Minnesota Uniform Companion Guide. Health Care Claim - Dental Electronic Transaction (ANSI ASC X12 837D)

Transcription

1 MINNEOTA DEPATMENT OF HEALTH DIVIION OF HEALTH POLICY CENTE FO HEALTH CAE PCHAING IMPOVEMENT Minnot niform Compnion Guid For th Implmnttion of th Hlth Cr Clim - Dntl Elctronic Trnction (ANI AC X12 837D) Prprd In Conulttion With Minnot Adminitrtiv niformity Committ MACH, 2009 VEION 4.0

2 Diclimr Th followin Minnot niform Compnion Guid i intndd to rv compnion documnt to th corrpondin HIPAA Implmnttion Guid ANI AC X12N Elctronic Trnction tndrd (Vrion X097A1). Th documnt furthr pcifi th rquirmnt to b ud whn prprin, ubmittin, rcivin nd procin lctronic hlth cr dminitrtiv dt. Th documnt upplmnt, but do not contrdict, dir, oppo, or othrwi modify th HIPAA Implmnttion Guid in mnnr tht will mk it implmnttion by ur to b out of complinc. in thi Compnion Guid do not mn tht clim will b pid. It do not imply pymnt polici of pyr or th bnfit tht hv bn purchd by th mployr or ubcribr. ttutory Authority Dvlopmnt, doption nd u of thi compnion uid i mndtd for ll roup purchr nd hlth cr providr undr Minnot ttut, 62J.536. Th rquird u of thi Minnot niform Compnion Guid w promultd rul undr Minnot ttut, 62J.61. Documnt Chn Th contnt of thi compnion uid i ubjct to chn. Th vrion, rl nd ffctiv dt of th documnt i includd in th documnt, wll dcription of th proc for hndlin futur updt or chn. About th Minnot Dprtmnt of Hlth Th Minnot Dprtmnt of Hlth i rponibl for protctin, mintinin nd improvin th hlth of Minnotn. Th dprtmnt oprt prorm in th r of di prvntion nd control, hlth promotion, community public hlth, nvironmntl hlth, hlth cr policy, nd ritrtion of hlth cr providr. About th Minnot Adminitrtiv niformity Committ Th Adminitrtiv niformity Committ (AC) i brod-bd roup rprntin Minnot hlth cr public nd privt pyr, hopitl, hlth cr providr nd tt nci. Th miion of th AC i to dvlop rmnt mon Minnot pyr nd providr on tndrdizd dminitrtiv proc whn implmnttion of th proc will rduc dminitrtiv cot. Th AC ct conultin body to vriou public nd privt ntiti, but do not formlly rport to ny orniztion nd i not ttutory committ. Contct for Furthr Informtion on thi Compnion Guid Minnot Dprtmnt of Hlth Diviion of Hlth Policy Cntr for Hlth Cr Purchin Improvmnt P.O. Box t. Pul, Minnot Phon: (651) Fx: (651) Intrnt: hlth.aauid@tt.mn.u Copyriht 2007 By Th Minnot Dprtmnt of Hlth, tt of Minnot

3 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction TABLE OF CONTENT P 1.0 COMPANION GE EVIION HITOY TATEMENT FOM THE MINNEOTA DEPATMENT OF HEALTH TATEMENT FOM THE MINNEOTA ADMINITATIVE NIFOMITY COMMITTEE (MN-AC) INTODCTION AND OVEVIEW PPOE AND OVEVIEW INFOMATION ABOT THE 837D HEALTH CAE CLAIM DENTAL TANACTION POCE FO PDATING COMPANION GE DOCMENT MINNEOTA BET PACTICE FO THE IMPLEMENTATION OF ELECTONIC HEALTH CAE TANACTION D HEALTH CAE CLAIM DENTAL: COMPANION GE TABLE INTODCTION TO TABLE COMPANION GE TABLE APPENDICE 44 APPENDIX A: CODE ET PPLEMENTAL INFOMATION FO MINNEOTA COMPANION GE 45 APPENDIX B: DATE EPOTED IN THE 837 DENTAL TANACTION 47 APPENDIX C: EGMENT EPOTING MLTIPLE VALE FOM AME CODE ET 48 APPENDIX D: EPOTING MNCr TAX AND ALE TAX 49 3

4 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction 1.0 Compnion Guid viion Hitory Vr viion Dt ummry Chn 1.0 Mrch 31, 2008 Vrion ld for Public Commnt 2.0 Jun 16, 2008 Finl Publihd Vrion for Implmnttion 3.0 Dcmbr 22, 2008 Tchnicl Chn Vrion ld for Public Commnt 4.0 Mrch 23, 2009 Finl Publihd Vrion with Tchnicl Chn for Implmnttion 4

5 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Protctin, mintinin nd improvin th hlth of ll Minnotn 2.0 ttmnt from th Minnot Dprtmnt of Hlth ummry Notic of Adoption of ul rdin niform, tndrd Compnion Guid for Hlth Cr Clim Elctronic Trnction; Purunt to Minnot ttut, ction 62J.536. Adoption: Notic i hrby ivn tht th Minnot niform Compnion Guid for th Implmnttion of th: Hlth Cr Clim Profionl Elctronic Trnction (837P); Hlth Cr Clim Intitutionl Elctronic Trnction (837I); Hlth Cr Clim Dntl Elctronic Trnction (837D); NCPDP Phrmcy Clim ubmiion nd pon [NCPDP 5.1 (nd th corrpondin NCPDP 1.1)]; nd NCPDP Phrmcy vrl ubmiion nd pon [NCPDP 5.1 (nd th corrpondin NCPDP 1.1 )]; propod t tt of Minnot tt itr, Volum 32, Numbr 40, p 1821, dtd Mrch 31, 2008 ( ) r doptd with modifiction. Compnion Guid Avilbl: Th Minnot niform Compnion Guid for th Implmnttion of th: Hlth Cr Clim Profionl Elctronic Trnction (837P); Hlth Cr Clim Intitutionl Elctronic Trnction (837I); Hlth Cr Clim Dntl Elctronic Trnction (837D); NCPDP Phrmcy Clim ubmiion nd pon [NCPDP 5.1 (nd th corrpondin NCPDP 1.1)]; nd NCPDP Phrmcy vrl ubmiion nd pon [NCPDP 5.1 (nd th corrpondin NCPDP 1.1 )]; dfind by th Commiionr of Hlth, r vilbl on th World Wid Wb t nd t Minnot Booktor t (651) or (800) Th Minnot Booktor TTY rly rvic phon numbr i (800) If you hv ny qution, pl mil hlth.aaguid@tt.mn.u. Th doptd rul diffr from th rul propod on Mrch 31, A complt copy of th rul howin ll of th chn in trik/undrlin formt i vilbl t: Intrtd prti my lo obtin printd copy of th rul howin ll of th chn in trik/undrlin formt by contctin Colln Mor by phon t or by fx t Dcription nd ttutory frnc: Th Minnot niform Compnion Guid for Hlth Cr Clim Elctronic Trnction r th inl, uniform compnion uid to th implmnttion uid dcribd undr th Cod of Fdrl ultion, titl 45, prt 162, * P.O. Box * int Pul, Minnot * Gnrl Informtion: (651) * TDD/TTY: (651) * Minnot ly rvic: (800) * For dirction to ny of th MDH loction, cll (651) * An qul opportunity mployr 5

