tracks and Mnitrs Claims thrugh claim status reprts received electrnically. Electrnic claim submissin t the Cventry Health Care payers is easy t establish. Cntact yur practice management system vendr r clearinghuse t initiate the prcess. Electrnic claim submissins will be ruted thrugh Emden wh will review and validate the claims fr HIPAA cmpliance and frward them directly t Cventry. Prviders can als submit directly t Emden. Emden will prvide the electrnic requirements and set-up instructins. Prviders shuld call (800) r g t fr infrmatin n direct submissin t Emden. EDI claim submitters shuld review the electrnic claim submissin requirements starting n the next page. Cventry encurages and recmmends regular review f all EDI Acknwledgement and Reject reprts returned t yu. We have staff available t assist yu with EDI claim filing. Fr mre details n each f these tpics please select frm the tpics belw. This dcument was last revised March 2011.

2 1. EDI Specificatins - The 837 claim transactin is utilized fr electrnic prfessinal and institutinal claims and encunters. Cventry Health Care, Inc. uses the ASC X12N 837 Prfessinal Health Care Claim (004010X098A1) and the ASC X12N 837 Institutinal Health Care Claim (004010X096A1) implementatin guides. The fficial implementatin guides fr claim transactins are available electrnically frm the Washingtn Publishing Cmpany website at This Cventry dcument cntains clarificatins and payer specific requirements related t data usage and cntent with submitting an EDI claims t Cventry. Please nte that this dcument is intended t list nly thse elements where payer specific requirements r clarificatins apply. The lp, segment and data element references belw in italics relate t the X098A1r X096A1 frmat. If yu submit yur electrnic claims using a different frmat, yu shuld check with yur sftware vendr r clearinghuse t ensure that yur data is mapped t the prper data elements. 2. Cventry Specific Payer Edits at Emden: All EDI claims submitted thrugh Emden will be subject t these Cventry specific payer edits (unless indicated fr ne transactin nly) that are in place at Emden. Submitters will receive these type f rejectins n their level 1 payer rejectin reprts. The insured id must be at least tw characters in length r the claim will reject. T allw zer dllar line charges and zer dllar claim charges. The billing prvider id may nt cntain a value f r the claim will reject. If the prcedure cde begins with 0, then Anesthesia Minutes are required r the claim will reject (Prf Only). Excluding prcedure cde is r then service units are required and the Anesthesia Minutes shuld cntain 00 r the claim will reject. If the prcedure cde begins with a 0 and ends with a T, then service units are required and the Anesthesia Minutes shuld cntain 00 r the claim will reject (Prf Only). If the prcedure cde des nt begin with a 0, then service units are required and the Anesthesia Minutes shuld cntain 00 r the claim will reject (Prf Only). The discharge hur must cntain a numeric value f r 99 if the batch type cntains an inpatient value f x10, x11, x14 r x17 and the statement perid frm date is equal t the statement perid thru date (Inst Only). NOTE: Refer t 2010 Claim Submissin Lg Grid t lcate the respective Emden payer ID and paper mailing address fr all Cventry health plans. Cventry has cnslidated several f ur Emden Payer IDs int a single payer id t make claim submissin easier. Please refer t the cnslidated Emden Payer ID n the lg grid fr the Health plans included. 3. Prfessinal EDI Claim Submissin Infrmatin Key Infrmatin required by HIPAA/Cventry r clarified as t Cventry's use f the data: Prvider Federal Tax ID (TIN) f Billing Prvider (9 digit number). Natinal Prvider ID (NPI) is required fr Billing, Rendering, Referring prviders, and all ther prvider lps. Billing Prvider's Last Name (NM103) and Prvider's First Name (NM104) are bth required if the prvider entity type qualifier indicates "persn". Prvider first name shuld be

