837 Institutional Health Care Claim. Section 1 837I Institutional Health Care Claim: Basic Instructions

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1 Companion Document 837I 837 Institutional Health Care Claim This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained in this document are supplemental and should be used in conjunction with the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) as published by the Washington Publishing Company. Section 1 837I Institutional Health Care Claim: Basic Instructions Section 2 837I Institutional Health Care Claim: Front End Edits Section 3 837I Institutional Health Care Claim: Enveloping Section 4 837I Institutional Health Care Claim: Charts for Situational Rules Any questions? Contact E-Solutions LiveChat Page 1 of 19

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted to Anthem for processing pass through compliance edits acknowledgments and reports for accepted/rejected files will be placed in the submitter s trading partner mailbox for pickup. TA1 Interchange Acknowledgment. Anthem returns TA1 X12 and proprietary reports to the submitter of inbound 837 files containing envelope errors in the ISA and GS segments. Level 1. Anthem returns a 999 Interchange Acknowledgment to the submitter for every inbound 837 transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 837 is not X12 compliant, the 999 will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected. Level 2. When encountering HIPAA compliance (including balancing) and code set errors, Anthem returns: 1) 277 Claims Acknowledgment (CA) and 2) 864 Level 2 Status Report to the submitter identifying which claim(s) have failed. Level 3. In addition to checking for compliance, Anthem applies front end business edits to ensure that the necessary information is populated and complete for efficient processing. Anthem returns the Level 3 Adjudicated Claims Response Report to the submitter identifying which claim(s) have failed. 1.2 HIPAA Compliant Codes Use HIPAA-compliant codes from current versions of the following: Physician s Current Procedure Terminology (CPT) Health Care Financing Administration Common Procedural Coding System (HCPCS) International Classification of Diseases Clinical Mod (ICD-9-CM) Diseases National Uniform Billing Committee (NUBC) Codes Diagnosis Related Group Number (DRG) Provider Taxonomy Codes National Drug Code *ICD-10 Codes will not be accepted any earlier than October 1, Diagnosis Codes According to the 837I TR3, a transaction is not X12 compliant if decimal points are used in diagnosis codes. Therefore, should a diagnosis code contain a decimal point, Anthem will return a 999 to the submitter indicating that the transaction has been rejected. 1.4 Procedure Codes and Modifiers All valid CPT and HCPCS codes and modifiers are accepted for claim adjudication. Refer to your billing guidelines or provider contract for submission of these codes. If submitted codes are invalid, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. Page 2 of 19

3 1.5 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, spaces, and other special characters. All alpha characters must be submitted in UPPERCASE letters only. Suggested delimiters for the transaction are assigned as part of the trading partner set up. EDI Representative will discuss options with trading partners, if applicable. To avoid syntax errors, hyphens, parentheses and spaces are not recommended to be used in values for identifiers. Examples: Recommended: Zip Code Medical Record # Since originally submitted values may be returned on outbound transactions, Anthem encourages trading partners to not use the following special characters as part of the value: asterisk (*), less than/greater than signs (<, >), colon (:), and slash (/). This minimizes the risk for a special character to be recognized as a delimiter. Example: Provider assigns a Patient Control Number 12* Although an asterisk (*) is a valid special character, it adversely affects processing since it is also a common delimiter. The value 12* may process incorrectly as two separate values 12 and Decimal R Data Element Types Inbound Delimiters Suggested Value Data Element Separator * Asterisk Sub-Element Separator : Colon Segment Terminator ~ Tilde Repetition Separator ^ Caret R data element types contain a decimal point; involving monetary amounts, units, visits, weights, and frequency. Anthem recommends using decimal points for monetary amounts, and whole numbers for other types of R data elements. Except for monetary amounts, if R data element type includes a decimal and numbers after the decimal, Anthem adjudicates the claim based on the whole number. Numbers after the decimal will not be considered. 1.7 Numeric Values, Monetary Amounts and Units Anthem pays all claims in US dollars and therefore, accepts monetary amounts in US dollars only. If codes related to foreign currencies are used, then a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. Anthem recognizes units in whole numbers only. Anthem recognizes units in values of less than 9999 and greater than or equal to zero. If a negative service line charge or negative units are used, then a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. SV203 Monetary Amount - Line Item Charge Amount SV205 Quantity - Service Unit Count Page 3 of 19

4 1.8 Address Information P.O. mailboxes / Lock Boxes are not allowed in the Billing Provider loop. If submitted in the Billing Provider loop, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. The Pay-to Address loop does support P.O. Box / Lock Box addresses. Therefore, if payment is expected to be remitted to a P.O. Box / Lock Box, submit the P.O. Box / Lock Box address. Full 9-digit zip codes are required in the Billing Provider and Service Facility Location loops. If 5-digit zip codes are used in these loops, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. 1.9 Taxonomy Codes (PRV) The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are 10-alphanumeric positions in length. Health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. It is strongly recommended that the taxonomy be populated in PRV segments for all applicable claims that you are filing. Refer to the CMS website for a listing of codes, Filing Electronic Claims with Adjustment Information Submitting claims for charges not included on a prior claim is done using claim frequency codes. Code 5 Late Charge(s) 7 Replacement of Prior Claim 8 Void/Cancel of Prior Claim Claim Frequency Code (Loop 2300 CLM05-3) Description Filing Instructions Action Use to submit additional charges for the same dates of service (statement covers period) as a previous claim. Use to replace an entire claims (all but identity information). Use to entirely eliminate a previously submitted claim for a specific provider, patient, payer, insured, and statement covers period. File electronically, as usual. Include only the additional late charges that were not included on the original claim. File electronically, as usual. File the claim in its entirety, including all services for which you are requesting consideration. File electronically, as usual. Include all charges that were on the original claim. Anthem will add the late charges to the previously processed claim. Anthem will consider the original claim null and void, and Anthem will void the original claim from records based on request. Claim is identified as inquiry on the L3 report and 151 response is sent to provider. When submitting adjustments noted with claim frequency code 5, 7, or 8, populate Loop 2300 REF02 Payer Claim Control Number (from the 835, Provider Remittance Voucher, or 835 Supplement on Point of Care). Without this original Anthem internal tracking number, adjustment request cannot be completed. Anthem only accepts claim frequency codes 5, 7, and 8. Claims with frequency codes other than for late charges, to replace a prior claim, or void a prior claim will be rejected and identified on the L3 Adjudicated Claims Response Report. Page 4 of 19

