Minnesota Uniform Companion Guide

Transcription

1 005010X222A1 Health Care Claim: Professional (837), v. 4.0 with Changes Adopted May MINNESOTA DEPARTMENT OF HEALTH DIVISION OF HEALTH POLICY CENTER FOR HEALTH CARE PURCHASING IMPROVEMENT Minnesota Uniform Companion Guide For the Implementation of the ASC X12/005010X222A1 HEALTH CARE CLAIM: PROFESSIONAL (837) Prepared In Consultation With Minnesota Administrative Uniformity Committee MAY VERSION 4.0

2 005010X222A1 Health Care Claim: Professional (837), v. 4.0 with Changes Adopted May Disclaimer The following Minnesota Uniform Companion Guide is intended to serve as a companion document to the corresponding ASC X12/005010X222A1 Health Care Claim: Professional (837). The document further specifies the requirements to be used when preparing, submitting, receiving and processing electronic health care administrative data. The document supplements, but does not contradict, disagree, oppose, or otherwise modify the X222A1 in a manner that will make its implementation by users to be out of compliance. Using this Companion Guide does not mean that a claim will be paid. It does not imply payment policies of payers or the benefits that have been purchased by the employer or subscriber. Statutory Authority Development, adoption and use of this companion guide is mandated for all group purchasers and health care providers under Minnesota Statutes, 62J.536. The required use of this Minnesota Uniform Companion Guide was promulgated as a rule under Minnesota Statutes, 62J.61. Document Changes The content of this companion guide is subject to change. The version, release and effective date of the document is included in the document, as well as a description of the process for handling future updates or changes. About the Minnesota Department of Health The Minnesota Department of Health is responsible for protecting, maintaining and improving the health of Minnesotans. The department operates programs in the areas of disease prevention and control, health promotion, community public health, environmental health, health care policy, and registration of health care providers. About the Minnesota Administrative Uniformity Committee The Administrative Uniformity Committee (AUC) is a broad-based group representing Minnesota health care public and private payers, hospitals, health care providers and state agencies. The mission of the AUC is to develop agreement among Minnesota payers and providers on standardized administrative processes when implementation of the processes will reduce administrative costs. The AUC acts as a consulting body to various public and private entities, but does not formally report to any organization and is not a statutory committee. Contact for Further Information on this Companion Guide Minnesota Department of Health Division of Health Policy Center for Health Care Purchasing Improvement P.O. Box St. Paul, Minnesota Phone: (651) Fax: (651) Internet: Health.ASAGuides@state.mn.us Copyright 2010 By The Minnesota Department of Health, State of Minnesota

3 TABLE OF CONTENTS Page 1.0 COMPANION GUIDE REVISION HISTORY STATEMENT FROM THE MINNESOTA DEPARTMENT OF HEALTH STATEMENT FROM THE MINNESOTA ADMINISTRATIVE UNIFORMITY COMMITTEE (MN-AUC) INTRODUCTION AND OVERVIEW PURPOSE AND OVERVIEW INFORMATION ABOUT THE HEALTH CARE CLAIM: PROFESSIONAL (837) TRANSACTION PROCESS FOR UPDATING COMPANION GUIDE DOCUMENT MINNESOTA BEST PRACTICES FOR THE IMPLEMENTATION OF ELECTRONIC HEALTH CARE TRANSACTIONS HEALTH CARE CLAIM: PROFESSIONAL (837): MINNESOTA UNIFORM COMPANION GUIDE TABLE INTRODUCTION TO TABLE COMPANION GUIDE TABLE APPENDICES 32 APPENDIX A: MEDICAL CODE SET SUPPLEMENTAL INFORMATION FOR MINNESOTA UNIFORM COMPANION GUIDES 33 APPENDIX B: K3 SEGMENT USAGE 60 APPENDIX C: REPORTING MNCare TAX 61 3

4 1.0 Companion Guide Revision History Version Revision Date Summary Changes 1.0 February 8, 2010 Version Released for Public Comment 2.0 May 24, 2010 Final Published Version for Implementation 3.0 February, Incorporates Proposed Technical Changes and Updates to v May Incorporates All Changes Adopted to v

5 Protecting, maintaining and improving the health of all Minnesotans 2.0 Statement from the Minnesota Department of Health Summary Notice of Adoption of Rules Regarding the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837); Pursuant to Minnesota Statutes, Section 62J.536. Adoption: Notice is hereby given that the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837), as proposed at State of Minnesota State Register, Volume 34, Number 32, page 1079, February 8, 2010, (34 SR 1079) is adopted with modifications. Companion Guide Available: The Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837), as defined by the Commissioner of Health, is available on the World Wide Web at and at Minnesota s Bookstore at (651) or (800) The Minnesota s Bookstore TTY relay service phone number is (800) If you have any questions, please health.asaguides@state.mn.us. The adopted rule differs from the rule proposed on February 8, A complete copy of the rule showing all of the changes in a strike/underline format is available at: Interested parties may also obtain a printed copy of the rule showing all of the changes in a strike/underline format by contacting Mayumi Reuvers via e- mail at mayumi.reuvers@state.mn.us or by phone at or fax at: (651) Description and Statutory Reference: Minnesota Statutes, section 62J.536, requires the Minnesota Commissioner of Health, in consultation with the Minnesota Administrative Uniformity Committee (AUC), to promulgate rules pursuant to section 62J.61 establishing and requiring group purchasers and health care providers to use electronic claims and eligibility transactions with a single, uniform companion guide to the implementation guides described under Code of Federal Regulations, title 45, part 162. At present, all Minnesota health care providers and group purchasers subject to Minnesota Statutes, section 62J.536 must use Version ASC X12/004010A1 ( Version 4010A1 ) of the Minnesota Uniform Companion Guides. As further discussed below, in order to comply with recent federal regulations, new versions of the Minnesota Uniform Companion Guides, (Version ASC X12/005010, also referred to as Version 5010 ), are being adopted for use no later than January 1,