3 submitted cmpletely and nt just a first initial. Rendering Prvider Name and ID Number (Lp 2310B) is required when different than the billing prvider (2010AA). Prvider first name shuld be submitted cmpletely and nt just a first initial. If yu submit rendering prvider infrmatin at the claim header level (Lp 2310B), d nt als submit service line level (Lp 2420A) rendering prvider infrmatin. Cventry will read the prvider at the claim header level nly. If yu d nt have a rendering prvider at the claim header, Cventry will read the billing prvider data. Referring Prvider Name and ID Number (Lp 2310A) If the referring prvider is a persn, bth the first name(nm104) and last name (NM103) are required. D nt submit referring prvider infrmatin at the service line level (Lp 2420F). Cventry will read prvider data at the claim level nly (Lp 2310A). When there is nly ne referral n the claim, use cde DN in NM101. When tw referrals are reprted, use cde DN in NM101 f the first iteratin f the lp and cde P3 in NM101 in the secnd iteratin f the lp. Cventry will nly read the first referral submitted. Service Facility Lcatin (Lp 2310D) is required when the service lcatin is different than the lcatin in the billing prvider (2010AA). Service facility lcatin name (NM1) is required except when the place f service is the patient's hme. Include Service Facility NPI D nt submit service facility lcatin infrmatin at the service line level (Lp 2420C). Pay-T Prvider (Lp Cventry accepts and stres "Pay-T" prvider data. Hwever, will nly use this data in claim filing n an exceptin basis. Please cntact the EDI supprt number belw if yur submissins require prvider matching based n data in this lp. The Cventry standard is t use the rendering r billing prvider infrmatin fr claims. Other Claim Header Infrmatin: Admissin Date (Ref02 where REF0=435) is required per HIPAA guides fr inpatient medical visits and ambulance claims when the patient was admitted t the hspital. Cmpliant Medical Cde Sets such as HCPCS, ICD-9, and CPT-4 are required n bth electrnic and paper claims. ICD-9-CM cdes shuld be submitted with the highest level f specificity (the crrect number f digits) fr prper adjudicatin. Patient Member ID Number as shwn n the patient's ID card. Member Date f Birth & Gender Cde Subscriber's Date f Birth (DMG02 where DMG01=D8) and Gender Cde (DMG03)are preferred and are required if either: The subscriber is the same persn as the patient. Fr secndary COB claims when using Lps 2320 and Insurance Type Cde is required n secndary COB claims (Lp 2320 SBR05). Other Data Items Anesthesia EDI Claims. Cventry requires the submissin f time-based CPT cdes (frmally called ASA cdes) fr all anesthesia services. Anesthesia claims submitted with surgical CPT cdes will be denied during prcessing. Ttal Anesthesia Minutes are required n all time-based CPT cdes, with the exceptin f and Ttal Minutes shuld be entered in the SV104. The qualifier MJ shuld be entered in the SV103. All nn time-based services (01996 included) require units f service. Units shuld be entered in the SV104, with a Qualifier f UN in the SV103.

