Client Companion Guide

Transcription

1 for Viant Direct EDI Clients For HIPAA 837I TR X223A2 and 837P TR X222A1 Last Updated: December 3, 2012 Version: 2.0.5

2 Contents Document Control Summary... 4 Version 5010 Change Summary... 6 Purpose and Objective... 7 Overview How to use this Client Companion Guide General Information References Compliance Tools Definitions of Level 1, Level 2 and Level 3 Compliance Checks Viant Transaction Process Flow Process Flow Connectivity and Communications System Requirements Transmission Schedules Transmission Method PGP Keys FTP Account Support Contact File Naming Business Edit Error File Business Edit Results File FTP Directory Structure File Information Compliance Checking Delimiters Data In/Data Out Duplicate or Non-Sequential Claim File Submissions Unprintable Characters Copyright 2010 Viant, Inc. All Rights Reserved 2

3 4.6 Enveloping Transaction Set Header Loop SBR Segment Loop REF Segment Claim Identifiers Viant (OON) Inbound Data Elements HI Segment ICD-9 / ICD-10 Version Loop Viant (OON) Inbound Data Elements Processing/Repricing Results Network Pricing Results Loop 2300 NTE Loop 2300 HCP Loop 2400 NTE Loop 2400 HCP Invalid Codes Health Care Claim ASC X12N 837 Sender/Receiver Information File Acknowledgement (999s) Acknowledgement Response Time Provider Data Pricing Examples Appendix A: Viant Business Edits Appendix B: Viant Business Edit Results File Proprietary Format Appendix C: Trading Partner Setup Form Copyright 2010 Viant, Inc. All Rights Reserved 3

4 Document Control Summary Date Version Modified by Section(s) Modification Description 12/3/ H. Rolfsmeyer 4.3 Added bullet for overwriting inbound HCP segments New section added for indicating ICD9 vs. ICD10 codes in the HI segment 5.1 Corrected the segment for returning the claim received date Removed reference for rejecting ICD10 claims 5.2 Corrected the table for ineligible OON results; added a note for clarification 9 Corrected OON pricing examples 4/9/ D. Wittenberg Updated HSM network code description. 1/9/ S. Hunter Appendix C Added questions about single ST/SE envelope, nested claims and file naming conventions 6/28/ P. Strand Removed reference to OON-specific AMT and DTP segments. 5/16/ P. Strand Copyright page Added Institutional claim rules for Excluded Lines Added Loop 2430/Excluded Line general rule. Overview Purpose and Scope Deleted Changed verbiage for Section 8 description Removed references to Errata TR1 documents. Updated TR3 names to reflect Combined documents Expanded description of Level 3 financial balancing. Updated Viant-specific exclusions Section deleted. Renumbered subsequent 4.8 sections Removed OON AMT and REF segment rules Added K3 segment rules New section for SV207 Excluded Line option New Excluded Line section for Loop New section for UCR values an Loop New section for partial line amount disclaimer Section deleted Appendix A Removed note reference from VE013. 2/28/ P. Strand Added Viant HIPAA rule exclusions. Copyright 2010 Viant, Inc. All Rights Reserved 4

5 Date Version Modified by Section(s) Modification Description Changed support address to 3.7 Modified naming conventions and parameters for 999 files. 3.8 Added 5010 folder to example Added HCN, PHCS2, and TRP as possible HCP04 values Appendix A 10/22/ P. Strand Purpose and Scope /5/ P. Strand Appendix C Added error messages VE021, VE022, and VE023. Removed error message VE004. Added references to X12 Type 1 errata documents for 222A1 and 223A2 Added references to ISA11 Repetition Separator. Changed Viant outbound ISA11 value from a space to a caret ( ^ ). Copyright 2010 Viant, Inc. All Rights Reserved 5