6 On January 16, 2009, the U.S. Department of Health and Human Services (HHS) published rules (CMS 0009 F) announcing the adoption of new versions of the federal transaction standards, known as ASC X12/ ( Version 5010 ). As a result, MDH, in consultation with the AUC, has adopted the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837) in order to be consistent with the federal regulations as cited above. The health care claims or equivalent encounter information transaction is the transmission of either of the following: a. A request to obtain payment, and the necessary accompanying information from a health care provider to a group purchaser, for health care. b. If there is no direct claim, because the reimbursement contract is based on mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care. Health care providers and group purchasers subject to Minnesota Statutes, section 62J.536 must exchange transactions covered by the statute as follows. From the date of each Version 5010 Uniform Companion Guides final adoption until January 1, 2012, providers and group purchasers may use only: the Minnesota Uniform Companion Guides, Version ASC X12N/004010A1 (Version 4010), including any subsequent technical changes or updates; or, by mutual agreement between trading partners, the Minnesota Uniform Companion Guides, Version ASC X12/ (Version 5010). Beginning January 1, 2012, providers and group purchasers may only use the Minnesota Uniform Companion Guides, Version ASC X12/ (Version 5010), including this Guide, the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X222A1 Health Care Claim: Professional (837). Development: The Commissioner of Health developed this rule in consultation with the AUC and its Claims Data Definition Technical Advisory Group (TAG). This rule was submitted for public comment in the State Register, Volume 34, Number 32, page 1079, February 8, The comment period was from February 8, 2010 through March 10, MDH consulted with the AUC Claims Data Definition TAG in reviewing comments and in making modifications to the rule proposed on February 8, Required Date of Compliance: As described above, the required date of compliance is no later than January 1, Dated: May 24, 2010 Sanne Magnan, M.D., Ph.D. Commissioner P.O. Box St. Paul, MN

7 3.0 Statement from the Minnesota Administrative Uniformity Committee (MN-AUC) Administrative Uniformity Committee C/O Minnesota Department of Health P.O. Box St. Paul, MN December, 2009 The 2007 Minnesota Legislature amended the Minnesota Health Care Administrative Simplification Act (Minnesota Statutes, 62J.50-62J.61) by adding 62J.536, entitled Uniform Electronic Transactions and Implementation Guide Standards. This section requires all group purchasers and health care providers to electronically transmit and accept eligibility verification, claims and remittance advice transactions using a single uniform companion guide. The Commissioner of Health is required to base the companion guides billing, coding rules, and standards on the Medicare program and to consult with the Minnesota Administrative Uniformity Committee (AUC) in the development of the uniform companion guides. The AUC is a broad-based group representing Minnesota health care public and private group purchasers, hospitals, physicians, other providers and State agencies. The goal of the AUC is to reduce administrative costs for both payers and providers by standardizing their administrative processes and requirements. The AUC is made up of a Strategic Steering Committee, an Operations Committee, and various Technical Advisory Groups (TAGs), and Work Groups. Minnesota Statutes, 62J.536 builds upon Minnesota s already significant leadership in health care administrative simplification. The AUC is confident that the Minnesota approach will provide more efficient communication of administrative health care information between payers and providers throughout the state. This Health Care Claim Transaction Companion Guide was developed by the AUC Claims Data Definition TAG. The TAG reviewed and considered the ASC X12/005010X222A1 Health Care Claim: Professional (837) and recommended clarifications to it where Minnesota providers and payers deemed it appropriate. As part of its responsibility of consultation, the AUC Operations Committee presented recommendations for content of this Minnesota Companion Guide to the Commissioner of Health on January 12, The AUC also recommended that this companion guide be reviewed and updated approximately every 12 months or more often if deemed necessary by the Commissioner of Health in consultation with the AUC. The AUC will continue to work in partnership with the Commissioner of Health to improve the clarity and usefulness of the manual. 7