4 Billed Amunts -- Cventry requires applicable ttal charged amunts t be submitted fr all encunter/capitated submissins at bth the claim header (2300 CLM02) and line level (2400 SV102). Nte: Cventry accepts zer dllar billed amunts fr apprpriate n charge situatins. Claims with Attachments. Cventry is able t receive and use in prcessing the EDI Claim Supplemental Infrmatin paperwrk segment as defined in the Health Care Claim 837 Implementatin Guide. This segment cntains paperwrk cdes t indicate dcuments available t the payer if needed Specificatins fr 2300 Lp - PWK Segment PWK01 - Reprt Type Cde (see applicable cdes belw) PWK02 - Reprt Transmissin Cde must be 'AA' fr available n request at prvider site. PWK06 - Attachment Cntrl number (if applicable). PWK07 - Descriptin (ptinal)(ub claims nly). Cventry's business practices supprt the fllwing paperwrk cdes (PWK01), which will be cnsidered during adjudicatin: (AS) Admissin Summary (DG) Diagnstic Reprt (DS) Discharge Summary (NN) Nurse Ntes (PN) Physical Therapy Ntes (B3) Physician Order (OB) Operative Ntes (EB) Explanatin f Benefits (RT) Reprt f Tests and Analysis Reprt (RR) Radilgy Reprts Please nte fr claims with attachments: The PWK segment and attachments shuld nly be used when supplemental infrmatin is necessary fr the claim t be accurately and cmpletely adjudicated accrding t established plicies. If the dcumentatin is needed fr adjudicatin, Cventry will cntact yu and request a faxed cpy. This cpy must be received within 72 hurs f the request r the claim will be denied. The specific paperwrk cdes in the PWK segment will trigger prcessrs t cnsider the cntents f the supplemental infrmatin btained via fax. Therefre, use f these cdes incrrectly may delay the prcessing f the claim as cmpared t a like claim withut a PWK. Cventry will cntinue t accept paper claims with attachments. Secndary COB Claims - secndary claims may be submitted electrnically. Send the secndary claim electrnically using the A1 using Lps 2320 and 2330 fr claim header data and Lps 2420G and 2430 fr claim service line data. All COB secndary claims must cntain infrmatin regarding the ther payer apprved and allwed amunts. Additinally, we need t receive the applicable claim adjustment reasn cdes at the header r line level fr ther payer amunts. Cventry des nt require secndary COB claims t be submitted electrnically. Prviders may cntinue t submit COB claims n paper and attach a cpy f the paper EOB. NOTE: Cventry receives Medicare Part A & B primary claims autmatically thrugh the crss ver prcess fr secndary payment. T eliminate duplicate claim submissins, refer t the EOB/RA frm Medicare (lk fr cde "MA-18" n yur Medicare Remittance Advice) befre submitting secndary claims directly t Cventry.

5 Resubmitted Claims - Crrected r replacement claims may be submitted electrnically. Use the Claim Frequency Type Cde (CLM05-3) value equal t "7" t indicate a replacement claim. Pharmaceutical Claims - May be submitted electrnically. These drug claims shuld nt be fr retail pharmacy claims nr can they be in an NCPDP frmat. If yu are submitting a claim fr pharmaceutical services, the HCPCS J cdes are required t identify the drug. Hwever, if the apprpriate J-cde is J3490 r J9999, we als require the NDC cde using Lp Use a F2 qualifier n the service line level t indicate DOSAGE fr this NDC cde. If yu cannt submit the 2410 lp, then place the NDC and dsage infrmatin in the claim header nte segment (2300 NTE). We d nt read NTE infrmatin at the claim line level. DATA NOT USED Althugh Cventry accepts the fllwing data, it is nt used in claim adjudicatin. Prviders lps and segments at the claim line level. Supervising prvider infrmatin - Please cntact the EDI supprt number belw if yur submissins require prvider matching based n data in this lp. The Cventry standard is t use the rendering r billing prvider infrmatin fr claims. Purchasing prvider infrmatin. Currency. Infrmatin in the CUR segment will nt be cnsidered in prcessing. All electrnic transactins will be with trading partners in the United States. Select Patient Infrmatin Segment including date f death (PAT06), Weight (PAT08), and Pregnancy Indicatr (PAT09). Respnsible Party Infrmatin (Lp 2010 BC) infrmatin submitted n apprpriate legal dcumentatin and maintained in internal files will be used. Participatin Indicatr (Lp 2300 CLM16) we will use the participatin indicatr in ur internal prvider files. Service Authrizatin Exceptin Cde in Lp 2300 REF. Ambulatry Patient Grup in Lp 2300 REF. Demnstratin Prject Identifier in Lp 2300 REF. Durable Medical Equipment Service (Lp 2400 SV5 segment). DME shuld be billed in the Lp 2400 SV1 segment. Mandatry Medicare Crssver Indicatr (Lp 2300 REF). Mammgraphy Certificatin Number (Lps 2300 and 2400 REF). DMERC CMN Indicatr (Lp 2400 PWK). Hspice Emplyee Indicatr (Lp 2400 CRC). Credit/Debit Card Accunt Hlder Name (Lp 2010BD) and Credit/Debit Card Maximum Amunt (Lp 2300 AMT segment) 4. Institutinal (UB) Claim Submissin Infrmatin Key Infrmatin required by HIPAA/Cventry r clarified as t Cventry's use f the data: Prvider Federal Tax ID (TIN) f Prvider (9 digit number). Natinal Prvider ID (NPI) fr Billing, Rendering, Attending prviders, and all ther prvider lps. Billing Prvider's Last Name (NM103) and Prvider's First Name (NM104) are bth required if the prvider entity type qualifier indicates "persn". Prvider first name shuld be submitted cmpletely and nt just a first initial. Attending Prvider Name and ID Number (Lp 2310A) is recmmended n all institutinal claims.