5 1.11 Coordination of Benefits (COB) Specific 837 data elements work together to coordinate benefits between Anthem and Medicare or other carriers. Following the Provider-to-Payer-to-Provider model; The provider sends the 837 to the primary payer. The primary payer adjudicates the claim and sends an 835 Payment Advice to the provider. The 835 includes the claim adjustment reason code and/or remark code for the claim. Upon receipt of the 835, the provider sends a second 837 with COB information populated in Loops 2320, 2330A-I, and/or 2430 to the secondary payer. The secondary payer adjudicates the claim and sends an 835 Payment Advice to the provider. Anthem recognizes submission of an 837 transaction to a sequential payer populated with data from the previous payer s 835. Based on the information provided and the level of policy, the claim may be adjudicated without the paper copy of the Explanation of Benefits from Medicare or the primary carrier. When more than one payer is involved on a claim, data elements for all prior payers must be present (i.e., if a tertiary payer is involved, then all the data elements from the primary and secondary payers must also be present). If data elements from previous payer(s) are omitted, Anthem will fail the particular claim Other COB Allowed Amount - Calculation If Loop 2320 CAS populated: Claims Total Charge (Loop 2400 SV = 001 (Rev)) minus any instance when adjustment amount (Loop 2320 CAS03,06,09,12,15) is unrelated to deductible, coinsurance and/or copayment. Loop 2320 CAS01 = CO, OA, PR, PI Loop 2320 CAS02 1, 2, 3 where 1 =Deductible, 2 =Co-insurance and 3 =Co-payment If Loop 2430 CAS populated: Claims Total Charge (Loop 2400 SV = 001 (Rev)) minus any instance when adjustment amount (Loop 2430 CAS03,06,09,12,15) is unrelated to deductible, coinsurance and/or copayment. Loop 2430 CAS01 = CO, OA, PR, PI Loop 2430 CAS02 1, 2, 3 where 1 =Deductible, 2 =Co-insurance and 3 =Co-payment If no CAS segments present in either Loop 2320 or 2430, Total Charge will be the allowed amount Claim and COB Balancing For COB claims, balancing is performed at both claim and service line on the payment charges for each payer. If not balanced, a 277CA and an 864 Level 2 Status Report will be returned to the submitter identifying which claim(s) have failed. Loop 2300 CLM02 (Total Claim Charge) must equal the sum of Loop 2400 SV203 (Line Item Charge). Loop 2320 AMT02 (COB Payer Paid Amount) must equal the sum of Loop 2430 SVD02 (Line Adjudication Information) less the sum of Loop 2300 CAS (Claim Level Adjustments). Loop 2400 SV203 (Line Item Charge Amount) must equal the sum of Loop 2430 SVD02 (Line Adjudication Information) plus the sum of Loop 2430 CAS (Claim Level Adjustments). Page 5 of 19

6 1.14 Preparing Unsolicited Attachments to Support a Claim (Loop 2300 PWK) Loop 2300 PWK segment is required when paper documentation (attachments) supports a claim. If sending attachment electronically (PWK02=EL) and using Medical Electronic Attachment vendor (MEA), enter prefix MEA and all alpha/numeric characters assigned as your tracking number (ex. MEA12345B) to become the Attachment Control Number (PWK06). If sending attachment by mail or by fax (PWK02=BM, FX), prepare a 151 Claim Information/ Adjustment Request (151) for each patient and claim requiring supporting documentation. The 151 is available from 1) VA Portal, or 2) VA > communications > answers & anthem > provider forms > 151. Complete the fields on the 151. Note that the attachment control # must be a unique identifier for each attachment claim constructed using the NPI, Member ID #, and date of service. Attachment Control Number YTA XXXXXXX National Provider Identifier (NPI) = Member ID # including prefix from ID card = YTA Date of Service (MMDDCCYY format) = Distinctive Provider-assigned Sequence # (OPTIONAL) = XXXXXXXXXX The claim and supporting documentation matches based on the attachment control number. If the number is not used, the claim may be denied. Multiple attachments to support a single claim use the same attachment control number and identified on the 151 with multiple documents attached. Illegible information will delay processing. If claim with supporting documentation is rejected, correct the claim using the same attachment control number. Anthem will hold the attachment and match the claim once it is received. However, if a new attachment control number is assigned for the retransmission of the claim, supporting documentation referencing the new attachment control number will need to be submitted Sending Unsolicited Attachments to Support a Claim Mail the attachment(s) the day before or the day the claim is submitted Do not send a copy of the claim with the attachment Do not send unnecessary attachments (i.e., do not send a copy of the member s ID card) Attach the 151 with the supporting documentation. If you send by mail or fax, include the attachment control # (matched on the 151) in the upper right hand corner of the supporting documentation. Mailing Address: Anthem BCBS Fax Number: (804) P.O. Box Richmond, VA Page 6 of 19