6 Version 5010 Change Summary Version 5010 Change Summary Below is a list of Viant 837 Companion Guide rules that have been changed effective with HIPAA Version 5010 TR3s. # Viant sends Rate Sheet ID in Loop 2010AA REF*B3 segment 2 Viant sends Unique Provider ID in Loop 2010AA REF*1J segment 3 Viant sends Unique Network ID in Loop 2010AA REF*G5 segment 4 Viant sends Unique Location ID in Loop 2010AA REF*LU segment 5 OON: Client s claim received date sent in Loop 2300 DTP*050 segment N/A N/A N/A N/A OON: Client s claim received date sent in Loop 2300 K3 segment 6 N/A Viant sends the claim received date in Loop 2300 DTP*050 segment 7 Viant provider lookup uses Rendering Provider Tax ID, if present, else Billing Provider Tax ID 8 Viant exchanges 997 Functional Acknowledgements for all 837s received Viant provider lookup uses Billing Provider Tax ID Viant exchanges 999 Implementation Acknowledgements for all 837s received Copyright 2010 Viant, Inc. All Rights Reserved 6

7 Purpose and Objective Purpose and Objective Client Companion Guides are available to electronic Trading Partners to clarify information on HIPAAcompliant electronic data interchanges (EDI) with Viant. The information contained in this guide will address issues regarding how data is exchanged with Viant for repricing purposes and what information should be included in certain data fields. The following file characteristics are Viant s preferred expectations, and variations from any of the guidelines contained in the Client Companion Guide may result in an extended implementation timeline, depending on the modifications requested. This Client Companion Guide is to be used as a supplement to the following ASC X12N TR3 (combined) documents: Health Care Claim: Institutional (837), X223A2 published June 2010 Health Care Claim: Professional (837), X222A1 published June 2010 and as a supplement to the following ASC X12C TR3 document: Implementation Acknowledgement For Health Care Insurance (999), originally published June 2007 as X231 The purpose of this Client Companion Guide is to expedite the goal of achieving a totally electronic data interchange of health claims for a repricing environment. It should not be considered a replacement for the above mentioned Electronic Data Interchange TR3s, but rather used as an additional source of information. Rules for format, content, and field values can be found in the TR3s. This document describes the technical interface environment with Viant, including connectivity requirements and protocols, and electronic interchange procedures. The information provided in this document defines what Viant considers a standard 837 implementation and contains Viant s transmission requirements and preferences. It may be necessary during a client implementation to modify and/or supplement these Viant conventions. During the Trading Partner EDI implementation, the Trading Partner will be provided with a Client Implementation Document (CID) that outlines specifics of the Trading Partner requirements and any deviations from this Companion Guide that are determined to exist. Copyright 2010 Viant, Inc. All Rights Reserved 7

8 Overview How to use this Client Companion Guide Overview How to use this Client Companion Guide This Client Companion Guide is comprised of several major sections and a set of appendices. Each section builds on the preceding sections to help the Trading Partner determine the necessary steps to prepare for successful exchange of electronic transactions with Viant. Appendix C includes an example of the Trading Partner Setup Form to be completed by the Trading Partner and returned to Viant. Section 1: General Information Provides electronic data interchange references and explains the various levels of compliance checking performed by Viant Section 2: Viant Transaction Process Flow Provides an explanation and flowchart of the 837 claim and 999 Implementation Acknowledgement Section 3: Connectivity and Communications Explains the communications protocols, provides preliminary information regarding transaction exchanges with Viant, and provides standard file and FTP directory naming conventions Section 4: File Information Defines Viant s preferred expectations pertaining to the contents of the 837 claim files Section 5: Processing/Repricing Results Explains the values in claim segments for processed claims from Viant and the Reject Codes that may apply to a claim Section 6: Health Care Claims ASC X12N 837 Companion Documents Provides transaction information relevant to Trading Partners and Viant for the 837 Health Care Claim Professional and 837 Health Care Claim Institutional claim formats Section 7: File and Claim Acknowledgements (999s) Provides an explanation of the 837 file submission and the 999 response files Section 8: Provider Data Explains the standard provider data retrieval used by Viant Section 9: Pricing Examples Provides various examples of how 837 claim data will be returned to the Trading Partner Copyright 2010 Viant, Inc. All Rights Reserved 8