6 If the attending prvider is a persn, bth the first name and the last name are required. Service Facility Name and Address (Lp 2310E) is required when the service facility is different than the billing prvider (2010AA). Other Claim Header Infrmatin: Admissin Date and Time is required fr all inpatient claims. DTP03 shuld be in this frmat: CCYYMMDDHHMM where DTP01=435 and DTP02=DT. Service Line Date is required n utpatient claims. DTP03 where DTP01=472 in Lp Unit r Basis fr Measurement Cde SV204 in Lp 2400 (days, units, internatinal unit r dsage) is required at the service line level. Quantity Segment (QTY in Lp 2300) shuld nly be used fr infrmatin related t DAYS, such as the number f cvered, c-insured, life-time reserve r nn-cvered days. D nt use this segment n utpatient claims. Cmpliant Medical Cde Sets such as HCPCS, ICD-9, and CPT-4 are required n bth Patient electrnic and paper claims. ICD-9-CM cdes shuld be submitted with the highest level f specificity (the crrect number f digits) fr prper adjudicatin. These cdes shuld be submitted withut the decimal pint n electrnic claims. ICD-9-CM cdes are expected n all utpatient surgery claims. Member ID Number (10-11 digit number) as shwn n the patient's ID card. Member's Date f Birth and Gender Cde Subscriber's Date f Birth (DMG02 where DMG01=D8) and Gender Cde (DMG03) are required if either: The subscriber is the same persn as the patient. Fr secndary COB claims when using Lps 2320 and Patient Status Cde CL103 in Lp 2300 (2-digit cde frm bx 22 f the UB-92) is required n all inpatient claims. Other Data Items: Billed Amunts -- Cventry requires applicable ttal charged amunts t be submitted fr all encunter/capitated submissins at bth the claim header (2300 CLM02) and line level (2400 SV102). Nte: Cventry accepts zer dllar billed amunts fr apprpriate n charge situatins.. Claims with Attachments. Cventry is able t receive and use in prcessing the EDI Claim Supplemental Infrmatin paperwrk segment as defined in the Health Care Claim 837 Implementatin Guide Specificatins fr 2300 Lp - PWK Segment PWK01 - Reprt Type Cde (see applicable cdes belw) PWK02 - Reprt Transmissin Cde must be 'AA' fr available n request at prvider site. PWK06 - Attachment Cntrl number (nt used nw, but will be implemented in the future). PWK07 - Descriptin (ptinal)(ub claims nly). Cventry's business practices supprt the fllwing paperwrk cdes (PWK01), which will be cnsidered during adjudicatin: (AS) Admissin Summary (DG) Diagnstic Reprt (DS) Discharge Summary (NN) Nurse Ntes

7 (PN) Physical Therapy Ntes (B3) Physician Order (OB) Operative Ntes (EB) Explanatin f Benefits (RT) Reprt f Tests and Analysis Reprt (RR) Radilgy Reprts Please nte fr claims with attachments: The PWK segment and attachments shuld nly be used when supplemental infrmatin is necessary fr the claim t be accurately and cmpletely adjudicated accrding t established plicies. The specific paperwrk cdes in the PWK segment will trigger prcessrs t cnsider the cntents f the supplemental infrmatin btained via fax. Therefre, use f these cdes incrrectly may delay the prcessing f the claim as cmpared t a like claim withut a PWK. If the dcumentatin is needed fr adjudicatin, Cventry will cntact yu and request a faxed cpy. This cpy must be received within 72 hurs f the request r the claim will be denied. Cventry will cntinue t accept paper claims with attachments. Secndary COB Claims - secndary claims may be submitted electrnically: Send the secndary claim electrnically using the A1 using Lps 2320 and 2330 fr claim header data and Lp 2430 fr claim service