7 1.16 Claim and Billing Notes (Loop 2300 NTE) When appropriate, if supplemental information can be conveyed in 880 bytes or less, use the NTE segments rather than sending attachments (PWK). If a Claim Note requires more than 800 bytes, you may continue it in the allotted 80 bytes of the Billing Note segment; continuation is called overflow. When notes apply to a specific service rendered, enter the corresponding service line number from Loop 2400 LX01 at the beginning of the text. Unlisted or Non-Specific Supplies and Equipment - When appropriate, include the manufacturer s description of the supply or equipment in an NTE segment. Include Only Pertinent Information in NTE segments - In NTE segments, include only pertinent information. Information such as Anthem Blue Cross and Blue Shield, the name of the other insurance carrier or not a duplicate, may delay processing. Attachment and Notes (PWK and NTE) Type Revenue Codes (Inpatient or Outpatient) Lab or Pathology Revenue Codes ending in 9 (Other) Radiology Revenue Codes ending in 9 (Other) Other Revenue Codes ending in 9 (Other) HCPCS Procedure Codes (Outpatient) Unlisted and Non-Specific Surgery and Maternity Procedure(s) Unlisted and Non-Specific Radiology Procedure(s) Unlisted and Non-Specific Pathology and Laboratory Procedure(s) Other Unlisted or Non-Specific Services or Procedures that are not specifically listed as requiring attachments Supporting Notes and/or Attachments A complete description of the service or procedure. Attach pathology and/or lab report as applicable. A complete description of the service or procedure. Attach x-ray report as applicable. Complete description of the accommodation, service, supply or special charge. A complete description of the service or procedure. Attach operative report as applicable. A complete description of the service or procedure. Attach x-ray report as applicable. A complete description of the service or procedure. Attach pathology and/or lab report as applicable. Complete description of the service or procedure Medicaid Reclamation / Subrogation Claims (BHT06 = 31) Situations exist when a Patient who has BCBS as primary and Medicaid as secondary (last payer), indicates to the provider that he has Medicaid insurance only. The service is rendered and the provider bills Medicaid as primary. Medicaid pays the claim as the sole payer ( pays out of turn ) and later determines that the patient actually had primary insurance. In order to reclaim monies, states submit claims to the primary insurance after reconciliation of eligibility files between BCBS and Medicaid. Exempt from NPI, trading partners on behalf of states must submit specific data elements in Loops 2010AA, 2010AC, 2010BB, 2310A, 2310E and 2320 for Medicaid reclamation. Page 7 of 19

8 Section 2 - Front End Edits Business editing performed to check for data validity (for Anthem processing), data compatibility, and formatting. If error encountered, it is reported via the L3 Claims Adjudication Response report. Code 837I Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E0006 SUBSCRIBER NOT FOUND Submit valid member ID E0038 INVALID PROVIDER NUM Submit 6-position alphanumeric; not all zeroes/nines/alpha Only 3rd or 4th position may contain alpha character E0051 INVALID NAME Submit only A-Z, spaces, asterisks, hyphens and apostrophes 1st position must be alpha character E0055 INVALID STATE Submit valid state code per state/location table E0063 INVALID PROCEDURE CODE Submit valid procedure code for claim service line E0083 DATE CONFLICT Ensure Thru Date From Date, no greater than 365 days (366 leap year) Ensure Occurrence Span Thru Date Occurrence Span From Date E0117 INVALID NUMBER Number of units must be blank or numeric Number of units is required for the Revenue Code entered Number of units is required for Room and Board When Rev Code = 001, number of units must be blank E0124 INVALID CODE Valid patient status code: 01-07, 20, 30, 40-42, blank Discharge date must be absent for patient status code Valid gender code: F, M Valid Bill Type code: (Ex: , 131, 191, , 231, , , 821, 824, 831.) Valid Occurrence Code: 42, 70-77, blank Valid Condition Code: 01, 02, 04-17, 20,21, 31, 33, 35-40, 50-61, 66-77, First position of Diagnosis Code must be other than E. If any Revenue Code is or , Principal Procedure Code must not be blank Valid Patient Relationship to Insured Code: E0125 INVALID AMOUNT Value Code = 30, 83: value amount > 0 Value Code = 82, 85: value amount must be blank Rev Code is present, then original charge > 0 Rev Code = 189: original charge must be blank Rev Code = 182, 184: original charge = non-covered amount Total Charge > 0: non-covered amount < original charge E0126 INVALID DATE Ensure Current Date Date fields Ensure Admission Date Current Date Ensure Principal Procedure Date From Date Ensure Principal Procedure Date Through Date Submit Date of Birth for patient age 100 by adding 2 to current year (i.e., DOB 1887, current year > submit 1999) Page 8 of 19

9 Code 837I Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E0187 NUMBER CONFLICT If Rev code applies to Room & Board, number of units = (Last Date - First Date) If From Date = Thru Date, number of units must equal 2 E0222 INVALID FST DT Ensure First Date Date of Birth E0446 PROV PAY TO ONLY Submit individual ID number of provider who rendered the service E0522 AGE/ICD9 CONFLICT Diagnosis Code must be age-appropriate E0523 SEX/ICD9 CONFLICT Diagnosis Code must be gender-appropriate E0538 DIAGNOSIS NOT FOUND Submit valid Diagnosis code E0659 REV NUMBER REQ CONFLICT Combination of Revenue Code and Number is invalid E0756 SEX/SVCD CONFLICT Revenue code must be gender-appropriate E0757 AGE/SVCD CONFLICT Revenue code must be age-appropriate E1030 PROV NOT AUTH FOR SPEC PRG Value Code 80 only authorized for specific provider E1034 PRE-ADMT TEST? Value Code 30 and no rev code line items have description of Lab or Xray E1039 ACCIDENT/DIAG CONFLICT Diagnosis codes (accidents) must be associated with Occurrence Code of 01-05, 50 or 51 E1054 INVALID PROVIDER TYPE Type of provider does not submit this bill type E1188 INVALID DX Diagnosis Code valid for outpatient only E1189 POS/DIAG CONFLICT Diagnosis Code invalid for this bill type E1207 INVALID V DX/POS V-Code invalid for any bill type E1848 INVALID HCPCS/REV COMBINATION Combination of HCPCS and Rev Code is invalid E1849 INVALID HCPCS/REV DATE RANGE Admission Date does not fall between a valid effective/cancellation date range for this E1850 HCPCS/REV COMBINATION EXPIRED Combination of HCPCS and Rev Code on this claim has been cancelled on the OHAS table E1851 HCPCS CODE REQUIRED Facility must use HCPC codes with Rev Code to indicate what services are being rendered E2000 DRG EDIT AGE CONFLICT Diagnosis and/or procedure codes must be age-appropriate E2001 DRG EDIT E-CODE AS PRINCIPAL DX E-Code is not used as principal diagnosis E2002 DRG EDIT INVALID XXXXX CODE Diagnosis or procedure code is invalid Page 9 of 19