6 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction dvlopd purunt to Minnot ttut, ction 62J.536. Th ttut rquir tht binnin July 15, 2009 ll roup purchr mut ccpt from hlth cr providr th hlth cr clim or quivlnt ncountr informtion trnction dcribd undr Cod of Fdrl ultion, titl 45, prt 162, ubprt K. Th ttut lo rquir tht binnin July 15, 2009, ll hlth cr providr mut ubmit to roup purchr th hlth cr clim or quivlnt ncountr informtion trnction dcribd undr Cod of Fdrl ultion, titl 45, prt 162, ubprt K. Th hlth cr clim or quivlnt ncountr informtion trnction i th trnmiion of ithr of th followin: () A rqut to obtin pymnt, nd th ncry ccompnyin informtion from hlth cr providr to hlth pln, for hlth cr. (b) If thr i no dirct clim, bcu th rimburmnt contrct i bd on mchnim othr thn chr or rimburmnt rt for pcific rvic, th trnction i th trnmiion of ncountr informtion for th purpo of rportin hlth cr. Minnot ttut, ction 62J.536, furthr rquir tht ch trnction dcribd bov hll u inl, uniform compnion uid to th implmnttion uid dcribd undr th Cod of Fdrl ultion, titl 45, prt 162. In ddition, th ttut rquir ll roup purchr nd hlth cr providr to xchn clim nd liibility informtion lctroniclly uin th trnction, compnion uid, implmnttion uid, nd timlin t forth in ubdiviion 1 of th ttut. Th ttut rquir th Commiionr of Hlth to promult rul purunt to ction 62J.61, t lt 12 month prior to th timlin rquird in ubdiviion 1 of Minnot ttut, ction 62J.536. ndr Minnot ttut, ction 62J.61, th Commiionr of Hlth i xmpt from chptr 14, includin ction , in implmntin ction 62J.50 to 62J.54, ubdiviion 3, nd 62J.56 to 62J.59. Dvlopmnt: Th Commiionr of Hlth dvlopd thi rul in conulttion with th Minnot Adminitrtiv niformity Committ (AC) nd th followin AC Tchnicl Adviory Group (TAG) nd Work Group: Clim Dt Dfinition TAG; MN Intitutionl Clim (837I) nd Profionl Clim (837P) Work Group; MN Dntl Clim (837D) Work Group; MN Phrmcy Clim (NCPCP 5.1) Work Group; nd th Mdicl Cod TAG. Thi rul w ubmittd for public commnt in th tt itr, Volum 32, Numbr 40, p 1821, dtd Mrch 31, 2008 ( ). Th commnt priod w from Mrch 31, 2008 until April 29, Th Minnot Dprtmnt of Hlth collctd th public commnt. Commnt wr rcivd from vnty-two individul nd orniztion. Th Minnot Dprtmnt of Hlth conultd with th AC nd th followin Tchnicl Adviory Group (TAG) nd Work Group in rviwin commnt nd mkin modifiction to th rul propod on Mrch 31, 2008: Clim Dt Dfinition TAG; MN Intitutionl Clim (837I) nd Profion Clim (837P) Work Group; MN Dntl Clim (837D) Work Group; MN Phrmcy Clim (NCPCP 5.1) Work Group; nd th Mdicl Cod TAG. quird Dt of Complinc: Th rquird dt of complinc i July 15, Dtd: Jun 16, 2008 nn Mnn, M.D., Ph.D. Commiionr P.O. Box t. Pul, MN

7 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction 3.0 ttmnt from th Minnot Adminitrtiv niformity Committ (MN-AC) Adminitrtiv niformity Committ C/O Minnot Dprtmnt of Hlth P.O. Box t. Pul, MN hlth.uc@tt.mn.u Mrch 2008 Th 2007 Minnot Liltur mndd th Minnot Hlth Cr Adminitrtiv implifiction Act (Minnot ttut, 62J.50-62J.61) by ddin 62J.536, ntitld niform Elctronic Trnction nd Implmnttion Guid tndrd. Thi ction rquir ll roup purchr nd hlth cr providr to lctroniclly trnmit nd ccpt liibility vrifiction, clim nd rmittnc dvic trnction uin inl uniform compnion uid. Th Commiionr of Hlth i rquird to b th compnion uid billin, codin rul, nd tndrd on th Mdicr prorm nd to conult with th Minnot Adminitrtiv niformity Committ (AC) in th dvlopmnt of th uniform compnion uid. Th AC i brod-bd roup rprntin Minnot hlth cr public nd privt roup purchr, hopitl, phyicin, othr providr nd tt nci. Th ol of th AC i to rduc dminitrtiv cot for both pyr nd providr by tndrdizin thir dminitrtiv proc nd rquirmnt. Th AC i md up of trtic trin Committ, n Oprtion Committ, nd vriou Tchnicl Adviory Group (TAG), nd Work Group. Minnot ttut, 62J.536 build upon Minnot lrdy inificnt ldrhip in hlth cr dminitrtiv implifiction. Th AC i confidnt tht th Minnot pproch will provid mor fficint communiction of dminitrtiv hlth cr informtion btwn pyr nd providr throuhout th tt. Thi Hlth Cr Clim - Dntl Trnction Compnion Guid w dvlopd by th Clim/Dt Dfinition TAG nd it 837D Work Group. Cro-rfrnc work w don with th othr 837 Workroup (Intitutionl nd Profionl). A prt of it rponibility of conulttion, th AC Oprtion Committ prntd rcommndtion for contnt of thi Minnot Compnion Guid to th Commiionr of Hlth on Mrch 11, Th AC lo rcommndd tht thi compnion uid b rviwd nd updtd pproximtly vry 12 month or mor oftn if dmd ncry by th Commiionr of Hlth in conulttion with th AC. Th AC will continu to work in prtnrhip with th Commiionr of Hlth to improv th clrity nd ufuln of th mnul. 7

8 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction 4.0 Introduction nd Ovrviw 4.1 Purpo nd Ovrviw Purpo Th purpo of thi Compnion Guid i to clrify, upplmnt nd furthr dfin pcific dt contnt rquirmnt to b ud in conjunction with th HIPAA 837D Hlth Cr Clim Dntl Implmnttion Guid crtd for th lctronic trnction tndrd mndtd by th HIPAA rultion. Th trm compnion uid, uid, tt compnion uid nd tt uid r ud intrchnbly throuhout thi documnt to rfr to ch inl, uniform compnion uid bin crtd purunt to Minnot ttut, 62J Applicbility Effctiv July 15, 2009, ll roup purchr licnd or doin buin in Minnot nd hlth cr providr providin rvic for f in Minnot mut xchn hlth cr clim lctroniclly uin th trnction, compnion uid, implmnttion uid, nd timlin rquird undr Minnot ttut, ction 62J.536. Th only xcption to th ttutory rquirmnt r follow: Th rquirmnt do NOT pply to th xchn of hlth cr clim trnction with Mdicr nd othr pyr for Mdicr product; nd ction Excption to Applicbility blow. Minnot ttut, ction 62J.03, ubd. 6 dfin roup purchr follow: "Group purchr" mn pron or orniztion tht purch hlth cr rvic on bhlf of n idntifid roup of pron, rrdl of whthr th cot of covr or rvic i pid for by th purchr or by th pron rcivin covr or rvic, furthr dfind in rul doptd by th commiionr. "Group purchr" includ, but i not limitd to, community intrtd rvic ntwork; hlth inurnc compni, hlth mintnnc orniztion, nonprofit hlth rvic pln corportion, nd othr hlth pln compni; mploy hlth pln offrd by lf-inurd mployr; trut tblihd in collctiv brinin rmnt undr th fdrl Lbor-Mnmnt ltion Act of 1947, nitd tt Cod, titl 29, ction 141, t q.; th Minnot Comprhniv Hlth Aocition; roup hlth covr offrd by frtrnl orniztion, profionl ocition, or othr orniztion; tt nd fdrl hlth cr prorm; tt nd locl public mploy hlth pln; workr' compntion pln; nd th mdicl componnt of utomobil inurnc covr. 8