line data. All COB secndary claims must cntain infrmatin regarding the ther payer apprved and allwed amunts. Additinally, we need t receive the applicable claim adjustment reasn cdes at the header r line level fr ther payer amunts. Cventry des nt require secndary COB claims t be submitted electrnically. Prviders may cntinue t submit COB claims n paper and attach a cpy f the paper EOB. NOTE: Cventry receives Medicare Part A & B primary claims autmatically thrugh the crss ver prcess fr secndary payment. T eliminate duplicate claim submissins, refer t the EOB/RA frm Medicare (lk fr cde "MA-18" n yur Medicare Remittance Advice) befre submitting secndary claims directly t Cventry. Pharmaceutical Claims - may be submitted electrnically using an 837. These drug claims shuld nt be fr retail pharmacy claims nr can they be in an NCPDP frmat. If yu are submitting a claim fr pharmaceutical services, the HCPCS J cdes are required t identify the drug. Hwever, if the apprpriate J-cde is J3490 r a J9999, we als require the NDC cde using Lp Use a F2 qualifier n the service line level t indicate DOSAGE fr this NDC cde. If yu cannt submit the 2410 lp, then place the NDC and dsage infrmatin in the claim header nte segment (2300 NTE). We d nt read NTE infrmatin at the claim line level. DATA NOT USED Althugh Cventry accepts the fllwing data, it is nt used in claim adjudicatin. Prviders lps and segments at the claim line level. Currency. Infrmatin in the CUR segment will nt be cnsidered in prcessing. All electrnic transactins will be with trading partners in the United States. Respnsible Party Infrmatin (Lp 2310BC) will nt be cnsidered in prcessing. The infrmatin submitted n apprpriate legal dcumentatin and maintained in internal files will be used. Demnstratin Prject Identifier in Lp 2300 REF.

8 File Infrmatin in Lp 2300 K3 segment. This is nt needed as n usage fr this segment has been defined. Peer Review Organizatin Apprval Number (Lp 2300 REF segment). Infrmatin n internal files will be used. Medicare PPS Assessment Date (Lp 2400 DTP). Explanatin f Benefits Indicatr (CLM18). Infrmatin frm ur internal files will be used. Treatment Cde Infrmatin (in Lp 2300 HI segment). Hme Health Agency treatment plan infrmatin is nt needed fr prcessing at this time. Credit/Debit Card Accunt Hlder Name (Lp 2010BB) and Credit/Debit Card Maximum Amunt (Lp 2300 AMT segment) Prperty and Casualty Claim Number (REF segments in Lps 2010BA and 2010CA) 4. EDI Acknwledgement and Reject Reprts Fr every claim filed electrnically, the prvider shuld mnitr whether r nt that claim has been rejected by reviewing EDI Acknwledgement and Reject reprts n a regular basis. The fllwing reprts shuld be mnitred regularly. Initial Reject Reprt (Emden reprt Rpt 05 r equivalent vendr reprt) - This is a reprt that shws claims rejected by Emden that were nt frwarded t Mail Handlers Benefit Plan. These claims shuld be crrected and re-submitted electrnically. Initial Accept Reprt (Emden Envy Reprt Rpt 04 r equivalent vendr reprt) -This is a reprt that shws Emden accepted the EDI claim and frwarded it t Cventry fr prcessing. Payer Reject Reprt (Emden Reprt Rpt 11 r equivalent vendr reprt) - This reprt states why the Cventry health plan rejected the claim. These claims shuld be crrected and re-submitted electrnically when pssible. Mnitring Yur EDI Reprts Please nte that claims appearing n the Initial Reject Reprt have nt met the initial clearinghuse criteria apprved by Cventry and have nt been sent t Cventry fr adjudicatin. Any claims appearing n this reprt must be crrected and shuld be