10 Code 837I Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E2003 DRG EDIT REQUIRES SECONDARY DX Secondary diagnosis code is required E2004 DRG EDIT SEX CONFLICT Diagnosis and/or procedure codes must be gender-appropriate E2005 DRG EDIT UNACCEPTABLE PRINCIPAL DX V-Code is not used as principal diagnosis E2007 DRG INVALID AGE, ADMIT,BIRTH Age, Admit/Discharge and Birth dates must be valid in order to assign DRG code E2009 DRG INVALID OR UNKNOWN DISCHARGE Discharge status is invalid E2100 DRG EDIT INVALID OR UNKNOWN SEX Patient gender is invalid E3021 LOC #45 DATE REQUIRED Submit valid date for services rendered E3022 LOC #45 DATE INVALID Submit valid date for services rendered E3023 LOC #45 DATE CONFLICT Submit valid date for services rendered E4130 INVALID PAT LAST NAME Submit only A-Z, spaces, asterisks, hyphens and apostrophes E4131 INVALID BIRTH DATE Ensure Birth Date Current Date E4145 INVALID BILL TYPE Valid bill type: INPATIENT = , , , , , , , , , ,322, , , , OUTPATIENT =131,135, ,141,145, , , , , , , , , , , , , , , ,831,835, E4149 INVALID ADM SOURCE Valid code: 1, 2, 3, 4, 5, 6, 7, 8, 9 E4150 INVALID PAT STATUS Submit for inpatient services Valid code: Do not submit 30 with Bill Type XX2 or XX3 E4151 INVALID CONDITION CD Valid code: 01-11,16-24,26-29,31-34,36-41,46,48,55-57,60,61,66,70-79,A0-A9,B3,C1-C7,DR Do not submit code 71 with code 74 on same claim E4152 INVALID OCCURRENCE CODE Codes 01, 02, 03, 04 or 05, must accompany value code of 45 Code 41 must accompany value code of 30 E4154 INVALID VALUE CODE Valid code:01,02,04-16,30,31,37-53,56-61,68,72-74,79-83,85,a0-a3,a8,a9,b1-b3,c1-c3,d3,d5,y1-y4 Submit value code = 30, if occurrence code = 41 Submit value code = 45 (accident time), if occurrence code = E4155 INVALID VALUE CODE AMOUNT For value code 02: amount = 0 For value code A1,B1,C1,A2,B2,C2,06,08,09,10,11: amount < total claim charge E4156 INVALID PRIN PROC CD Submit for inpatient services with revenue code , 0481, Page 10 of 19

11 Code 837I Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E4157 INVALID PROC CD DATE Ensure Proc CD Date Date of Birth Ensure Proc CD Date = DOS or falls within DOS range E4158 INVALID FROM DOS Ensure Date of Service Date of Birth Ensure Date of Service Date of Service (From) E4161 INVALID DIAGNOSIS CODE Submit at least one diagnosis code Do not submit codes beginning with 'E' E4162 INVALID CHARGE AMOUNT Amount must be numeric, populated, and 0 unless Revenue Code = 183, 189 E4164 INVALID UNITS For revenue code : units must be > 0 For revenue code 0001: units = 0 For revenue codes 0183, 0189: units must be > 0 and charge = 0 E4172 INVALID REVENUE CODE Submit revenue code 0001 on last line, if it applies to claim Submit revenue code 0001 on last line, if claim has 999 service lines Do not submit more than one occurrence of revenue code 0001 Do not submit revenue codes , 0652 for outpatient bill type E4173 INVALID RATE For revenue codes 0183, 0189: units must be > 0 and charge = 0 For revenue codes not 0183, 0189, 0023: charges must be > 0 E4174 INVALID SERVICE DATE Submit valid date for services rendered E4209 INVALID PAT FIRST NAME Submit only A-Z, spaces, asterisks, hyphens and apostrophes E4210 INVALID THRU DOS Ensure Date of Service Date of Birth Ensure Date of Service Date of Service (From) E4412 DEP NOT FOUND Dependent Information is not on file E4474 INVALID ADMIT QUAL Submit for inpatient services E4479 REPORT TYPE CODE REQUIRED Submit explanation of benefits (PWK01=EB) or other payer information (Loop 2320, 2330A, 2330B) when SBR01 not 'P' (secondary/tertiary claim) E4481 ORIGINAL REFERENCE NUMBER REQUIRED Submit if type of bill is XX5-XX8 format E4482 INVALID PRINCIPAL PROC CODE QUAL Submit 'BR' qualifier only E4483 INVALID OTHER PROC CODE DATE Ensure Other Proc CD Date Date of Birth Ensure Other Proc CD Date = DOS or falls within DOS range E4484 INVALID OTHER PROC CODE QUAL Submit 'BQ' qualifier only E4485 INVALID REPORT TRANSMISSION CODE Do not submit 'EM' or 'FT' Page 11 of 19