8 4.0 Introduction and Overview 4.1 Purpose and Overview Purpose The purpose of this Companion Guide is to clarify, supplement and further define specific data content requirements to be used in conjunction with the ASC X12/005010X222A1 Health Care Claim: Professional (837) created for the electronic transaction standard mandated by the HIPAA regulations. The terms companion guide, guide, state companion guide and state guide are used interchangeably throughout this document to refer to each single, uniform companion guide being created pursuant to Minnesota Statutes, 62J Applicability Effective July 15, 2009, all group purchasers licensed or doing business in Minnesota and health care providers providing services for a fee in Minnesota must exchange health care claims electronically using the transactions, companion guides, X222A1, and timelines required under Minnesota Statutes, section 62J.536. The only exceptions to the statutory requirements are as follow: The requirements do NOT apply to the exchange of health care claim transactions with Medicare and other payers for Medicare products; and See section Exceptions to Applicability below. Minnesota Statutes, Section 62J.03, Subd. 6 defines group purchaser as follows: "Group purchaser" means a person or organization that purchases health care services on behalf of an identified group of persons, regardless of whether the cost of coverage or services is paid for by the purchaser or by the persons receiving coverage or services, as further defined in rules adopted by the commissioner. "Group purchaser" includes, but is not limited to, community integrated service networks; health insurance companies, health maintenance organizations, nonprofit health service plan corporations, and other health plan companies; employee health plans offered by self-insured employers; trusts established in a collective bargaining agreement under the federal Labor-Management Relations Act of 1947, United States Code, title 29, section 141, et seq.; the Minnesota Comprehensive Health Association; group health coverage offered by fraternal organizations, professional associations, or other organizations; state and federal health care programs; state and local public employee health plans; workers' compensation plans; and the medical component of automobile insurance coverage. Minnesota Statutes, Section 62J.03, Subd. 8 defines provider or health care provider as follows: 8

9 "Provider" or "health care provider" means a person or organization other than a nursing home that provides health care or medical care services within Minnesota for a fee and is eligible for reimbursement under the medical assistance program under chapter 256B. For purposes of this subdivision, "for a fee" includes traditional feefor-service arrangements, capitation arrangements, and any other arrangement in which a provider receives compensation for providing health care services or has the authority to directly bill a group purchaser, health carrier, or individual for providing health care services. For purposes of this subdivision, "eligible for reimbursement under the medical assistance program" means that the provider's services would be reimbursed by the medical assistance program if the services were provided to medical assistance enrollees and the provider sought reimbursement, or that the services would be eligible for reimbursement under medical assistance except that those services are characterized as experimental, cosmetic, or voluntary. Minnesota Statutes, Section 62J.536, Subd. 3 defines "health care provider" to also include licensed nursing homes, licensed boarding care homes, and licensed home care providers. As described in the beginning of this section, this Minnesota Uniform Companion Guide applies to all professional health care claims submitted electronically after July 15, 2009 that use the transaction standard and corresponding X222A1 described under Code of Federal Regulations, title 45, part 162, subpart K - the ASC X12/005010X222A1 Health Care Claim: Professional (837), herein referred to as X222A1. The Companion Guide applies ONLY to the purposes identified and described in the X222A1 for which the health care claims transaction is used. Entities conducting (e.g., submitting or receiving) professional health care claim transactions electronically via direct data entry system (e.g., internet-based interactive applications) must also comply with the data content requirements established in this Companion Guide. This Companion Guide contains the maximum data set of values allowed to be submitted or received by health care providers and group purchasers when conducting a professional health care claim transaction. No other Data Element values will be allowed to be used in connection with this transaction. If information is submitted on the X222A1 that is needed to adjudicate, then it must be utilized. A group purchaser may not make additional requirements of the provider to submit the information in another format or in a different element or position than that defined in the X222A1 and the Minnesota Companion Guide. Consistent with Minnesota Statutes, 62J.536, no additions or modifications may be made to this Companion Guide by group purchasers or health care providers through their own companion guides or by establishing other requirements Exceptions to Applicability Chapter 305, section 7, of 2008 Minnesota Laws (to be codified as Minnesota Statutes, section 62J.536, subd. 4) authorizes the Commissioner of Health to exempt group purchasers not covered by HIPAA (group purchasers not covered 9

10 under United States Code, title 42, sections 1320d to 1320d-8) from one or more of the requirements to exchange information electronically as required by Minnesota Statutes, 62J.536 if the Commissioner determines that: i. a transaction is incapable of exchanging data that are currently being exchanged on paper and is necessary to accomplish the purpose of the transaction; or ii. another national electronic transaction standard would be more appropriate and effective to accomplish the purpose of the transaction. If group purchasers are exempt from one or more of the requirements, providers shall also be exempt from exchanging those transactions with the group purchaser. The Commissioner has determined that the criteria above are not met and that all health care providers and group purchasers are required to comply with these rules for the standard, electronic exchange of health care claims. No exception to these rules has been granted Scope This Companion Guide covers all the required and situational Loops, Segments and Data Elements contained in the Reference X222A1. This Companion Guide does NOT include any of the Loops, Segments or Data Elements defined as NOT USED in the Reference X222A1. Consistent with the HIPAA requirements and X222A1 instructions, the NOT USED Loops, Segments and Data Elements are not permitted to be submitted or received when conducting this transaction. This Companion Guide excludes any of the EDI transmission instructions, generally defined in trading partner agreement documents. The Interchange Control Header (ISA) and Trailer (IEA), and the Functional Group Header (GS) and Trailer (GE) are not covered by this Companion Guide. The specifications of these Loops, Segments and Data Elements are generally defined in trading partner agreement documents ASC X12/005010X222A1 Health Care Claim: Professional (837) The reference for this Companion Guide is the ASC X12/005010X222A1 Health Care Claim: Professional (837) (Copyright 2008, Data Interchange Standards Association on behalf of ASC X12. Format 2008, Washington Publishing Company. All Rights Reserved). A copy of the full X222A1 can be obtained from the Washington Publishing Company at Key Terminology Used in This Companion Guide 10