9 1. General Information 1. General Information 1.1 References The primary reference documents for the ASC X12N transactions are the TR3s and TR1 s published by Washington Publishing Company. The following resources may be helpful to a Trading Partner in electronic data interchanges. ASC X12N Insurance Subcommittee Technical Report Type 3 s ASC X12C Communications/Controls Subcommittee Technical Report Type 3 Washington Publishing Company Workgroup for Electronic Data Exchange Centers for Medicaid and Medicare Services National Uniform Billing Committee Department of Health and Human Services This Companion Guide is supplementary to the information provided in the TR3s. The applicable TR3s include: ASC X12 Standards for Electronic Data Interchange Technical Report Type 3: Health Care Claim: Institutional (837) X12N/005010X223A2 ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 Health Care Claim: Professional (837) X12N/005010X222A1 ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 Implementation Acknowledgement For Health Care (999) X12C/005010X Copyright 2010 Viant, Inc. All Rights Reserved 9

10 1. General Information 1.2 Compliance Tools Viant uses third party software as validation tools on inbound and outbound transactions exchanged during the implementation. Viant performs four levels of edit checking on claims. Those edits include: Level 1: Transaction Format (X12) Syntax Integrity Compliance Checking Level 2: Level 1 plus HIPAA TR3 Compliance Checking Level 3: Level 2 plus Balanced totals within the transaction. Viant Business Edits If the transaction successfully passes Level 1, Level 2 and Level 3 edits, a 999 Implementation Acknowledgement is returned indicating acceptance of the transaction. If the transaction fails Level 1, Level 2 or Level 3 compliance checking, the 999 Implementation Acknowledgement will report the errors as outlined in the Acknowledgement Files (999s) section. The 999 is Viant s standard acknowledgement. Viant maintains the capability of utilizing the 997 Functional Acknowledgement transaction for Trading Partners unable to support the 999. Transactions that fail at the Viant Business Edit validation are returned to the Trading Partner in a separate 837 file. If Trading Partner is unable to accept the error file in 837 format, a Viant proprietary text format is also available. Refer to section Business Edit Error File for more detail Definitions of Level 1, Level 2 and Level 3 Compliance Checks Level 1: Transaction Format (X12) Syntax Integrity Compliance Checking ISA length (106 bytes, fixed length) Legal/valid separators and terminators X12 Standards Requirements Valid Loops/Segments Segment Order Data Element Attributes (i.e.; Mandatory, Min/Max Sizes, etc.) Numeric Validations X12 Syntax Validations X12 Rules Level 2: Level 1 plus HIPAA Implementation Specification Requirements (Compliance with basic outlines of a TR3 without relational checks) Repeat Counts Used and Not Used Codes, Elements and/or Segments Required or Intra-Segment Situational Data Elements Validation of Non-Medical Codes Contained within the TR3 Code Referenced within the TR3 Copyright 2010 Viant, Inc. All Rights Reserved 10

11 1. General Information Level 3: Level 2 plus Balanced Totals within the Transaction (checking for simple counts and balancing within the transaction set no relational checking.) Financial Balancing Balancing o Total claim amount equals sum of line item amounts. o Line item amount equals sum of any adjustment amount (CAS segment) and allowed amount (SVD segment) used by Viant for Excluded Line and UCR values. Segment Counts Transaction Counts Summary Data Elements Viant-specific exclusions: Viant has relaxed the HIPAA edits and will accept the following: Loop 2310A and 2310D NM1 segments specifying a Person (NM102 = 1 ) but without a First Name (NM104) NPIs without check digit integrity in any Provider loop P.O. Box address in Billing Provider Loop 2010AA 5-digit zip code in Billing Provider Loop 2010AA and Service Facility loops (Professional 2310C and Institutional 2310E) SBR data elements 03 and 04 both populated in a single occurrence of the segment Sender s Claim ID (REF*D9) up to 27 characters in length Duplicate diagnosis codes (HIxx -1 with qualifier = BF) Viant Business Edits: In addition to checking for X12 and HIPAA compliance, Viant applies business edits to each 837 transaction. See Appendix A: Viant Business Edits for the list of edits performed on Trading Partner s claims during the Viant Business Edit validation step. Copyright 2010 Viant, Inc. All Rights Reserved 11