12 Code 837I Error Codes for Rejected/Failed Claims Business Pre-Adjudication Edits Level 3 Adjudicated Claims Response Report Description/Resolution E4486 PAYER PRIOR PAYMENT REQUIRED Ensure payer prior payment 0 E4495 MAX ERROR COUNT EXCEEDED Claim cannot exceed 999 errors E4500 NARRATIVE OR PWK REQUIRED Submit narrative or attachment for outpatient claim with 1) revenue code = XXX9 and no procedure code, or 2) procedure codes ending in '99' E4503 INVALID DAYS Days for Room and Board = units E4508 COB TOTAL NON COVERED When submitted, ensure 1) SBR01 not 'P'; 2) Other Subscriber Claim Filing Indicator qualifier not 'MA' or 'MB'; 3) Other Sub Claim Filing Indicator qualifier 'ZZ' and code = spaces; and 4) PWK Supplemental Report Type Code = 'EB' E4509 INVALID PROCEDURE CODE QUALIFIER Do not submit qualifier 'WK' or 'HP' (for Local and HMO claims only) E4541 SVCS NOT COVERED Medicaid Reclamation Only All service lines contain Procedure code starting with H, T or G0307, G9016, G9006, G9008, G9007, G9006, G9002, G0124, G9001 E4542 CLM FILED WRONG PLAN Medicaid Reclamation Only Member ID is not within the VA Service area E4566 POSSIBLE REL CODE CONFLICT Relationship Code does not match information on file for the claimant with this name E4564 LAB ONLY SUB CMS1500 PAR/PPO Facility Provider has signed Lab Agreement to bill lab only services on a professional CMS1500 form. Note: This edit excludes HMO, Medicare Advantage and Medicare Primary claim submissions. E4571 INVALID REV CODE PARTIAL DAY O/P Partial Day Psychiatric Services for statement date 07/01/14 and after must be submitted with revenue codes 905, 906, 912 and/or 913 only. Please correct your claim and resubmit. E4572 RESIDENTIAL TREATMENT INVALID I/P Residential Treatment claims submitted with bill type , 865 and/or received with admission date prior to 07/01/14 is invalid.resubmit. E4577 RESIDENTIAL TREATMENT INVALID REV I/P Residential Treatment claims submitted with bill type , 865 and/or received with admission date greater than or equal to 07/01/14 must be submitted with revenue codes other than 1001 and/or 1002 is invalid. Please correct your claim and resubmit. E4579 INCORRECT BILL TYPE OUTPATIENT O/P Institutional services received with bill type or 139 are invalid. Please correct your claim and resubmit. E4588 OBSERVATION HOURS EXCEEDED For Local Members. If Institutional Inpatient claim with a Bill Type ending in a "1" or a "2" Service Line contains Room and Board/Nursery Revenue Codes and the Admit Date is greater than the Facility contract on Observation hours in the Statement From date, please review Admit Date, correct and resubmit claim for processing. Page 12 of 19

13 Section 3 - Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 837 Institutional Health Care Claim Envelope Specific to Anthem (TR3, Appendix C) ISA Interchange GS Functional Group GE Functional Group IEA Interchange Control Header Header Trailer Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 refer to TR3 GS02 SENDER ID GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 EDI assigned ISA04 refer to TR3 Left-justified followed by ISA05 ZZ no zeroes or spaces ISA06 SENDER ID EDI assigned GS CMSCOS Left-justified GS04 refer to TR3 followed by spaces GS05 refer to TR3 GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 ANTHEM GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA NOTE. Critical Batching and Editing Information ISA13 refer to TR3 *Transactions must be batched in separate functional group by GS03. ISA14 refer to TR3 *Unique group control number (GS06) MUST NOT be duplicated within 365 days ISA15 refer to TR3 by Trading Partner ID (GS02); files containing duplicate or previously received ISA16 refer to TR3 group control numbers will be rejected. 837 Institutional Health Care Claim Envelope Specific to Anthem Medicaid Reclamation (TR3, Appendix C) ISA Interchange GS Functional Group GE Functional Group IEA Interchange Control Header Header Trailer Control Trailer ISA01 00 GS01 HC GE01 refer to TR3 IEA01 refer to TR3 ISA02 refer to TR3 GS02 SENDER ID GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 EDI assigned ISA04 refer to TR3 Left-justified followed by ISA05 ZZ no zeroes or spaces ISA06 SENDER ID EDI assigned GS03 MEDICAIDRECVA Left-justified GS04 refer to TR3 followed by spaces GS05 refer to TR3 GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 MEDICAIDREC GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA NOTE. Critical Batching and Editing Information ISA13 refer to TR3 *Transactions must be batched in separate functional group by GS03. ISA14 refer to TR3 *Unique group control number (GS06) MUST NOT be duplicated within 365 days ISA15 refer to TR3 by Trading Partner ID (GS02); files containing duplicate or previously received ISA16 refer to TR3 group control numbers will be rejected. Page 13 of 19