re-submitted electrnically as sn as pssible t avid timely filing issues. Claims displayed n the Initial Accept Reprt have passed the clearinghuse edits and have been frwarded t Cventry fr additinal payer editing. D t the size f this reprt a file summary reprt might be mre apprpriate t mnitr the number f accepted claims. It is als imprtant t nte that a claim can pass the clearinghuse edits and be displayed n the Initial Accept Reprt, but still be rejected by Cventry. Claims rejected by Cventry payrs will appear n the Payer Reject Reprt. Any claims appearing n this reprt shuld be crrected and re-submitted electrnically as sn as pssible t avid timely filing issues. Timely Filing Cventry must accept a claim within its timely filing limit r it will be denied fr untimely filing. If yu are nt receiving the described clearinghuse and payer reprts n a regular basis, please cntact yur clearinghuse r Emden. A prvider can avid timely filing issues thrugh understanding and regular mnitring f EDI Reprts. This prcess will help t ensure all rejected claims are re-filed timely and electrnically. 5. Cmmn Rejectin Reasns Review the fllwing tips fr assistance with reslving the mst cmmn rejectins received by

9 prviders. The mst cmmn claim reject reasn fr Cventry is member nt fund. Use the Cventry Health Care secure prvider prtal, directprvider.cm, Emden, r an integrated slutin thrugh yur vendr r clearinghuse t verify/validate member s eligibility prir t submitting claims. Member Identificatin Number Submit the 10 r 11 digit number as displayed n the patient's ID card. Patient Date f Birth Submit a valid date f birth fr the patient. - D nt send "00" fr the mnth r date. - D nt send dummy dates such as " ". - D nt send a date f birth greater than the date f service. A claim will be rejected if a valid date f birth des nt match the date f birth n file in the Cventry system. If this is the case, please verify the patient date f birth with the patient r plicyhlder. Date Frmat Submit all dates in the fllwing frmat CCYYMMDD unless therwise specified. - Submit valid dates f service. - D nt submit future dates f service. Mnetary Amunt Frmat Include the decimal pint in all mnetary amunts unless therwise specified. - D nt submit negative dllar amunts. Cding Detail Cnsider the fllwing when verifying service cdes and/r mdifiers that have been rejected. - Submit service cdes and mdifiers apprpriate t the age and gender f the patient. - Submit service cdes and mdifiers apprpriate t the date f service. - Submit service cdes t their greatest level f specificity. 6. EDI Assistance Yur Clearinghuse - typically, yur first pint f cntact fr reslving an EDI issue is yur practice's specific clearinghuse r vendr. Emden - The Emden custmer service center can track all EDI submissins received by them. Emden als maintains the status message returned n an EDI claim frm the health plan. This infrmatin is readily available fr 45 days after the submissin. Infrmatin n lder submissins is als available but will need frwarded t their research divisin fr fllw-up. Emden Custmer Supprt can be reached at (877) Additinally, Emden has a new web-based applicatin, Visin fr Claim Management, that cmpiles claim infrmatin received and generated during claim filing and prcessing. It in an easy t use applicatin fr tracking EDI claim submissins. Fr mre infrmatin and registratin fr Visin fr Claim Management, g t Cventry staff is available t assist yu with electrnic filling cncerns as they relate t ur submissin requirements r status messages. Please cntact us at (302) r via at [email protected].