12 2. Viant Transaction Process Flow 2. Viant Transaction Process Flow 2.1 Process Viant EDI processing is a critical component to the exchange of electronic data transactions with Trading Partners, and it expedites the movement of transactions to the destinations by performing the following functions: Editing for syntax according to the X12 Control and Transaction standards Balancing control segments Returning the 999 Implementation Acknowledgment Routing transactions to appropriate destinations This section provides an explanation and diagram of the Viant claim process flow. The following steps are performed after the Trading Partner has completed and returned the Trading Partner Setup Form (found in Appendix C), provided their PGP key, and an FTP tunnel has been established. Trading Partner extracts and transmits 837 claims to Viant Viant loads 837 Health Care Claim transactions, performs compliance checking and returns a detailed 999 Implementation Acknowledgement to the Trading Partner in their outbound directory (as described in FTP Directory Structure) for each claim file received Viant performs Viant Business Edits on transactions that have passed Level 1, Level 2 and Level 3 compliance checking Viant performs repricing activities Viant extracts 837 Health Care Claim transactions to Trading Partner and posts to the Trading Partner s outbound directory Viant extracts a file for Trading Partner to identify claims that do not pass Viant Business Edits and places the file in the Trading Partner s outbound directory Trading Partner retrieves 999 files, corrects claims with errors and resubmits claims in another transmission Trading Partner retrieves and loads 837 processed claim file and returns a detailed 999 Implementation Acknowledgement to Viant Viant loads the 999 files, corrects claims with errors, and resubmits claims in another transmission Copyright 2010 Viant, Inc. All Rights Reserved 12

13 2. Viant Transaction Process Flow 2.2 Flow The diagram below shows the basic claim flow for a standard Viant EDI Implementation. Copyright 2010 Viant, Inc. All Rights Reserved 13

14 3. Connectivity and Communications 3. Connectivity and Communications To setup a communication link with Viant, the Trading Partner must first complete and submit the Trading Partner Setup Form that can be found in Appendix C. This form provides Viant with basic information needed for the EDI implementation. The Trading Partner must also provide Viant with their public PGP key. After the Trading Partner Setup Form is completed and submitted to Viant, the necessary information to establish connectivity and communications will be sent to the Trading Partner based on the data provided within the request form. 3.1 System Requirements In order to exchange transaction files electronically to the Viant FTP Server, you should be able to perform the following: Create an electronic file in the required ASC X12N format as indicated in the TR3 and this Client Companion Guide Pre-edit all required fields for content and format before the files are transferred Name and send the files as outlined in the File Naming section Correct and resubmit electronic transactions that fail front-end (Level 1, Level 2 and Level 3) 3.2 Transmission Schedules Agreed upon transmission schedules will be determined during the EDI implementation and will be described in the individual CID for each Trading Partner. Please refer to that specific document for transmission schedule expectations. 3.3 Transmission Method To protect PHI data (Protected Health Information) Viant requests that data be processed via Viant standard FTP transmission with PGP encryption which applies an adequate level of protection. Viant will be the host of the FTP site. The host that the Trading Partner will connect to for Production files is ecv01.viant.com. The host that the Trading Partner will connect to for Test files is ecv02.viant.com. This hostname should be used as opposed to the IP address, as the IP address may change in the future. If IP specific information needs to be exchanged to allow access through firewalls, etc, the Trading Partner should work with the Client Implementation Manager at Viant to get these specifics. 3.4 PGP Keys Viant will encrypt all files for the Trading Partner using a PGP key. Likewise, Viant expects all files to be encrypted with a PGP key (Key ID 0xB15D0C7A). PGP keys will be exchanged during the EDI implementation. Copyright 2010 Viant, Inc. All Rights Reserved 14