11 This Companion Guide treats the required and situational Loops, Segments and Data Elements included in the X222A1 as described in the following sections Required Loops, Segments and Data Elements In some instances, the values and conditions defined in the X222A1 for required Loops, Segments and Data Elements are further clarified by the Companion Guide. Such further clarifications are appropriately noted in the Companion Guide table included in Section 5. Under no circumstance does the Companion Guide add new or different values to those defined in the Reference X222A Situational Loops, Segments and Data Elements The Companion Guide further defines or refines the conditions and values of Situational Loops, Segments and Data Elements to one of the following three possibilities: o o Required, with further definition of condition and/or values: This means that in Minnesota, group purchasers do consider and need this data for proper adjudication of the transaction and that the Loop, Segment and Data Element will be REQUIRED for ALL values further defined in the Minnesota Companion Guide. Situational, with or without further definition of condition: This means that the Loop, Segment or Data Element will retain in the Minnesota Companion Guide the original Situational classification given in the X222A1, and that the Minnesota Companion Guide will follow either: The exact same conditions and values defined in the X222A1 (because the conditions and values are closeended, unambiguous, and straight-forward); or A set of further refined conditions and values applicable to that Situational Loop, Segment or Data Element. o Not Considered for Processing: see next section Segments and Data Elements Classified as Not Considered for Processing (NCFP) Required and Situational Segments and Data Elements may also be classified in the Minnesota Companion Guide as Not Considered for Processing. This means that receivers of this transaction in Minnesota do not consider these Segments or Data Elements necessary for adjudication of the transaction for services covered under this companion guide. 11

12 With respect to these NCFP Segments and Data Elements, the interpretation of this classification will be as follows: o o If the Segment or Data Element is REQUIRED by the X222A1 and the Minnesota Usage in the table included in Section 5 of this Companion Guide is NCFP, then the Segment or Data Element must be sent by the sender and received by the receiver (to meet HIPAA requirements) but the receiver may ignore it for adjudication. If the Segment or Data Element is SITUATIONAL in the X222A1 and the Minnesota Usage in the table included in Section 5 of this Companion Guide is NCFP, then the Segment or Data Element: Will not be required by a receiver May be submitted by a sender Will be accepted by a receiver May be ignored by the receiver for adjudication The receiver will not reject transaction if sender submits this element It is important to note that the parameters of Situational elements in the X222A1 are generally written in a manner that creates a requirement for the element to be used (if such conditions are met). Please refer to the disclaimer in the front matter of this guide Addressing Code Set Issues in the Companion Guide Code sets utilized in HIPAA electronic transactions are classified as: Internal Transaction Codes (included and defined inside the X222A1). The Companion Guide may define a set of values that are identical to or a subset of the values permitted in the X222A1. Within the Companion Guide there are situations where only a subset of values is permitted. As business needs change, additional codes may be defined and made available for use as a best practice. Please refer to Section 4.4 for information on AUC Best Practices. External Code Sets (referenced by X222A1, defined and maintained by external bodies) including: 1) Non-Medical External Code Sets (such as Taxonomy Codes, Claims Adjustment Reason Codes, Remark Codes, etc). These values are effective based upon transaction date; 2) Medical External Code Sets (such as ICD-9, ICD-10, HCPCS). These values are effective based upon service date 12

13 This Companion Guide does not redefine existing external code sets used in the transactions. Rather, the Companion Guide may identify a subset of external codes to be used in specific Loops, Segments and Data Elements of the transaction. For information regarding clarification of medical code set usage see Appendix A Trading Partner Agreements This Companion Guide is not intended to replace trading partner agreements that define other transaction parameters (such as EDI transmission parameters or transaction header information). Trading partner agreements may NOT add or modify the requirements established by this Companion Guide. Trading Partners will exchange the appropriate and necessary identification numbers to be reported in Loops 1000A and 1000B (Submitter and Receiver). 4.2 Information About the Health Care Claim: Professional (837) Transaction Business Terminology 1 For purposes of this Companion Guide, the following terms have the meaning given to them in this section. Definitions used apply at both the claim and line level. For other definitions related to the professional health care claim, please refer to section 1.5 of the X222A1. Provider Definitions Billing Provider The Billing Provider must be a health care or service provider. Information concerning a billing agent or a healthcare clearinghouse may never be reported in the billing provider loop. Please refer to the X222A1 for more billing provider and other types of provider requirements. Billing Provider Name: Titles must not be used as part of the name as there is a separate field to report titles. If enrolled with the payer, the Billing Provider Name must match the enrollment with the payer. Billing Provider Address: 1 Sources: X222A1; National Uniform Billing Committee UB04 Manual. Cited with permission. 13