9 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Minnot ttut, ction 62J.03, ubd. 8 dfin providr or hlth cr providr follow: "Providr" or "hlth cr providr" mn pron or orniztion othr thn nurin hom tht provid hlth cr or mdicl cr rvic within Minnot for f nd i liibl for rimburmnt undr th mdicl itnc prorm undr chptr 256B. For purpo of thi ubdiviion, "for f" includ trditionl ffor-rvic rrnmnt, cpittion rrnmnt, nd ny othr rrnmnt in which providr rciv compntion for providin hlth cr rvic or h th uthority to dirctly bill roup purchr, hlth crrir, or individul for providin hlth cr rvic. For purpo of thi ubdiviion, "liibl for rimburmnt undr th mdicl itnc prorm" mn tht th providr' rvic would b rimburd by th mdicl itnc prorm if th rvic wr providd to mdicl itnc nroll nd th providr ouht rimburmnt, or tht th rvic would b liibl for rimburmnt undr mdicl itnc xcpt tht tho rvic r chrctrizd xprimntl, comtic, or voluntry. Minnot ttut, ction 62J.536, ubd. 3 dfin "hlth cr providr" to lo includ licnd nurin hom, licnd bordin cr hom, nd licnd hom cr providr. A dcribd in th binnin of thi ction, thi Minnot niform Compnion Guid ppli to ll dntl hlth cr clim ubmittd lctroniclly ftr July 15, 2009 tht u th trnction tndrd nd corrpondin implmnttion uid dcribd undr Cod of Fdrl ultion, titl 45, prt 162, ubprt K - th ANI AC X12N 837D, hrin rfrrd to frnc HIPAA Implmnttion Guid. Th Compnion Guid ppli ONLY to th purpo idntifid nd dcribd in th HIPAA Implmnttion Guid for which th hlth cr clim trnction i ud. Th Compnion Guid my b doptd voluntrily by trdin prtnr prior to July 15, Entiti conductin (.., ubmittin or rcivin) dntl clim trnction lctroniclly vi dirct dt ntry ytm (.., intrnt-bd intrctiv ppliction) mut lo comply with th dt contnt rquirmnt tblihd in thi Compnion Guid. Thi Compnion Guid contin th mximum dt t of vlu llowd to b ubmittd or rcivd by hlth cr providr nd roup purchr whn conductin dntl hlth cr clim trnction. No othr Dt Elmnt vlu will b llowd to b ud in connction with thi trnction. If informtion i ubmittd on th 837 dntl clim trnction tht i ndd to djudict, thn it mut b utilizd. A roup purchr my not mk dditionl rquirmnt of th providr to ubmit th informtion in nothr formt or in diffrnt lmnt or poition within th 837 thn tht dfind in th HIPAA Implmnttion Guid nd th Minnot Compnion Guid. Conitnt with Minnot ttut, 62J.536, no ddition or modifiction my b md to thi Compnion Guid by roup purchr or hlth cr providr throuh thir own compnion uid or by tblihin othr rquirmnt. 9

10 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Excption to Applicbility Chptr 305, ction 7, of 2008 Minnot Lw (to b codifid Minnot ttut, ction 62J.536, ubd. 4) uthoriz th Commiionr of Hlth to xmpt roup purchr not covrd by HIPAA (roup purchr not covrd undr nitd tt Cod, titl 42, ction 1320d to 1320d-8) from on or mor of th rquirmnt to xchn informtion lctroniclly rquird by Minnot ttut, 62J.536 if th Commiionr dtrmin tht: i. trnction i incpbl of xchnin dt tht r currntly bin xchnd on ppr nd i ncry to ccomplih th purpo of th trnction; or ii. nothr ntionl lctronic trnction tndrd would b mor pproprit nd ffctiv to ccomplih th purpo of th trnction. If roup purchr r xmpt from on or mor of th rquirmnt, providr hll lo b xmpt from xchnin tho trnction with th roup purchr. Th Commiionr h dtrmind tht th critri bov r not mt nd tht ll hlth cr providr nd roup purchr r rquird to comply with th rul for th tndrd, lctronic xchn of hlth cr clim. No xcption to th rul h bn rntd cop Thi Compnion Guid covr ll th rquird nd itutionl Loop, mnt nd Dt Elmnt contind in th frnc HIPAA Implmnttion Guid. Thi Compnion Guid do NOT includ ny of th Loop, mnt or Dt Elmnt dfind NOT ED in th frnc HIPAA Implmnttion Guid. Conitnt with th HIPAA rquirmnt nd implmnttion uid intruction, th NOT ED Loop, mnt nd Dt Elmnt r not prmittd to b ubmittd or rcivd whn conductin thi trnction. Thi Compnion Guid xclud ny of th EDI trnmiion intruction, nrlly dfind in trdin prtnr rmnt documnt. Th Intrchn Control Hdr (IA) nd Trilr (IEA), nd th Functionl Group Hdr (G) nd Trilr (GE) r not covrd by thi Compnion Guid. Th pcifiction of th Loop, mnt nd Dt Elmnt r nrlly dfind in trdin prtnr rmnt documnt frnc HIPAA Implmnttion Guid Th frnc HIPAA Implmnttion Guid for thi Compnion Guid i th ANI AC X12N 837D Implmnttion Guid Vrion X097A1 (Copyriht 2000, Dt Intrchn tndrd Aocition on bhlf of AC X12. Formt 2000, Whinton Publihin Compny. All iht rvd). A copy of th full frnc HIPAA 10

11 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Implmnttion Guid cn b obtind from th Whinton Publihin Compny t Ky Trminoloy d in Thi Compnion Guid Thi Compnion Guid trt th rquird nd itutionl Loop, mnt nd Dt Elmnt includd in th frnc HIPAA Implmnttion Guid dcribd in th followin ction: quird Loop, mnt nd Dt Elmnt In om intnc, th vlu nd condition dfind in th HIPAA Implmnttion Guid for rquird Loop, mnt nd Dt Elmnt r furthr clrifid by th Compnion Guid. uch furthr clrifiction r ppropritly notd in th Compnion Guid tbl includd in ction 5. ndr no circumtnc do th Compnion Guid dd nw or diffrnt vlu to tho dfind in th frnc HIPAA Implmnttion Guid itutionl Loop, mnt nd Dt Elmnt Th Compnion Guid furthr dfin or rfin th condition nd vlu of itutionl Loop, mnt nd Dt Elmnt to on of th followin thr poibiliti: o o quird, with furthr dfinition of condition nd/or vlu: thi mn tht in Minnot, roup purchr do conidr nd nd thi dt for propr djudiction of th trnction nd tht th Loop, mnt nd Dt Elmnt will b EQIED for ALL vlu furthr dfind in th Minnot Compnion Guid. itutionl, with or without furthr dfinition of condition: thi mn tht th Loop, mnt or Dt Elmnt will rtin in th Minnot Compnion Guid th oriinl itutionl clifiction ivn in th HIPAA Implmnttion Guid, nd tht th Minnot Compnion Guid will follow ithr: Th xct m condition nd vlu dfind in th HIPAA Implmnttion Guid (bcu th condition nd vlu r clo-ndd, unmbiuou, nd triht-forwrd); or A t of furthr rfind condition nd vlu pplicbl to tht itutionl Loop, mnt or Dt Elmnt o Not Conidrd for Procin: nxt ction Loop, mnt nd Dt Elmnt Clifid Not Conidrd for Procin (NCFP) quird nd itutionl Loop, mnt nd Dt Elmnt my lo b 11