15 3. Connectivity and Communications 3.5 FTP Account Viant will provide two FTP user accounts one for production use and the other for system test use. The login and password information will be provided during the EDI implementation. 3.6 Support Contact Viant OPS Support can be reached via at 24 hours per day, 7 days per week. Viant requests a technical and business contact and the days and hours of availability for each from the Trading Partner. These can be supplied to Viant on the Trading Partner Setup Form. 3.7 File Naming Viant has established standard naming conventions for inbound and outbound ASC X12 transactions for automated transaction processing. The following is Viant s standard file naming convention: XXXXXX will be the assigned code that represents the Trading Partner # represents either I for institutional or P for professional claims CCYYMMDDHHMMSS is the date and time stamp NNNN represents a unique number used to differentiate 999 file names Inbound to Viant from Trading Partner: Claim File: XXXXXX_837#_IN_CCYYMMDDHHMMSS 999 File: XXXXXX_999_IN_CCYYMMDDHHMMSSNNNN Outbound to Trading Partner from Viant: Processed Claim File: XXXXXX_837#_OUT_CCYYMMDDHHMMSS 999 File: XXXXXX_999_OUT_CCYYMMDDHHMMSSNNNN Error File: ERRXXXXXX_837#_OUT_CCYYMMDDHHMMSS Business Edit Error File The Business Edit Error file is an 837 file containing claims that have passed initial compliance checking but have not passed the Viant business edits, which are outlined in Appendix A. An NTE segment containing the Viant error code and description will be included in the 2300 Loop of each claim returned in the Business Edit Error file. This file will be placed in the Trading Partner s outbound directory after it has been created. Example: NTE*ADD*VE010 Admission Date cannot be greater than current date~ Copyright 2010 Viant, Inc. All Rights Reserved 15

16 3. Connectivity and Communications Business Edit Results File If the Trading Partner is unable to accept the error file in X12N 837 format, a Viant proprietary text format is also available. See Appendix B for the proprietary file layout. The proprietary Results file name is associated with the inbound claim file from the Trading Partner, prefixed with BER. This naming convention is used to provide an easy method of identifying the associated inbound claim file. Proprietary Business Edit Results File Name: BERXXXXXX_837#_IN_CCYYMMDDHHMMSS 3.8 FTP Directory Structure Viant has established a standard directory structure for inbound and outbound ASC X12 transactions for automated transaction processing. Directories are named relevant to Viant, so files that are sent to Viant should be placed in the inbound directory, and files being picked up from Viant should be pulled from the outbound directory. Claim files, 999 Implementation Acknowledgements, and error files from Viant are placed in the Trading Partner s outbound directory. Once a data file has been successfully retrieved from the outbound directory, it is expected that the Trading Partner will delete it. If files are not retrieved and deleted by Trading Partner within 15 days, they will be automatically deleted by Viant. Trading partners may have a need to support Versions 4010 and 5010 concurrently. Viant will provide a separate 5010 directory inbound5010 in order to keep claims of the two versions separate. Trading Partners will see only those folders applicable to their implementation. The following is an example of Viant s directory structure: (user account) +- inbound +- inbound outbound Copyright 2010 Viant, Inc. All Rights Reserved 16