14 U.S. Postal Addressing Standards the address must meet the U.S. Postal addressing standards. Ordering Provider This is a physician or, when appropriate, a non-physician practitioner who orders non-physician services for the patient. Examples of services that might be ordered include diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, durable medical equipment, and services incident to that physician s or non-physician practitioner s service. Loop 2310A should be used to report the ordering provider when applicable. Pay-To Address Other Definitions The Pay-To Address loop allows the billing provider to indicate a payment address that is different than the billing. For providers who participate with the group purchaser health plan and are required to complete enrollment forms as part of the contracting process, the payment address submitted on the claim transaction may not be the address where payment is ultimately sent for the claim. The payer in this case may use the payment address from the enrollment form or within the contract rather than the address that is submitted in the 2010AB loop of an electronic claim. The contracted provider must request address changes to the payer records according to the instructions within the provider contract. When a Pay-To Address loop is sent in addition to billing provider loop, it is the pay-to loop address where the payment should be sent, unless the payer utilizes an enrollment form or a contract. Factoring Agent Business models exist in the healthcare industry where services are performed by a provider, which are billed to an entity acting as a receivables Factoring Agent. The entity pays the provider directly. The Factoring Agent then bills the insurance company. In this case both the name/address of Pay-To are different than Billing Provider. In order to use the X222A1 for this business situation, X12 recommends that the Factoring Agent entity name, address, and identification be submitted as the Pay-To Plan in loop 2010AC. The notes and guidelines should be followed as if the Pay-To Plan entity was performing post payment recovery as described. Other Payer The term other payer indicates any payer who is not the destination payer. The other payer may be the primary, secondary, tertiary, or even quaternary payer. Patient The term patient as used in this Companion Guide is intended to convey the case where the Patient loop (Loop ID-2000C) is used. In that case, the patient is 14

15 not the same person as the subscriber and can not be uniquely identified separately from the subscriber. However, it also happens that the patient is sometimes the same person as the subscriber. In that case, all information about the patient/subscriber is carried in the Subscriber loop (Loop ID-2000B). See Section 1.5 of the X222A1 for further details. Pay-To Plan In addition to the definition in the X222A1, business models exist in the healthcare industry where services are performed by a provider, which are billed to an entity acting as a receivables Factoring Agent. The entity pays the provider directly. The Factoring Agent then bills the insurance company. In this case both the name and address of Pay-To are different than the Billing Provider. The Factoring Agent name will be placed in the Pay-To Plan loop. Subscriber The subscriber is the person or entity whose name is listed on the insurance policy. Other synonymous terms include member and/or insured. In some cases the subscriber is the same person as the patient. See the definition of patient, and see Section 1.5 of the X222A1 for further details Provider Identifiers and NPI Assignments Provider Identifiers If the provider is a health care provider as defined under federal standards, then the only identifier that is valid is the NPI with the exception of the billing loop. For the billing provider, a secondary identifier of the TIN is also required. If the provider is not a health care provider as defined under federal standards they are known as atypical providers. Atypical providers do meet the Minnesota statutory definition of health care provider and therefore are required to utilize the electronic administrative transactions for eligibility, claims and remittance advices. For atypical providers, the primary identifier is the TIN and a secondary identifier is allowable. The qualifier for the secondary identifier is G2. The identifier for this qualifier would be the specific payer assigned/required identifier Minnesota Requirements for Compliance This section contains general Minnesota requirements for compliance applicable to this transaction Handling Adjustments and Appeals Determination of Action: 15

16 When determining whether to resubmit a claim as an original, request an adjustment or request an appeal, first determine whether the payer has accepted and adjudicated the original claim submission. If the original submission was not accepted into the payer adjudication system, resubmit the claim as an original. This is not considered to be an adjustment. If the original submission was accepted into the payer adjudication system, see definitions below to determine whether an adjustment or appeal should be requested. Definitions: Adjustment Provider has additional data that should have been submitted on the original claim or has a need to correct data that was sent incorrectly on the original claim. Appeal Provider is requesting a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted. Therefore the submission of the appeal is not covered by this guide. Examples of Appeals include: o o o o o o Timely filing denial Payer allowance Incorrect benefit applied Eligibility issues Benefit Accumulation Errors Medical Policy / Medical Necessity Process for submission: Adjustment Provider should submit an adjustment electronically using the appropriate value in CLM05-3 to indicate that this is a replacement claim. If the payer has assigned a payer number to the claim, it must be submitted in loop 2300, REF02, using qualifier F8 in REF01 (Note: the original payer-assigned claim number is not the property and casualty number). If additional information is required to support the adjustment based on payer business rules, the SV101-7, NTE segment, PWK segment, or Condition Codes should be used. See section below regarding these segments for appropriate instructions. Appeal Follow payer standard processes for requesting an appeal to a previously adjudicated claim. If paper appeal process is utilized, then a standard, Best Practice Minnesota appeal form is available at the AUC website at Additional documentation should be sent as required by the payer to support the appeal consideration; this documentation does not include resubmission of the claim Claim Frequency Type Code (CFTC) Values 16

17 Claim/Bill submissions are often original, first time submissions with no follow-up submissions. In some cases, subsequent submissions directly related to a prior submission will be necessary. When subsequent submissions occur, for legitimate business purposes, the normal processing flow may change. Since a relationship between an original submission and subsequent submissions are necessary, the data requirements both for original and subsequent submissions must be specified. For example, when a Replacement bill is submitted (CFTC 7), in order to meet the processing requirement to void the original and replace it with the re-submitted bill, common consistent data elements would be required. To qualify as a Replacement, some data would need to be different than the original. If the bill is re-submitted with no changes from the original, and the claim was accepted by the payer, this would be considered a Duplicate instead of a Replacement. If the bill is resubmitted with no changes from the original and the original was not accepted by the payer, this will be considered an original claim. These distinctions are important to allow for proper handling of the submission. Refer to the current National Uniform Billing Committee (NUBC) code list for allowed values and usage descriptions. Both the sender and receiver must understand how each code value should be interpreted and what processing requirements need to be applied. In conjunction with the CFTC code values, Condition Codes may be submitted that will impact processing and handling requirements. For example, a Replacement bill (CFTC 7) may also contain a Condition Code D0 indicating service dates have been changed Claim Attachments and Notes Use the NTE segment at the claim or line level to provide free-form text of additional information. The NTE segment must not be used to report data elements that are codified within this transaction. If reporting a simple description of the service is required, such as when a non-specific code is being reported, the SV101-7 in the 2400 loop must be used. Do not exceed the usage available in the X222A1. Be succinct and abbreviate when possible. Do not repeat code descriptions or unnecessary information. If the NTE segment must be exceeded, or a hard copy document sent, use the PWK segment at the claim level. If the number of characters for the NTE or SV101-7 will exceed available characters, use only the PWK segment at the claim level. When populating the PWK segment, the following guidelines must be followed: o PWK01 - Attachment Report Type Code is a required element: The qualifier value of OZ should only be used if none of the other values apply. The most specific qualifier value must be utilized. 17