12 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction clifid in th Minnot Compnion Guid Not Conidrd for Procin. Thi mn tht rcivr of thi trnction in Minnot do not conidr th Loop, mnt or Dt Elmnt ncry for djudiction of th trnction for rvic covrd undr thi compnion uid. With rpct to th NCFP Loop, mnt nd Dt Elmnt, th intrprttion of thi clifiction will b follow: o o If th mnt or Dt Elmnt i EQIED by th HIPAA Implmnttion Guid nd th Minnot in th tbl includd in ction 5 of thi Compnion Guid i NCFP, thn th mnt or Dt Elmnt mut b nt by th ndr nd rcivd by th rcivr (to mt HIPAA rquirmnt) but th rcivr myl inor it for djudiction If th mnt or Dt Elmnt i ITATIONAL in th HIPAA Implmnttion Guid nd th Minnot in th tbl includd in ction 5 of thi Compnion Guid i NCFP, thn th mnt or Dt Elmnt: Will not b rquird by rcivr My b ubmittd by ndr Will b ccptd by rcivr My b inord by th rcivr for djudiction Th rcivr will not rjct trnction if ndr ubmit thi lmnt It i importnt to not tht th prmtr of itutionl lmnt on Implmnttion Guid r nrlly writtn in mnnr tht crt rquirmnt for th lmnt to b ud (if uch condition r mt). Pl rfr to th diclimr in th front mttr of thi uid Addrin Cod t Iu in th Compnion Guid Cod t utilizd in HIPAA lctronic trnction r clifid : Intrnl Trnction Cod (includd nd dfind inid th Implmnttion Guid). Th Compnion Guid my dfin t of vlu tht r idnticl to or ubt of th vlu prmittd in th frnc HIPAA Implmnttion Guid. Within th Compnion Guid thr r itution whr only ubt of vlu i prmittd. A buin nd chn, dditionl cod my b dfind nd md vilbl for u bt prctic. Pl rfr to ction 4.4 for informtion on AC Bt Prctic. 12

13 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Extrnl Cod t (rfrncd by Implmnttion Guid, dfind nd mintind by xtrnl bodi) includin: 1. Non-Mdicl Extrnl Cod t (uch Txonomy Cod, Clim Adjutmnt on Cod, mrk Cod, tc). Th vlu r ffctiv bd upon trnction dt. 2. Mdicl Extrnl Cod t [uch Currnt Dntl Trminoloy (CDT)]. Th vlu r ffctiv bd upon rvic dt Thi Compnion Guid do not rdfin xitin xtrnl cod t ud in th trnction. thr, th Compnion Guid my idntify ubt of xtrnl cod to b ud in pcific Loop, mnt nd Dt Elmnt of th trnction. For informtion rrdin clrifiction of mdicl cod t u Appndix A Trdin Prtnr Armnt Thi Compnion Guid i not intndd to rplc trdin prtnr rmnt tht dfin othr trnction prmtr (uch EDI trnmiion prmtr or trnction hdr informtion). Trdin prtnr rmnt my NOT dd or modify th rquirmnt tblihd by thi Compnion Guid. Trdin Prtnr will xchn th pproprit nd ncry idntifiction numbr to b rportd in Loop 1000A nd 1000B (ubmittr nd civr). 4.2 Informtion About th 837D Hlth Cr Clim Dntl Trnction Buin Trminoloy 1 For purpo of thi Compnion Guid, th followin trm hv th mnin ivn to thm in thi ction. Dfinition ud pply t both th clim nd lin lvl. Providr Dfinition Billin Providr Th Billin Providr mut b hlth cr or rvic providr. Informtion concrnin billin nt or hlthcr clrinhou my nvr b rportd in th billin providr loop. Whn th Billin Providr i n orniztion, th NPI would blon to th orniztion hlth cr providr. Whn n orniztion hlth cr providr h 1 ourc: 837 Implmnttion Guid, Vrion 5010; Ntionl niform Billin Committ B04 Mnul. Citd with prmiion. 13

14 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction dtrmind tht it h ubprt tht r numrtd, tht orniztion hlth cr providr will rport th NPI of ubprt th Billin Providr. Th ubprt rportd th Billin Providr MT lwy rprnt th mot dtild lvl of numrtion dtrmind by th orniztion hlth cr providr nd MT b th m idntifir nt to ny trdin prtnr. Th Billin Providr my b n individul only whn th hlth cr providr prformin rvic i n indpndnt, unincorportd ntity. In th c, th Billin Providr i th individul who ocil curity numbr i ud for 1099 purpo. Tht individul NPI i rportd in NM109, nd th individul ocil curity numbr mut b rportd in th EF mnt in thi loop. Whn roup or orniztion ubmit clim, th 2010AA loop of th clim mut contin th idntifir tht ppli to th roup/orniztion (NPI ntity 2) tht ubmittd th clim. Th Txpyr Idntifyin Numbr (TIN) of th Billin Providr to b ud for I Form 1099 purpo mut b rportd in th EF mnt of thi loop. Whn th billin providr i conidrd hlth cr providr, thn th NPI mut b ubmittd in th NM109 nd th only condry idntifir vlid in th EF would b th TIN. Whn th Billin Providr i not hlth cr providr, nd thu not liibl to rciv n NPI (for xmpl, pronl cr rvic, crpntr, tc.), th Billin Providr hould b th ll ntity. Propritry/lcy idntifir ncry for th trdin prtnr to idntify th ntity r to b rportd in th EF mnt of thi loop. Th TIN to b ud for 1099 purpo mut b rportd in th NM1 mnt of thi loop. Providr tht r not conidrd hlth cr providr r dfind typicl providr in thi documnt. Billin Providr Nm: Titl hould not b ud prt of th nm If nrolld with th pyr, th Billin Providr nm hould mtch th nrollmnt with th pyr. Billin Providr Addr:.. Potl Addrin tndrd th ddr hould mt th.. Potl ddrin tndrd. Py to Providr Thi i th providr tht i rqutin to b pid for th rvic rndrd. Thi loop i popultd if th informtion i diffrnt from th billin nm nd/or ddr. 14

15 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Th py-to providr loop llow th billin providr to indict pymnt ddr tht i diffrnt thn th billin. All HIPAA rquird idntifir mut lo b ubmittd. For providr who prticipt with th roup purchr hlth pln nd r rquird to complt nrollmnt form prt of th contrctin proc, th pymnt ddr ubmittd on th clim trnction my not b th ddr whr pymnt i ultimtly nt for th clim. Th pyr in thi c my u th pymnt ddr from th nrollmnt form or within th contrct rthr thn th ddr tht i ubmittd in th 2010AB loop of n lctronic clim. Th fcility tht furnihd th cr, or th tblihd ownr of tht fcility, mut within th providr contrct. Whn py to providr loop i nt in ddition to billin providr loop, it i th py to loop ddr whr th pymnt hould b nt, unl th pyr utiliz n nrollmnt form or contrct. rvic Fcility Loction Thi i th individul or orniztionl nm of th plc whr dntl rvic i prformd. It i rquird if th rvic w rndrd in Inptint Hopitl, Outptint Hopitl, killd Nurin Fcility or Adult Livin Cr Fcility (cod vlu 21, 22, 31 or 35 in CLM05-1). ndrin Providr Th ndrin Providr i th pron or compny (lbortory or othr fcility) who providd th cr. In th c whr ubtitut providr (locum tnn) w ud, tht pron hould b ntrd hr. frrin Providr Othr Dfinition Th frrin Providr i providr who nd th ptint to nothr providr for rvic. quird if clim involvd rfrrl. Dpndnt In th hirrchicl loop codin, th dpndnt cod indict th u of th ptint hirrchicl loop (Loop 2000C). Dtintion Pyr Th dtintion pyr i th pyr who i pcifid in th Pyr loop (Loop BB). Ptint Th trm ptint i intndd to convy th c whr th Ptint loop (Loop -2000C) i ud. In tht c, th ptint i not th m pron th ubcribr. Howvr, it lo hppn tht th ptint i omtim th m 15