14 Section 4 - Charts for Situational Rules Listed below are loops, segments, and data elements required for proper adjudication by Anthem per the situational rules in the 837I TR3. TR3 Segment 837 Institutional Health Care Claim Reference Designator(s) Value Definitions and Notes Specific to Anthem P.67 ST ST03 Transaction Set Header Implementation Convention Ref P.68 BHT BHT06 CH Beginning of Transaction Type 31 Hierarchical Trx Code Loop ID 1000A Submitter Name P.71 NM1 Submitter Name NM109 Identification Code (Submitter Identifier) UPPERCASE P.73 PER Submitter EDI Contact Information - Refer to TR3 Loop ID 1000B Receiver Name P.76 NM1 Receiver Name NM103 Last Name or Organization Name NM109 Identification Code - Health Care Claim, Institutional CH - Chargeable required for Medicaid Reclamation EDI assigned Sender ID. Equals the value entered in ISA06 and GS02. ANTHEM HEALTH PLANS OF VIRGINIA INC - represents Receiver Name CMSCOS - Code represents Anthem Health Plans of Virginia, Inc. (DUNS with suffix) Loop ID 2000A Billing Provider Hierarchical Level P.78 HL Billing Provider Hierarchical Level - Refer to TR3 P.80 PRV Billing Provider Specialty Info PRV03 Reference Identification (Provider Taxonomy Code) It is strongly encouraged to enter the taxonomy code to uniquely identify the provider. P.81 CUR CUR02 USD USD - US dollars Foreign Currency Currency Code Monetary amounts recognized in US dollars Information only. Loop ID 2010AA Billing Provider Name P.84 NM1 Billing Provider Name NM103 Last Name or Organization Name Enter the provider name noted on the W-9 (Request for taxpayer Identification Number and Certification). P.87 N3 N301 (Billing Billing Provider Address Address Information Provider Address Line) Enter the physical address to uniquely identify the provider. Submitting PO Box/Lock Box address will result in claim failure, and return of 277CA and Level 2 Status report. P.88 N4 Billing Prov City, State, ZIP Code - Refer to TR3 P.90 REF REF02 (Billing Billing Provider Tax Reference Provider Tax Identification # Identification Identification #) P.91 PER Billing Provider Contact Information - Refer to TR3 Loop ID 2010AB Pay-To Address Name P.94 NM1 Pay-to Address Name - Refer to TR3 P.96 N3 Pay-to Address N301 Address Information (Pay-to Provider Address Line) Enter the address to uniquely identify the provider. If payment expected to be remitted to PO Box/Lock Box, submit in Pay-to loop. P.97 N4 Pay-To Address City, State, ZIP Code - Refer to TR3 Loop ID 2010AC Pay-To Plan Name P.99 NM1 Pay-to Plan Name NM103 Name Last or Organization Name (Pay-to Plan Organizational Name) *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 14 of 19

15 TR3 Segment Reference Value Designator(s) Loop ID 2010AC Pay-To Plan Name (cont'd) P.101 N3 P.102 N4 P.104 REF Pay-to Plan Address - Refer to TR3 Pay-to Plan City, State, ZIP Code - Refer to TR3 Pay-to Plan Secondary Identification - Refer to TR3 P.106 REF Pay-to Plan Tax Identification # REF02 Reference Identification (Pay-to Plan Tax Identification #) Loop ID 2000B Subscriber Hierarchical Level P.107 HL P.109 SBR Subscriber Hierarchical Level - Refer to TR3 Subscriber Information - Refer to TR3 Loop ID 2010BA Subscriber Name P.112 NM1 NM109 Subscriber Name Identification Code 837 Institutional Health Care Claim Definitions and Notes Specific to Anthem ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Enter format: Example Format Explanation XXX XXXX XXX999X99999 YTA ALTJ YTA123X character alpha prefix (uppercase) followed by 9-character alphanumeric subscriber ID code. R R R (uppercase) followed by 8-position numeric subscriber ID code. P.115 N3 P.116 N4 P.118 DMG P.120 REF P.121 REF Subscriber Address - Refer to TR3 Subscriber City, State, ZIP Code - Refer to TR3 Subscriber Demographic Information - Refer to TR3 Subscriber Secondary Identification - Refer to TR3 Property and Casualty Claim Number - Refer to TR3 Loop ID 2010BB Payer Name P.122 NM1 Payer Name NM103 Payer Name ANTHEM HEALTH PLANS OF VIRGINIA INC - represents Payer NM108 PI PI - Payer Identification ID Code Qualifier NM109 Identification Code (Payer Primary Identifier) CMSCOS P.124 N3 P.125 N4 P.127 REF Payer Address - Refer to TR3 Payer City, State, ZIP Code - Refer to TR3 Payer Secondary Identification - Refer to TR3 P.129 REF REF01 G2 G2 - Provider Commercial Number Billing Provider Ref ID Qualifier Secondary Identification REF02 Ref Identification (Billing Prov Secondary ID) Loop ID 2000C Patient Hierarchical Level P.131 HL P.133 PAT Patient Hierarchical Level - Refer to TR3 Patient Information - Refer to TR3 Loop ID 2010CA Patient Name P.135 NM1 P.137 N3 P.138 N4 P.140 DMG P.142 REF Patient Name - Refer to TR3 Patient Address - Refer to TR3 Patient City, State, ZIP Code - Refer to TR3 Patient Demographic Information - Refer to TR3 Property and Casualty Claim Number - Refer to TR3 *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 15 of 19