18 o PWK06 - Attachment Control Number is a situational element that is required if the transmission type is anything other than available upon request. This value is used to identify the attachment. Billing providers must use a unique number for this field for each individual attachment on the claim, as well as, a unique number across all claims requiring attachments. This unique number identifies a specific attachment within the billing providers system. This unique number is the key that associates the attachment to the claim. The number must be sent in PWK06 of the claim and with the attachment. The provider must not use the same number on any other claim in their system to identify different attachments. 4.3 Process for Updating Companion Guide Document The process for updating Minnesota Uniform Companion Guide documents, including submitting and collecting change requests, reviewing and evaluating requests and making recommendations, adopting and publishing a new version of the guide is available from the Minnesota Department of Health s website at Minnesota Best Practices for the Implementation of Electronic Health Care Transactions The Minnesota Administrative Uniformity Committee (MN AUC) is continuously working on the identification of Best Practices for the implementation of administrative transactions and processes. Although they are not required as part of this Companion Guide, they are helpful in aiding payers and providers in implementing these transactions. Please visit the MN-AUC website at for more information about Best Practices for implementing electronic health care transactions in Minnesota. 18

19 5.0 ASC X12/005010X222A1 Health Care Claim: Professional (837) - Minnesota Uniform Companion Guide Table Introduction to Table All the information related to the way this Companion Guide classifies and defines required and situational Data Elements is presented in a table format in the next sections. The table is organized by Loops and Segments, to make it easier to review and locate. The table includes the following: o o ALL of the Loops, Segments and Data Elements that are classified as REQUIRED by the X222A1 (except as noted in Section Compressing Data Element Rows into Segment Rows below) ALL of the Loops, Segments and Data Elements that are classified as SITUATIONAL by the X222A1 (except as noted in Section Compressing Data Element Rows into Segment Rows below) The table DOES NOT include any of the Loops, Segments or Data Elements classified as NOT USED by the X222A1. The table is organized into the following columns: o o Segment and Data Element Information: The ID, NAME, USAGE and X222A1 VALUES given to Segments and Data Elements on the X222A1 Minnesota Information: Minnesota Usage - The only permitted values are: R for Required S for Situational NCFP for Not Considered for Processing Values, Definition and Notes: The specific values and other notes applicable to the Segment/Data Element required to be followed in Minnesota. If Minnesota values have been limited to a subset of values, additional HIPAA compliant values will be considered NCFP. MN Usage Same as X222A1: If checked, it means that the Minnesota Companion Guide conditions, values and notes for the Segment or Data Element are identical to the conditions, values and notes from the X222A1 A single row (with no column separators) across the entire table designates a transaction Loop. Segment rows are noted with a light gray background Compressing Data Element Rows into Segment Rows 19

20 In preparing the companion guides, some compression or collapsing of Data Element rows into Segment rows has been done to simplify the size and content of the document. This compression or collapsing was done as follows: If the Minnesota Usage classification of a Segment and its Data Elements are ALL IDENTICAL with the X222A1, then the Data Element rows for that Segment are NOT included in these tables and only the Segment-level row is presented Relationship Between Condition Given to Segments and Data Elements in the X222A1 and the Minnesota Usage Classification Given in this Companion Guide A summary of the seven (7) scenarios that could occur in the companion guide when relating the following three elements are presented in the table below: 1. The condition that a Loop, Segment or Data Element has in the original X222A1 (Required or Situational) 2. The Minnesota Usage as defined by the companion guide development teams (Required; Situational; Not Considered for Processing) 3. Whether the Minnesota Usage and Notes are identical to the X222A1 Table 1 Seven Specific Minnesota Companion Guide Scenarios for Minnesota-defined Usage of Loops, Segments and Data Elements Condition of Loop/ Segment/Data Element from X222A1 Minnesota Usage Classification Companion Guide Minnesota Notes about Usage 1. Required Required Same as X222A1 2. Required Required Further clarifies the X222A1 3. Required NCFP (Not Considered for Processing) Same as X222A1 4. Situational Required Further defines the requirements from the X222A1 5. Situational Situational Same as X222A1 6. Situational Situational Further refines the requirements from the X222A1 7. Situational NCFP (Not Considered for Processing) Same as X222A1 20