16 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction pron th ubcribr. In tht c, ll informtion bout th ptint/ubcribr i crrid in th ubcribr loop (Loop -2000B). ction of th HIPAA Implmnttion Guid for furthr dtil. Evry ffort h bn md to nur tht th mnin of th word ptint i clr in it pcific contxt. Othr Pyr Th trm othr pyr indict ny pyr who i not th primry pyr. Th othr pyr my b th condry, trtiry, or vn qutrnry pyr. ubcribr Th ubcribr i th pron or ntity who nm i litd on th inurnc policy. Othr ynonymou trm includ mmbr nd/or inurd. In om c th ubcribr i th m pron th ptint. th dfinition of ptint, nd ction of th HIPAA Implmnttion Guid for furthr dtil. Trnmiion Intrmdiry A trnmiion intrmdiry i ny ntity tht hndl th trnction btwn th providr (oriintor of th clim/ncountr trnmiion) nd th dtintion pyr. Th trm intrmdiry i not ud to convy pcific Mdicr contrctor typ Providr Idntifir nd NPI Ainmnt Providr Idntifir If th providr i hlth cr providr thn th only idntifir tht i vlid i th NPI with th xcption of th billin/py to loop. For th billin/py-to providr, condry idntifir of th TIN i lo rquird. If th providr i not hlth cr providr (typicl) thn th primry idntifir i th TIN nd condry idntifir i llowbl. Th qulifir for th condry idntifir would b G2. Th idntifir for thi qulifir would b pyr ind idntifir Minnot quirmnt for Complinc Thi ction contin nrl Minnot rquirmnt for complinc pplicbl to thi trnction Formttin quirmnt Mximum Numbr of Clim pr Trnction t: Thr cnnot b mor thn 5,000 clim pr trnction t. 16

17 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Dt portd in Trnction: Crtin dt in hlth cr clim trnction mut b bfor or qul to th trnction crt dt (BHT04) Appndix B for mor informtion. mnt portin Multipl Vlu From m Cod t: om mnt hv multipl lmnt tht contin vlu from th m cod t. Whn it i ncry to rport multipl vlu, thy mut b popultd quntilly within th mnt, p btwn dt lmnt r not llowd. Appndix C for mor informtion. pcil Chrctr: th HIPAA Implmnttion Guid Appndic A Extndd Chrctr t nd A Dlimitr ction. Dt ud within mnt nd lmnt mut not contin th dt chrctr chon Dlimitr, tht ppr in th IA. Occurrnc of dlimitr chrctr in trnmittd dt within dt lmnt cn rult in rror in trnltion prorm Hndlin Adjutmnt nd Appl Dtrmintion of Action: Whn dtrminin whthr to rubmit clim n oriinl, rqut n djutmnt or rqut n ppl, firt dtrmin whthr th pyr h ccptd nd djudictd th oriinl clim ubmiion. If th oriinl ubmiion w not ccptd into th pyr djudiction ytm, rubmit th clim n oriinl. Thi i not conidrd to b n djutmnt. If th oriinl ubmiion w ccptd into th pyr djudiction ytm, dfinition blow to dtrmin whthr n djutmnt or ppl hould b rqutd. Dfinition: Adjutmnt Providr h dditionl dt tht hould hv bn ubmittd on th oriinl clim or h nd to corrct dt tht w nt incorrctly on th oriinl clim. Appl Providr i rqutin rconidrtion of prviouly djudictd clim but thr i no dditionl or corrctd dt to b ubmittd. Thrfor th ubmiion of th ppl i not covrd by thi uid. Exmpl of Appl includ: o o o o o o Timly filin dnil Pyr llownc Incorrct bnfit pplid Eliibility iu Bnfit Accumultion Error Mdicl Policy / Mdicl Ncity 17

18 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Proc for ubmiion: Adjutmnt Providr hould ubmit n djutmnt lctroniclly uin th pproprit vlu in CLM05-3 to indict tht thi i rplcmnt clim. If th oriinl pyr-ind clim numbr i known it mut b ubmittd in loop 2300, EF02, uin qulifir F8 in EF01 (Not: th oriinl pyr-ind clim numbr i not th proprty nd culty numbr). If dditionl informtion i rquird to upport th djutmnt bd on pyr buin rul, th NTE mnt, PWK mnt, or Condition Cod hould b ud. ction blow rrdin th mnt for pproprit intruction. Appl Follow pyr tndrd proc for rqutin n ppl to prviouly djudictd clim. If ppr ppl proc i utilizd, thn tndrd Minnot ppl form i vilbl t th AC wbit t Additionl documnttion hould b nt rquird by th pyr to upport th ppl conidrtion; thi documnttion do not includ rubmiion of th clim Clim Frquncy Typ Cod (CFTC) Vlu All not nd llowd vlu commnt for th Frquncy Typ lmnt tht wr oriinlly in th 4010 uid hv bn rmovd from th 4010A1 uid. Thi mn tht th uid will llow ny currnt vlu pprovd by NBC to b nt in th trnction (codt 235). Both th ndr nd rcivr mut undrtnd how ch cod vlu hould b intrprtd nd wht procin rquirmnt nd to b pplid. Clim/Bill ubmiion r oftn oriinl firt tim ubmiion with no follow-up ubmiion. In om c, ubqunt ubmiion dirctly rltd to prior ubmiion will b ncry. Whn ubqunt ubmiion occur, for litimt buin purpo, th norml procin flow my chn. inc rltionhip btwn n oriinl ubmiion nd ubqunt ubmiion r ncry, th dt rquirmnt both for oriinl nd ubqunt ubmiion mut b pcifid. For xmpl, whn plcmnt bill i ubmittd (CFTC 7), in ordr to mt th procin rquirmnt to void th oriinl nd rplc it with th r-ubmittd bill, common conitnt dt lmnt would b rquird. To qulify plcmnt, om dt would nd to b diffrnt thn th oriinl. If th bill i r-ubmittd with no chn from th oriinl, nd th clim w ccptd by th pyr, thi would b conidrd Duplict intd of plcmnt. If th bill i rubmittd with no chn from th oriinl nd th oriinl w not ccptd by th pyr, thi will b conidrd n oriinl clim. Th ditinction r importnt to llow for propr hndlin of th ubmiion. fr to th currnt NBC codlit for llowd vlu nd u dcription. In conjunction with th CFTC cod vlu, Condition Cod my b ubmittd tht will impct procin nd hndlin rquirmnt. For xmpl, 18