17 4. File Information 4. File Information This section provides information to help Trading Partners prepare for the ASC X12N 837 Health Care Claims (837) transactions. The following file characteristics are Viant s preferred expectations, and variations from any of the guidelines documented below may result in an extended implementation timeline, depending on the modifications requested. 4.1 Compliance Checking Viant strongly recommends that Trading Partners perform Level 3 compliance checking on all claim file exchanges with Viant to reduce the number of rejected transactions. See the section Definitions of Level 1, Level 2 and Level 3 Compliance Checks for compliance checking performed by Viant. 4.2 Delimiters Viant can accept any commonly recognized segment and element delimiters, however, the use of unprintable characters or characters that may appear as data content is discouraged. Therefore, Viant recommends the use of the delimiters defined in the following table: Character Name Delimiter * Asterisk Data Element Separator : Colon Sub-element Separator ^ Caret Repetition Separator ~ Tilde Segment Terminator If the Trading Partner uses delimiters other than those shown in the above table, it is critical that they be indicated in the Trading Partner Setup Form which can be found in Appendix C. Failure to do so may result in the data file being rejected by Viant or a 999 Implementation Acknowledgement not being returned. In order to ensure end-to-end operability, Viant will suppress certain characters found in alphanumeric data elements when forwarding claims to third-party repricers. The following characters will be converted to spaces when being forwarded to a third-party. Character Name * Asterisk : Colon ~ Tilde Pipe (vertical bar) ` ^ Tick Caret < Left Arrow > Right Arrow Copyright 2010 Viant, Inc. All Rights Reserved 17

18 4. File Information 4.3 Data In/Data Out All data sent in the inbound file to Viant will be returned to the Trading Partner along with the repricing information, with the exception of the following: Loop 2300 NTE segments may be used in the outbound file from Viant to provide information pertaining to not priced claims (see Section for more detail). If the Trading Partner submits an NTE segment in Loop 2300 on a claim that cannot be repriced, Viant will overwrite the Trading Partner information and return the Viant information. Loop 2300 K3 segments may be used to provide the client with additional claim processing comments. If the Trading Partner submits K3 segments on the inbound file, and Viant requires the use of ten (10) segments, Viant will overwrite the Trading Partner information and return the Viant information. Loop 2300 and Loop 2400 HCP segments are used to provide the client with the claim repricing details. In the event the Trading Partner submits HCP segments on the inbound file, Viant will overwrite the Trading Partner information and return the Viant information. 4.4 Duplicate or Non-Sequential Claim File Submissions To avoid unnecessary processing, do not send a claim file more than once. If there is concern that Viant did not receive a claims submission, contact Viant OPS Support as specified in 3.6 Support Contact. Viant OPS Support will research the situation and provide a solution. If a duplicate claim file is submitted, Viant can reject the file in its entirety and the Trading Partner can be notified by Viant that the file was rejected. A duplicate claim file is identified as a claim file containing a previously submitted Group Control Number in GS06 of the Functional Control Header by the same Trading Partner. Viant can also verify that the Group Control Number in GS06 is sequential. This is to ensure that Viant has not inadvertently missed a file transmission. If the Group Control Number is not sequential, the claim file can be held for review. An EDI Analyst can contact the Trading Partner to determine if a file was missed or if the EDI Analyst will need to increment the Group Control Number to accept the file. The Trading Partner will indicate on the Trading Partner Setup Form if sequential incrementing of the GS06 will be provided in the inbound claim files to Viant. Viant strongly encourages and recommends that the Trading Partner provide sequentially incremented Group Control Numbers. 4.5 Unprintable Characters The file should not contain any unprintable characters, including carriage returns, line feeds or other new line characters. Copyright 2010 Viant, Inc. All Rights Reserved 18

19 4. File Information 4.6 Enveloping The purpose of an electronic envelope is to control and track communications between the Trading Partner and Viant. One envelope may contain many transactions grouped into functional groups. The envelope includes the following components: Interchange Control Header (ISA) Interchange Control Trailer (IEA) Functional Group Header (GS) Functional Group Trailer (GE) Viant requests that each file contain one Interchange Control and one Functional Group per claim file. This request results in a separate file for institutional claims and a separate file for professional claims. Submission of multiple envelopes within a single transaction file is considered outside of the Viant standards and will ultimately result in an extended implementation timeline. When constructing your data files, Viant will expect that you submit one file per Payer Identification Number. The Trading Partner Interchange Control Structure must reflect this requirement. This will restrict your Interchange Control Structure to one Functional Group Header [GS] per Communication Envelope (transmitted data file). The outbound 837 file from Viant will contain the value 0 in the ISA14 element. Viant does not support the Interchange Acknowledgements (TA1) Transaction Set Header Viant requests that each claim in the transaction file be wrapped individually in its own ST/SE Segments. Wrapping each claim individually eliminates the rejection of an entire claim file when a single claim within the file fails validation. Additionally, wrapping each claim individually provides the detail needed in order for Viant to return detail reject reasons within the 999 Implementation Acknowledgments. Viant can have partial claim file acceptance if the file has multiple ST/SE batches. 4.7 Loop SBR Segment Viant requires that a valid active Viant Client ID be submitted on each claim record for accurate processing. The Client ID will be passed in the Loop 2000B SBR03 field. The client s Viant account manager will work with the client as necessary to ensure that this element is populated correctly. Copyright 2010 Viant, Inc. All Rights Reserved 19