21 5.2 Companion Guide Table Please note: Table 5.2 below references the ASC X12/005010X221A1 Health Care Claim Payment/Advice (835) transaction as 835. Minnesota Uniform Companion Guide for the Implementation of the ASC/X X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e X222A1 Values Usage Values, Definition and Notes MN Usage Same as X222A1 ST - TRANSACTION SET HEADER (Loop Repeat: 1) ST Transaction Set Header R R X BHT - BEGINNING OF HIERARCHICAL TRANSACTION (Loop Repeat: 1) BHT Beginning of Hierarchical Transaction R R X LOOP ID A SUBMITTER NAME (Loop Repeat: 1) NM1 Submitter Name R R X PER Submitter EDI Contact Information R R X LOOP ID B RECEIVER NAME (Loop Repeat: 1) NM1 Receiver Name R R X LOOP ID A BILLING PROVIDER HIERARCHICAL LEVEL (Loop Repeat: >1) HL Billing Provider Hierarchical Level R R X PRV Billing Provider Specialty Information S S X CUR Foreign Currency Information S NCFP X LOOP ID AA BILLING PROVIDER NAME (Loop Repeat: 1) NM1 Billing Provider Name R R See front matter Section for definition and usage of billing information. N3 Billing Provider Address R R X N4 Billing Provider City, State, ZIP Code R R X REF Billing Provider Tax Identification R R X REF Billing Provider UPIN/License Information R NCFP X PER Billing Provider Contact Information S S X LOOP ID AB PAY-TO ADDRESS NAME (Loop Repeat: 1) NM1 Pay-to Address Name S S See front matter Section for definition and usage of pay-to information. N3 Pay-to Address-Address R R X N4 Pay-To Address City, State, ZIP Code R R X LOOP ID AC PAY-TO PLAN NAME (Loop Repeat: 1) NM1 Pay-To Plan Name S S See front matter Section for definition and usage of pay-to plan information. N3 Pay-to Plan Address R R X N4 Pay-To Plan City, State, ZIP Code R R X REF Pay-to Plan Secondary Identification S S X REF Pay-To Plan Tax Identification Number R R X LOOP ID B SUBSCRIBER HIERARCHICAL LEVEL (Loop Repeat: >1) HL Subscriber Hierarchical Level R R X SBR Subscriber Information R R X 21

22 Minnesota Uniform Companion Guide for the Implementation of the ASC/X X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e X222A1 Values Usage Values, Definition and Notes MN Usage Same as X222A1 SBR01 Payer Responsibility Sequence Number Code R A, B, C, D, E, F, G, H, P, S, T, U R Do not send claims to secondary, tertiary, or any subsequent payer until previous payer(s) has processed. SBR02 Individual Relationship Code S 18 S X SBR03 Subscriber Group or Policy Number S S X SBR04 Subscriber Group Name S S X SBR05 Insurance Type Code S 12, 13, 14, 15, 16, 41, 42, 43, 47 S X SBR09 Claim Filing Indicator Code S 11, 12, 13, 14, 15, 16, 17, AM, BL, CH, CI, DS, FI, HM, LM, MA, S X MB, MC, OF, TV, VA, WC, ZZ PAT Patient Information S S X PAT05 Date Time Period Format Qualifier S D8 S X PAT06 Patient Death Date S S X PAT07 Unit or Basis for Measurement Code S 01 S X PAT08 Patient Weight S S X PAT09 Pregnancy Indicator S Y NCFP X LOOP ID BA SUBSCRIBER NAME (Loop Repeat: 1) NM1 Subscriber Name R R X NM101 Entity Identifier Code R IL R X NM102 Entity Type Qualifier R 1, 2 R X NM103 Name Last or Organization Name R R For Workers' Compensation this is the employer name. For Property & Casualty this may be a non-person. NM104 Name First S S X NM105 Name Middle S S X NM107 Name Suffix S S X NM108 Identification Code Qualifier S II, MI S X NM109 Identification Code S S X N3 Subscriber Address S S X N4 Subscriber City, State, ZIP Code S S X DMG Subscriber Demographic Information S S X DMG01 Date Time Period Format Qualifier R D8 R X DMG02 Subscriber Birth Date R R Services to unborn children should be billed under the mother as the patient. DMG03 Subscriber Gender Code R F, M, U R X REF Subscriber Secondary Identification S NCFP X REF Property and Casualty Claim Number S S X PER Property and Casualty Subscriber Contact Information S S X LOOP ID BB PAYER NAME (Loop Repeat: 1) NM1 Payer Name R R X N3 Payer Address S NCFP X 22