19 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction plcmnt bill (CFTC 7) my lo contin Condition Cod D0 indictin rvic dt hv bn chnd Clim Attchmnt nd Not th NTE mnt t th clim or lin lvl to provid fr-form txt of dditionl informtion whr impl dcription of th rvic i ll tht i rquird. Do not xcd th u vilbl in th HIPAA implmnttion uid. B uccinct nd bbrvit whn poibl. Do not rpt cod dcription or unncry informtion. If th NTE mnt mut b xcdd, or hrd copy documnt nt, u th PWK mnt t th clim lvl. If th numbr of chrctr for th NTE will xcd vilbl chrctr, u only th PWK mnt t th clim lvl. ction for informtion rrdin formttin rquirmnt nd pcil chrctr u. Whn popultin th PWK mnt, th followin uidlin mut b followd: o o PWK01 - Attchmnt port Typ Cod i rquird lmnt: Th qulifir vlu of OZ hould only b ud if non of th othr vlu pply. Th mot pcific qulifir vlu mut b utilizd. PWK06 - Attchmnt Control Numbr i itutionl lmnt tht i rquird if th trnmiion typ i nythin othr thn vilbl upon rqut. Thi vlu i ud to idntify th ttchmnt. Billin providr mut u uniqu numbr for thi fild for ch individul ttchmnt on th clim, wll, uniqu numbr cro ll clim rquirin ttchmnt. Thi uniqu numbr idntifi pcific ttchmnt within th billin providr ytm. Thi uniqu numbr i th ky tht ocit th ttchmnt to th clim. Th numbr mut b nt in PWK06 of th clim nd with th ttchmnt. Th providr mut not u th m numbr on ny othr clim in thir ytm to idntify diffrnt ttchmnt ubmiion of Prior Pyr Adjudiction Informtion Th corrct popultion of CA mnt loctd in Loop 2320 nd Loop 2430 r dpndnt upon th providr rcivin HIPAA complint dt on prior pyr rmittnc dvic. Minn. tt. c. 62J.536 rquir Minnot to dvlop on uniform tndrd compnion uid dcribd undr th Cod of Fdrl ultion, Titl 45, Prt 162 with rul rrdin th u of th rmittnc dvic (835) lmnt. Th rul mut b implmntd by Dcmbr 15, 2009 (purunt to Minn. tt. c. 62J.536). For intruction on ndin prior pyr 19

20 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction djudiction informtion on ubqunt clim ubmiion, th followin ub-ction Clim ubmiion Prior to 12/15/09 To ccommodt trnition nd ytm chn in th priod until 12/15/09 flxibility will b llowd in how providr nd nd pyr mut rciv prior pyr djudiction informtion. Pl coordint with th pyr to dtrmin which option r uitbl. If providr lrdy ubmit th lmnt lctroniclly to pyr, it i rcommndd tht thy continu to do o. Accptbl option r notd blow. If th providr rcivd th rmittnc from th prior pyr HIPAA complint lctronic 835, th providr my popult CA mnt informtion dirctly in th lctronic clim rcord. Altrntivly, if th currnt pyr cn not yt ccpt or th providr cn not nd thi dt lctroniclly within th clim rcord, th providr my ubmit uin th PWK mnt nd forwrd ppr copy of th rmittnc dvic. If th providr rcivd HIPAA complint ppr rmittnc, th providr my popult CA mnt informtion dirctly in th lctronic clim rcord. Altrntivly, if th currnt pyr cn not yt ccpt or th providr cn not nd thi dt lctroniclly within th clim rcord, th providr my ubmit uin th PWK mnt nd forwrd ppr copy of th rmittnc dvic. If th providr rcivd non-complint ppr rmittnc, th providr hould ubmit uin th PWK mnt nd forwrd ppr copy of th rmittnc dvic Clim ubmiion 12/15/09 nd Aftr Th CA informtion mut b popultd dirctly from th 835 rmittnc dvic or HIPAA complint ppr rmittnc whn clim lvl or lin lvl djudiction i ud by th prior pyr. If th prior pyr did not nd HIPAA complint rmittnc, th providr mut ubmit uin th PWK mnt nd forwrd ppr rmittnc dvic. 4.3 Proc for pdtin Compnion Guid Documnt Th proc for updtin Minnot niform Compnion Guid documnt, includin ubmittin nd collctin chn rqut, rviwin nd vlutin rqut nd mkin rcommndtion, doptin nd publihin nw vrion of th uid i vilbl from th Minnot Dprtmnt of Hlth wbit t 20

21 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction 4.4 Minnot Bt Prctic for th Implmnttion of Elctronic Hlth Cr Trnction Th Minnot Adminitrtiv niformity Committ (MN AC) i continuouly workin on th idntifiction of Bt Prctic for th implmnttion of dminitrtiv trnction nd proc. Althouh thy r not rquird prt of thi Compnion Guid, thy r hlpful in idin pyr nd providr in implmntin th trnction. Pl viit th MN-AC wbit t for mor informtion bout Bt Prctic for implmntin lctronic hlth cr trnction in Minnot. 21

22 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction D Hlth Cr Clim Dntl - Compnion Guid Tbl Introduction to Tbl All th informtion rltd to th wy thi Compnion Guid clifi nd dfin rquird nd itutionl Dt Elmnt i prntd in tbl formt in th nxt ction. Th Tbl i ornizd by Loop nd mnt, to mk it ir to rviw nd loct. Th tbl includ th followin: o o ALL of th Loop, mnt nd Dt Elmnt tht r clifid EQIED by th HIPAA Implmnttion Guid (xcpt notd in ction Comprin Dt Elmnt ow into mnt ow blow) ALL of th Loop, mnt nd Dt Elmnt tht r clifid ITATIONAL by th HIPAA Implmnttion Guid (xcpt notd in ction Comprin Dt Elmnt ow into mnt ow blow) Th tbl DOE NOT includ ny of th Loop, mnt or Dt Elmnt clifid NOT ED by th HIPAA Implmnttion Guid. Th tbl i ornizd into th followin column: o o o o Loop : Th LOOP from th HIPAA Implmnttion Guid mnt Informtion: Th NAME nd AGE ivn to th mnt in th HIPAA Implmnttion Guid Dt Elmnt Informtion: Th, NAME, AGE, MIN/MAX Lnth nd VALE ivn to ch Dt Elmnt in th HIPAA Implmnttion Guid Minnot Informtion: Minnot - Th only prmittd vlu r: for quird for itutionl NCFP for Not Conidrd for Procin Vlu, Dfinition nd Not: Th pcific vlu nd othr not pplicbl to th mnt or Dt Elmnt rquird to b followd in Minnot. If Minnot vlu hv bn limitd to ubt of vlu, dditionl HIPAA complint vlu will b conidrd NCFP. MN m HIPAA IG: If chckd, it mn tht th Minnot Compnion Guid condition, vlu nd not for th mnt or Dt Elmnt r idnticl to th condition, vlu nd not from th HIPAA Implmnttion Guid Comprin Dt Elmnt ow into mnt ow In prprin th compnion uid, om comprion or collpin of Dt Elmnt row into mnt row h bn don to implify th iz nd contnt of th documnt. Thi comprion or collpin w don follow: If th Minnot clifiction of mnt nd it Dt Elmnt r ALL ENTICAL with th HIPAA IG, thn th Dt 22

23 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Elmnt row for tht mnt r NOT includd in th tbl nd only th mnt-lvl row i prntd ltionhip Btwn Condition Givn to mnt nd Dt Elmnt in HIPAA IG nd th Minnot Clifiction Givn in th Compnion Guid A ummry of th vn (7) cnrio tht could occur in th compnion uid whn rltin th followin thr lmnt r prntd in th tbl blow: 1. Th condition tht Loop, mnt or Dt Elmnt h in th oriinl HIPAA Implmnttion Guid (quird or itutionl) 2. Th Minnot dfind by th Compnion Guid Entil Elmnt Group (quird; itutionl; Not Conidrd for Procin) 3. Whthr th Minnot nd Not r idnticl to th HIPAA Implmnttion Guid Tbl 1 vn pcific Minnot Compnion Guid cnrio for Minnot-dfind of Loop, mnt nd Dt Elmnt Condition of Loop/ mnt/dt Elmnt from HIPAA Implmnttion Guid Minnot Clifiction Compnion Guid Minnot Not bout 1. quird quird m HIPAA Implmnttion Guid 2. quird quird Furthr clrifi th HIPAA Implmnttion Guid 3. quird NCFP (Not Conidrd for Procin) m HIPAA Implmnttion Guid 4. itutionl quird Furthr dfin th rquirmnt from th HIPAA Implmnttion Guid 5. itutionl itutionl m HIPAA Implmnttion Guid 6. itutionl itutionl Furthr rfind from HIPAA Implmnttion Guid 7. itutionl NCFP (Not Conidrd for Procin) m HIPAA Implmnttion Guid 23