16 TR3 Segment Reference Designator(s) Loop ID 2300 Claim Information P.143 CLM CLM01 Claim Information Claim Submitter's Identifier CLM02 Monetary Amount CLM05 CLM05-3 Claim Frequency Type Code P.149 DTP Discharge Hour - Refer to TR3 P.150 DTP Statement Dates DTP03 Date Time Period P.151 DTP P.152 DTP P.153 CL1 P.154 PWK PWK02 P.158 CN1 P.160 AMT P.161 REF P.163 REF P.164 REF REF Institutional Claim Code - Refer to TR3 BM Report AA Transmission Code FX EL PWK06 Identification Code Value (Patient Control Number) (Total Claim Charge Amt) Value must equal the sum of submitted service line charges in Loop 2400 SV203. This data element used to identify the place of service. (Third Position If '5' (late charges), '7' (replacement) or '8' of Uniform (void/cancel) then the Payer Claim Control # Billing Claim is required and must contain Anthem's Form Bill Type) originally assigned claim number. (Statement From or To Date) Service Authorization Exception Code - Refer to TR3 Referral Number - Refer to TR3 Prior Authorization - Refer to TR3 P.166 REF01 F8 F8 - Original Reference Number Payer Claim Ref ID Qualifier Control Number REF02 Reference Identification (Claim Original Reference Number) P.167 REF P.168 REF P.169 REF Repriced Claim Number - Refer to TR3 Adjusted Repriced Claim Number - Refer to TR3 Investigational Device Exemption Number - Refer to TR3 P.170 REF REF01 D9 D9 - Claim Number P.172 REF P.173 REF P.174 REF P.175 REF P.176 K3 837 Institutional Health Care Claim Admission Date/Hour - Refer to TR3 Date-Repricer Received Date - Refer to TR3 Claim Supplemental Information Contract Information - Refer to TR3 Patient Estimated Amount Due - Refer to TR3 Claim ID for Transmission Intermediaries Ref ID Qualifier REF02 Reference Identification Auto Accident State - Refer to TR3 (Value Added Network Trace Number) Medical Record Number - Refer to TR3 Demonstration Project Identifier - Refer to TR3 PRO Approval Number - Refer to TR3 File Information - Refer to TR3 Definitions and Notes Specific to Anthem Maximum of 20 alphanumeric characters. Value is returned on outbound 835 and other transactions. Valid medical codes will be based on the "Statement From Date" BM - By Mail AA - Available on Request at Provider Site FX - By Fax EL - Electronic attachment Providers using MEA for claims attachment, enter "MEA" and all alpha/numeric characters assigned as your tracking number. (Ex: MEA12345B) Providers using mail/fax, submit the 151 Adjustment Request Form with the supporting documentation. Represents the claim number assigned by Anthem. Providers should submit the original claim number indicated on the 835 when Loop 2300 CLM05-3 Claim Freq. Type Code equals '5', '7' or '8'. Will be returned on Level 2 Status Report, if submitted. Page 16 of 19

17 TR3 Segment Reference Designator(s) Loop ID 2300 Claim Information (cont'd) P.178 NTE NTE02 Claim Note Claim Note Text P.180 NTE NTE02 Billing Note Billing Note Text EPSDT Referral - Refer to TR3 P.181 CRC 837 Institutional Health Care Claim Value Notes beyond 80 bytes overflow to NTE02 Billing Note. Also, field reserved for overflow from NTE02 Billing Note. Notes beyond 80 bytes overflow to NTE02 Claim Note. Also, field reserved for overflow from NTE02 Claim Note. ICD-10 Codes will not be accepted any earlier than October 1, ICD-9-CM Guide requires diagnosis codes to the highest level of specificity. Code is invalid if it has not been coded to the full number of digits required for that code. P.184 HI Principal Diagnosis Information - Refer to TR3 P.187 HI Admitting Diagnosis - Refer to TR3 P.189 HI Patient's Reason for Visit - Refer to TR3 P.193 HI External Cause of Injury - Refer to TR3 P.218 HI DRG Information - Refer to TR3 P.220 HI Other Diagnosis Information - Refer to TR3 P.239 HI Principal Procedure Information - Refer to TR3 P.242 HI Other Procedure Information - Refer to TR3 P.258 HI Occurrence Span Information - Refer to TR3 P.271 HI Occurrence Information - Refer to TR3 P.284 HI Value Information - Refer to TR3 P.294 HI Condition Information - Refer to TR3 P.304 HI Treatment Code Information - Refer to TR3 P.313 HCP Claim Pricing/Repricing Information - Refer to TR3 Loop ID 2310A Attending Physician Name Required for services (non-emergency ambulance transportation) populated in 2400, SV202-2 P.319 NM1 Attending Provider Name - Refer to TR3 P.322 PRV PRV03 (Provider Attending Physician Reference Taxonomy Specialty Info Identification Code) provider. P.324 REF Attending Prov Sec Identification - Refer to TR3 Loop ID 2310B Operating Physician Name P.326 NM1 P.329 REF Operating Physician Name - Refer to TR3 Operating Physician Secondary Identification - Refer to TR3 Loop ID 2310C Other Operating Physician Name P.331 NM1 P.334 REF Other Operating Physician Name - Refer to TR3 Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2310D Rendering Provider Name P.336 NM1 P.339 REF Rendering Provider Name - Refer to TR3 Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2310E Service Facility Location Name P.341 NM1 Service Facility NM103 Last Name or Location Name Organization Name N301). P.344 N3 P.345 N4 P.347 REF Service Facility Location Address - Refer to TR3 Serv Fac Loc City, State, ZIP - Refer to TR3 Service Facility Location Secondary Identification - Refer to TR3 Loop ID 2310F Referring Provider Name P.349 NM1 P.352 REF Referring Provider Name - Refer to TR3 Referring Provider Secondary Identification - Refer to TR3 Definitions and Notes Specific to Anthem It is strongly encouraged to enter the taxonomy code to uniquely identify the Complete this segment if services were rendered at a different location than entered in the Billing Provider (Loop 2010AA *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 17 of 19