23 Minnesota Uniform Companion Guide for the Implementation of the ASC/X X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e X222A1 Values Usage Values, Definition and Notes MN Usage Same as X222A1 N4 Payer City, State, ZIP Code S NCFP X REF Payer Secondary Identification S NCFP X REF Billing Provider Secondary Identification S S REF01 Reference Identification Qualifier R G2, LU R Use G2 for atypical providers. REF02 Reference Identification R R X LOOP ID C PATIENT HIERARCHICAL LEVEL (Loop Repeat: >1) HL Patient Hierarchical Level S S X PAT Patient Information R R X LOOP ID CA PATIENT NAME (Loop Repeat: 1) NM1 Patient Name R R X N3 Patient Address R R X N4 Patient City, State, ZIP Code R R X DMG Patient Demographic Information R R X DMG01 Date Time Period Format Qualifier R D8 R X DMG02 Patient Birth Date R R Services to unborn children should be billed under the mother as the patient. DMG03 Patient Gender Code R F, M, U R X REF Property and Casualty Claim Number S S X REF Property and Casualty Patient Identifier S S X PER Property and Casualty Patient Contact Information S S X LOOP ID CLAIM INFORMATION (Loop Repeat: 100) CLM Claim Information R R X CLM01 Claim Submitter's Identifier R R X CLM02 Monetary Amount R R X CLM05 HEALTH CARE SERVICE LOCATION INFORMATION R R X CLM05-1 Facility Code Value R See Code Source 237 R X CLM05-2 Facility Code Qualifier R B R X CLM05-3 Claim Frequency Type Code R See Code Source 235 R See front matter section for definitions. CLM06 Yes/No Condition or Response Code R N, Y R X CLM07 Provider Accept Assignment Code R A, B, C R X CLM08 Yes/No Condition or Response Code R N, W, Y R X CLM09 Release of Information Code R I, Y R X CLM10 Patient Signature Source Code S P S X CLM11 RELATED CAUSES INFORMATION S S X CLM11-1 Related Causes Code R AA, EM, OA R X CLM11-2 Related Causes Code S AA, EM, OA S X CLM11-4 State or Province Code S S X CLM11-5 Country Code S S X CLM12 Special Program Code S 02, 03, 05, 09 S X CLM20 Delay Reason Code S If code 11 (Other) is used, additional 1, 2, 3, 4, 5, 6, 7, 8, 9, S documentation is 10, 11, 15 required using NTE or PWK,.. Refer to 23

24 Minnesota Uniform Companion Guide for the Implementation of the ASC/X X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e X222A1 Values Usage Values, Definition and Notes MN Usage Same as X222A1 section for usage. If CLM20 value of 11 is used, PWK02 must not be a value of AA. DTP Date - Onset of Current Illness or Symptom S S X DTP Date - Initial Treatment Date S S X DTP Date - Last Seen Date S NCFP X DTP Date - Acute Manifestation S S X DTP Date - Accident S S X DTP Date - Last Menstrual Period S S X DTP Date - Last X-ray Date S S X DTP Date - Hearing and Vision Prescription Date S S X DTP Date - Disability Dates S S X DTP Date - Last Worked S S X DTP Date - Authorized Return to Work S S X DTP Date - Admission S S X DTP Date - Discharge S S X DTP Date - Assumed and Relinquished Care Dates S S X DTP Date - Property and Casualty Date of First Contact S S X DTP Date - Repricer Received Date S NCFP X PWK Claim Supplemental Information S S See front matter Section for definition. PWK01 Report Type Code R 03, 04, 05, 06, 07, 08, 09, 10, 11, 13, 15, 21, A3, A4, AM, AS, B2, B3, B4, BR, BS, BT, CB, CK, CT, D2, DA, DB, DG, DJ, DS, EB, HC, HR, I5, IR, LA, M1, R X MT, NN, OB, OC, OD, OE, OX, OZ, P4, P5, PE, PN, PO, PQ, PY, PZ, RB, RR, RT, RX, SG, V5, XP PWK02 Report Transmission Code R Use of AA value may result in a delay in claim payment. If an AA, BM, EL, EM, FT, R attachment is known FX to be needed by the payer it should be sent. PWK05 Identification Code Qualifier S AC S X PWK06 Identification Code S S X CN1 Contract Information S S X AMT Patient Amount Paid S S X AMT01 Amount Qualifier Code R F5 R X AMT02 Monetary Amount R R Must not exceed total 24

25 Minnesota Uniform Companion Guide for the Implementation of the ASC/X X222A1 Health Care Claim: Professional (837) SEGMENT DATA ELEMENT Minnesota Information ID Name U s a g e X222A1 Values Usage Values, Definition and Notes MN Usage Same as X222A1 claim charge amount in CLM02. REF Service Authorization Exception Code S NCFP X REF Mandatory Medicare (Section 4081) Crossover Indicator S NCFP X REF Mammography Certification Number S S X REF Referral Number S S X REF Prior Authorization S S X REF Payer Claim Control Number S S If the original payer assigned claim number is obtained from the 835, it corresponds to CLP07. REF Clinical Laboratory Improvement Amendment (CLIA) Number S S X REF Repriced Claim Number S NCFP X REF Adjusted Repriced Claim Number S NCFP X REF Investigational Device Exemption Number S S X REF Claim Identifier For Transmission Intermediaries S S X REF Medical Record Number S S X REF Demonstration Project Identifier S S X REF Care Plan Oversight S S X K3 File Information S S See Appendix B for usage instructions. NTE Claim Note S S See front matter Section for definition. CR1 Ambulance Transport Information S S X CR2 Spinal Manipulation Service Information S NCFP X CRC Ambulance Certification S S X CRC Patient Condition Information: Vision S NCFP X CRC Homebound Indicator S NCFP X CRC EPSDT Referral S S Required for Medicaid Programs when service is rendered under the Minnesota Child and Teen Checkup Programs. HI Health Care Diagnosis Code R R X HI Anesthesia Related Procedure S S X HI Condition Information S S X HCP Claim Pricing/Repricing Information S NCFP X LOOP ID A REFERRING PROVIDER NAME (Loop Repeat: 2) NM1 Referring Provider Name S S X REF Referring Provider Secondary Identification REF01 Reference Identification Qualifier R 0B, 1G, G2 R S S See front matter Section for usage. Use G2 for atypical providers. 25