24 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction 5.2 Compnion Guid Tbl Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG Hdr Hdr Hdr TANACTION ET HEADE BEGINNING OF HIEACHICAL TANACTION TANMIION TYPE ENTIFICATION T X BHT X EF X LOOP A BMITTE NAME (Loop pt: 1) BMITTE 1000A NM1 X NAME 1000A BMITTE EDI CONTACT INFOMATION PE X LOOP B ECEIVE NAME (Loop pt: 1) 1000B ECEIVE NAME NM1 X LOOP A BILLING/PAY-TO POVE HIEACHICAL LEVEL (Loop pt: >1) 2000A 2000A BILLING/PAY-TO POVE HIEACHICAL LEVEL BILLING/PAY-TO POVE PECIALTY INFOMATION HL X PV X 2000A FOEIGN CENCY INFOMATION C NCFP X LOOP AA BILLING POVE NAME (Loop pt: 1) 2010AA BILLING POVE NAME NM1 front mttr for dfinition nd u of billin providr 24

25 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG NM101 Entity Idntifir Cod X NM102 Entity Typ Qulifir 1-1 1, 2 X NM103 Nm Lt or Orniztion Nm 1-35 X NM104 Nm Firt 1-25 X NM105 Nm Middl 1-25 X NM107 Nm uffix 1-10 X NM108 Idntifiction Cod Qulifir , 34, XX XX 2010AA 2010AA BILLING POVE ADDE BILLING POVE CITY/TATE/ZIP CODE NM109 Idntifiction Cod 2-80 X N3 X N4 X 2010AA BILLING POVE ECONDAY ENTIFICATION EF front mttr for dfinition nd u. EF01 frnc Idntifiction Qulifir 2-3 0B, 1A, 1B, 1C, 1D, 1E, 1H, EI, G2, G5, L, Y, TJ EI,G2,Y,TJ EF02 frnc Idntifiction 1-30 X 2010AA CLAIM BMITTE CEDIT/DEBIT CAD BILLING INFOMATION EF NCFP X 25

26 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG LOOP AB PAY-TO POVE NAME (Loop pt: 1) 2010AB PAY-TO POVE NAME NM1 front mttr for dfinition nd u NM101 Entity Idntifir Cod X NM102 Entity Typ Qulifir 1-1 1, 2 X NM103 Nm Lt or Orniztion Nm 1-35 X NM104 Nm Firt 1-25 X NM105 Nm Middl 1-25 X NM107 Nm uffix 1-10 X NM108 Idntifiction Cod Qulifir , 34, XX XX NM109 Idntifiction Cod 2-80 X 2010AB PAY-TO- POVE ADDE N3 X 2010AB PAY-TO- POVE CITY/TATE/ZIP N4 X 2010AB PAY-TO- POVE ECONDAY ENTIFICATION EF front mttr for dfinition nd u. EF01 frnc Idntifiction Qulifir 2-3 0B, 1A, 1B, 1C, 1D, 1E, 1H, EI, G2, G5, L, Y, TJ G2, Y, EI, TJ EF02 frnc Idntifiction 1-30 X 26

27 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG LOOP B BCIBE HIEACHICAL LEVEL (Loop pt: >1) 2000B BCIBE HIEACHICAL LEVEL HL X 2000B BCIBE INFOMATION B X B01 Pyr ponibility qunc Numbr Cod 1-1 P,, T Do not nd clim to condry or trtiry pyr until prviou pyr() h procd. B02 Individul ltionhip Cod X B03 frnc Idntifiction 1-30 X B04 Nm 1-60 X B06 COB Cod 1-1 1, 6 X B09 Clim Filin Indictor Cod LOOP BA BCIBE NAME (Loop pt: 1) 2010BA BCIBE NAME , 11, 12, 13, 14, 15, 16, 17, BL, CH, CI, D, FI, HM, LM, MB, MC, MH, OF, A, VA, WC, ZZ NM1 X NM101 NM102 Entity Idntifir Cod Entity Typ Qulifir 2-3 IL X 1-1 1, 2 X NM103 For Workr' Compntion thi i th Nm Lt or mployr nm. Orniztion 1-35 For Proprty & Nm Culty thi my b nonpron. NM104 Nm Firt 1-25 X X 27

28 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG 2010BA 2010BA 2010BA BCIBE ADDE BCIBE CITY/TATE/ZIP BCIBE DEMOGAPHIC INFOMATION NM105 Nm Middl 1-25 X NM107 Nm uffix 1-10 X NM108 NM109 Idntifiction Cod Qulifir Idntifiction Cod 1-2 MI, ZZ X 2-80 If th ptint i th ubcribr, thn th mmbr idntifir ubmittd mut b th ud to idntify th ptint. Th providr mut vrify with th roup purchr if individul idntifir r ind to ch mmbr. N3 X N4 X DMG X 2010BA BCIBE ECONDAY ENTIFICATION EF NCFP X 2010BA POPETY AND CAALTY CLAIM NMBE LOOP BB PAYE NAME (Loop pt: 1) EF X 2010BB PAYE NAME NM1 X 2010BB PAYE ADDE N3 NCFP X 2010BB PAYE CITY/TATE/ZIP N4 NCFP X 28

29 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG 2010BB PAYE ECONDAY ENTIFICATION NMBE EF NCFP X LOOP BC CEDIT/DEBIT CAD HOLDE NAME (Loop pt: 1) 2010BC 2010BC CEDIT/DEBIT CAD HOLDE NAME CEDIT/DEBIT CAD INFOMATION NM1 NCFP X EF NCFP X LOOP C PATIENT HIEACHICAL LEVEL (Loop pt: >1) 2000C PATIENT HIEACHICAL LEVEL HL X 2000C PATIENT INFOMATION PAT. X LOOP CA PATIENT NAME (Loop pt: 1) 2010CA PATIENT NAME NM1 X NM101 NM102 Entity Idntifir Cod Entity Typ Qulifir 2-3 QC X X NM103 Nm Lt or Orniztion Nm 1-35 X 2010CA PATIENT ADDE NM104 Nm Firt 1-25 X NM105 Nm Middl 1-25 X NM107 Nm uffix 1-10 X NM108 NM109 Idntifiction Cod Qulifir Idntifiction Cod 1-2 MI, ZZ X 2-80 quird whn uniqu idntifir h bn ind to th ptint. Thi mut b th ud to idntify th ptint. N3 X 29

30 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG 2010CA 2010CA 2010CA PATIENT CITY/TATE/ZIP PATIENT DEMOGAPHIC INFOMATION PATIENT ECONDAY ENTIFICATION N4 X DMG X EF NCFP X 2010CA POPETY AND CAALTY CLAIM NMBE LOOP 2300 CLAIM INFOMATION (Loop pt: 100) 2300 CLAIM INFOMATION EF X CLM X CLM01 CLM02 Clim ubmittr' Idntifir Montry Amount 1-38 X 1-18 Zro i vlid vlu. Totl chr mut qul th um of ll dtil lin chr. CLM05 HEALTH CAE EVICE LOCATION INFOMATION X CLM05-1 Fcility Cod Vlu 1-2 cod ourc 237 X CLM05-3 Clim Frquncy Typ Cod 1-1 cod ourc 235 front mttr for dfinition CLM06 Y/No Condition or pon Cod 1-1 N, Y X CLM07 Providr Accpt Ainmnt Cod 1-1 A, C, P quird whn th providr ccpt inmnt nd/or h prticiption 30