18 TR3 Segment 837 Institutional Health Care Claim Reference Designator(s) Value Definitions and Notes Specific to Anthem For COB claims, enter data elements in Loops 2320, 2330A, 2330B and/or Loop ID 2320 Other Subscriber Information P.354 SBR P.358 CAS P.364 AMT P.365 AMT Other Subscriber Information - Refer to TR3 Claim Level Adjustments - Refer to TR3 COB Payer Paid Amount - Refer to TR3 Remaining Patient Liability - Refer to TR3 P.366 AMT COB Total Non- AMT02 Monetary Amount If populated, submit Explanation of Benefits to validate noncovered amount for Commercial COB claims (Loop 2300 PWK, Covered Amount 'EB'). P.367 OI P.369 MIA P.374 MOA Other Insurance Coverage Information - Refer to TR3 Inpatient Adjudication Information - Refer to TR3 Outpatient Adjudication Information - Refer to TR3 Loop ID 2330A Other Subscriber Name P.377 NM1 P.380 N3 P.381 N4 P.383 REF Other Subscriber Name - Refer to TR3 Other Subscriber Address - Refer to TR3 Other Subscriber City, State, ZIP Code - Refer to TR3 Other Subscriber Secondary Identification - Refer to TR3 Loop ID 2330B Other Payer Name P.384 NM1 P.386 N3 P.387 N4 P.389 DTP P.390 REF P.392 REF P.393 REF P.394 REF P.395 REF Other Payer Name - Refer to TR3 Other Payer Address - Refer to TR3 Other Payer City, State, ZIP Code - Refer to TR3 Claim Check or Remittance Date - Refer to TR3 Other Payer Secondary Identifier - Refer to TR3 Other Payer Prior Authorization Number - Refer to TR3 Other Payer Referral Number - Refer to TR3 Other Payer Claim Adjustment Indicator - Refer to TR3 Other Payer Claim Control Number - Refer to TR3 Loop ID 2330C Other Payer Attending Provider P.396 NM1 P.398 REF Other Payer Attending Provider - Refer to TR3 Other Payer Attending Provider Secondary Identification - Refer to TR3 Loop ID 2330D Other Payer Operating Physician P.400 NM1 Other Payer Operating Physician - Refer to TR3 P.402 REF Other Payer Operating Physician Secondary Identification - Refer to TR3 Loop ID 2330E Other Payer Other Operating Physician P.404 NM1 P.406 REF Other Payer Other Operating Physician - Refer to TR3 Other Payer Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2330F Other Payer Service Facility Location P.408 NM1 P.410 REF Other Payer Service Facility Location - Refer to TR3 Other Payer Service Facility Location Secondary Identification - Refer to TR3 Loop ID 2330G Other Payer Rendering Provider Name P.412 NM1 P.414 REF Other Payer Rendering Provider Name - Refer to TR3 Other Payer Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2330H Other Payer Referring Provider P.416 NM1 P.418 REF Other Payer Referring Provider - Refer to TR3 Other Payer Referring Provider Secondary Identification - Refer to TR3 Loop ID 2330I Other Payer Billing Provider P.420 NM1 P.422 REF Other Payer Billing Provider - Refer to TR3 Other Payer Billing Provider Secondary Identification - Refer to TR3 *Although loops, segments and/or data elements required for Medicaid Reclamation are clarified in the definition and notes as, they are not exclusive to Medicaid Reclamation type of claims only. Page 18 of 19

19 TR3 Segment Reference Designator(s) Loop ID 2400 Service Line Number P.423 LX Service Line Number - Refer to TR3 P.424 SV2 SV201 Institutional Service Product/Service ID Line SV202-2 Product/Service ID SV203 Monetary Amount Value (Service Line Revenue Code) (Procedure Code) (Line Item Charge Amt) P.429 PWK Line Supplemental Information - Refer to TR3 P.433 DTP DTP03 (Service Date) Date span may require an itemized bill. Service Date Date Time Period P.435 REF P.437 REF P.438 REF P.439 AMT P.440 AMT P.441 NTE P.442 HCP Line Item Control Number - Refer to TR3 Repriced Line Item Reference Number - Refer to TR3 Adjusted Repriced Line Item Reference Number - Refer to TR3 Service Tax Amount - Refer to TR3 Facility Tax Amount - Refer to TR3 Third Party Organization Notes - Refer to TR3 Line Pricing/Repricing Information - Refer to TR3 Loop ID 2410 Drug Identification P.449 LIN Drug Identification LIN03 Product/Service ID (National Drug Code) For Medicaid, submit the NDC # for prescribed drugs and biologics. P.452 CTP Drug Quantity CTP04 Quantity (National Drug Unit Count) For Medicaid, submit the drug quantity associated with NDC #. P.454 REF Prescription of Compound Drug Association Number - Refer to TR3 Loop ID 2420A Operating Physician Name P.456 NM1 P.459 REF Operating Physician Name - Refer to TR3 Operating Physician Secondary Identification - Refer to TR3 Loop ID 2420B Other Operating Physician Name P.461 NM1 P.464 REF Other Operating Physician Name - Refer to TR3 Other Operating Physician Secondary Identification - Refer to TR3 Loop ID 2420C Rendering Provider Name P.466 NM1 P.469 REF Rendering Provider Name - Refer to TR3 Rendering Provider Secondary Identification - Refer to TR3 Loop ID 2420D Referring Provider Name P.471 NM1 P.474 REF Referring Provider Name - Refer to TR3 Referring Provider Secondary Identification - Refer to TR3 Loop ID 2430 Line Adjudication Information P.476 SVD P.480 CAS P.486 DTP P.487 AMT Line Adjudication Information - Refer to TR3 Line Adjustment - Refer to TR3 Line Check or Remittance Date - Refer to TR3 Remaining Patient Liability - Refer to TR3 P.488 SE 837 Institutional Health Care Claim Transaction Set Trailer - Refer to TR3 Definitions and Notes Specific to Anthem If the value ends in '9', then either Loop 2300 PWK (Claim Supplemental Information) or Loop 2300 NTE (Claim Note) is required. Codes ending in '99' require notes, procedure description, or attachment (Loop 2300 PWK). Attending Provider (2310A) required for nonemergency ambulance transportation codes A0426, A0428 (without modifier QL). Sum of service line charges must equal the Total Claim Charge Amount in Loop 2300 CLM02. Page 19 of 19