31 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG CLM08 CLM09 CLM11 Y/No Condition or pon Cod l of Informtion Cod ELATED CAE INFOMATION 1-1 N, Y rmnt with th dtintion pyr. O quird whn th providr do not ccpt inmnt nd/or hv prticiption rmnt, but i dviin th pyr to djudict thi pcific clim undr prticiptin providr bnfit llowd undr crtin pln. Thi i NOT th fild for rportin whthr th ptint h or h not ind bnfit to th providr. Thi lmnt nwr th qution whthr or not th inurd h uthorizd th pln to rmit pymnt dirctly to th providr. 1-1 N, Y X X CLM11-1 ltd Cu Cod 2-3 AA, EM, OA X CLM11-2 ltd Cu Cod 2-3 AA, EM, OA X 31

32 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG CLM11-3 ltd Cu Cod 2-3 AA, EM, OA NCFP X CLM11-4 tt or Provinc Cod 2-2 X ADMIION DATE DICHAGE DATE CLM11-5 CLM12 CLM19 CLM20 Country Cod 2-3 X pcil Prorm Cod Clim ubmiion on Cod Dly on Cod , 02, 03, 05 NCFP 2-2 PB X 1-2 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 If cod 11 (Othr) i ud, dditionl documnttion i rquird uin NTE or PWK. fr to ction for u. If CLM20 vlu of 11 i ud, PWK02 mut not b vlu of AA. DTP X DTP X 2300 EFEAL DATE DTP X 2300 ACCENT DATE DTP X 2300 APPLIANCE PLACEMENT DATE DTP X 2300 EVICE DATE DTP X 2300 quird whn thr i limitd intrcptiv or OTHODONTIC comprhniv TOTAL MONTH DN1 trtmnt OF TEATMENT oppod to minor trtmnt.. DN101 Quntity 1-15 X X 32

33 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG DN102 Quntity 1-15 DN103 Y/No Condition or pon Cod Numbr of month of orthodontic trtmnt onc pplinc hv bn plcd. 1-1 Y X 2300 TOOTH TAT DN CLAIM PPLEMENTAL INFOMATION PWK quird whn th tooth ttu cod in DN202 pply to th clim. front mttr for condition nd u PWK01 port Typ Cod 2-2 B4, DA, DG, EB, OB, OZ, P6, B, X Accptd vlu: BM, EL, EM, FX PATIENT AMONT PA CEDIT/DEBIT CAD MAXIMM AMONT PEDETEMINAT ION ENTIFICATION PWK02 PWK05 PWK06 port Trnmiion Cod Idntifiction Cod Qulifir Idntifiction Cod 1-2 AA, BM, EL, EM, FX of AA vlu my rult in dly in clim pymnt. If n ttchmnt i known to b ndd by th pyr it hould b nt. 1-2 AC X 2-80 X AMT X AMT NCFP X EF X 33

34 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG EVICE ATHOIZATION EXCEPTION CODE OIGINAL EFEENCE NMBE (ICN/DCN) PIO ATHOIZATION O EFEAL NMBE EF NCFP X EF X EF X 2300 CLAIM ENTIFICATION NMBE FO CLEAING HOE AND OTHE TANMIION INTEMEDIAIE EF X 2300 CLAIM NOTE NTE 20 p t Do not u mnt unl rquird condition i mt --quird whn in th judmnt of th providr, th informtion i ndd to ubtntit th mdicl trtmnt nd i not upportd lwhr within th clim dt t. Not: Th NTE mnt prmit frform informtion/dt which, undr ANI X12 tndrd implmntttion, i not mchin procbl. 34

35 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG LOOP A EFEING POVE NAME (Loop pt: 2) 2310A EFEING POVE NAME NM1 NM101 NM102 Entity Idntifir Cod Entity Typ Qulifir dfinition ction in front mttr. 2-3 DN, P3 X 1-1 1, 2 X NM103 Nm Lt or Orniztion Nm 1-35 X 2310A 2310A EFEING POVE PECIALTY INFOMATION EFEING POVE ECONDAY ENTIFICATION NM104 Nm Firt 1-25 X NM105 Nm Middl 1-25 X NM107 Nm uffix 1-10 X NM108 NM109 Idntifiction Cod Qulifir Idntifiction Cod , 34, XX XX 2-80 X PV NCFP X EF NCFP X LOOP B ENDEING POVE NAME (Loop pt: 1) 2310B ENDEING POVE NAME N:M1 dfinition ction in front mttr. NM101 Entity Idntifir Cod X NM102 Entity Typ Qulifir 1-1 1, 2 X NM103 Nm Lt or Orniztion Nm 1-35 X NM104 Nm Firt 1-25 X NM105 Nm Middl 1-25 X NM107 Nm uffix 1-10 X 35

36 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG 2310B 2310B ENDEING POVE PECIALTY INFOMATION ENDEING POVE ECONDAY ENTIFICATION NM108 NM109 Idntifiction Cod Qulifir Idntifiction Cod , 34, XX XX 2-80 X PV X EF NCFP X LOOP -2310C EVICE FACILITY LOCATION (Loop pt: 1) 2310C EVICE FACILITY LOCATION NM1 dfinition ction in front mttr. NM101 Entity Idntifir Cod 2-3 FA X NM102 Entity Typ Qulifir X NM103 Nm Lt or Orniztion Nm 1-35 X NM108 Idntifiction Cod Qulifir , 34, XX XX NM109 Idntifiction Cod 2-80 X 2310C EVICE FACILITY LOCATION ECONDAY ENTIFICATION EF NCFP X LOOP -2310D AITANT GEON NAME (Loop pt: 1) 2310D AITANT GEON NAME NM1 NCFP X 2310D 2310D AITANT GEON PECIALTY INFOMATION AITANT GEON ECONDAY ENTIFICATION PV NCFP X EF NCFP X 36

37 MINNEOTA NIFOM COMPANION GE FO THE 837D HEALTH CAE CLAIM - DENTAL Trnction Trnction: 837D - Dntl Clim Loop mnt Nm Elmnt Nm Min/ Mx HIPAA IG Vlu Minnot Informtion Vlu Dfinition nd Not MN m HIPAA IG LOOP OTHE BCIBE INFOMATION (Loop pt: 10) OTHE BCIBE INFOMATION CLAIM ADJTMENT B B01 B02 B03 Pyr ponibility qunc Numbr Cod Individul ltionhip Cod frnc Idntifiction 1-1 P,, T , 18, 19, 20, 21, 22, 29, 76 Do not nd clim to condry or trtiry pyr until primry pyr h procd. Whn vlu cod of B01 in 2000B loop i not P, thn thi mnt mut b nt. If P or i ud in B01of 2000B loop, thn tht vlu cnnot b rptd in thi loop X B04 Nm 1-60 X B09 09, 11, 12, 13, 14, 15, 16, 17, BL, Clim Filin CH, CI, D, 1-2 Indictor Cod FI, HM, LM, MB, MC, MH, OF, A, VA, WC, ZZ X CA front mttr ction for condition nd u. X 2320 COODINATION OF BENEFIT (COB) PAYE PA AMONT AMT X 37