20 4. File Information 4.8 Loop REF Segment Claim Identifiers The following table defines the transmission of data elements relative to Loop ID 2300 Claim Information pertaining to claim numbers. The REF*D9 claim number is used at Viant for claim support. Qualifier Inbound from Trading Partner Outbound from Viant REF*D9 Trading Partner Claim Number Trading Partner Claim Number REF*9A Not Applicable Viant Claim Number REF*F8 Not Applicable Third Party Repricer Claim Number, if applicable Viant (OON) Inbound Data Elements A Trading Partner may purchase Viant Out of Network (OON) services, such as Provider Negotiation Services. In this case, additional information may be required, depending on the implementation. Because the HIPAA 837 Companion Guides do not recognize these requirements, some data that Viant (OON) may require should be placed in K3 segments in order to maintain HIPAA compliancy. Loop Seg ID Data Description Ref Viant Description/Value 2300 K3 File Information Fixed Format Information: Client Received Date K301 Pos 1-5: DATE; Pos 6-10: CRDT= Pos 11-18: CCYYMMDD 2300 K3 File Information Fixed Format Information: Drop Dead Date K301 Pos 1-5: DATE; Pos 6-10: DROP= Pos 11-18: CCYYMMDD 2300 K3 File Information Fixed Format Information: Payer Liability Amount K301 Pos 1-5: AMTS; Pos 6-10: LIAB= Pos 11-21: K3 File Information Fixed Format Information: UCR Amount K301 Pos 1-5: AMTS; Pos 6-10: UNC= Pos 11-21: Copyright 2010 Viant, Inc. All Rights Reserved 20

21 4. File Information OON Date Examples K3*DATE;CRDT=CCYYMMDD K3*DATE;DROP=CCYYMMDD (Client Received Date) (Drop Dead Date) OON Monetary Amount Examples K3*AMTS;LIAB= (Payer Liability Amount = $125.10) K3*AMTS;UNC= (UCR Amount = $ ) Monetary Amounts are expressed as: Variable length with a maximum length of 10 characters Explicit decimal point is required Leading zeroes not required HI Segment ICD-9 / ICD-10 Version Viant s systems have been upgraded to accept and handle ICD-10 codes. It is expected that trading partners will not mix ICD-9 codes and ICD-10 codes within a single claim; each claim will have either all ICD-9 codes or all ICD-10 codes. The qualifier for the Principal Diagnosis Code, submitted in the Loop 2300 HI01-1 field, will determine the ICD Version that will be used at Viant for repricing: - When this value is BK, then the ICD Version will be set for ICD-9 coding - When this value is ABK, then the ICD Version will be set for ICD-10 coding 4.9 Loop Viant (OON) Inbound Data Elements This section outlines the Viant standard field designations for data elements that may be required for non-network services Excluded Lines Excluded lines can be expressed in two ways: In Loop 2430 (see below) In data element SV207 (Institutional claims only) Copyright 2010 Viant, Inc. All Rights Reserved 21

22 4. File Information SV207 example To Exclude a line, enter a SV207 amount equal to the SV203 line charge. Institutional Claim Rules: When a claim Service Line includes a Loop 2430 CAS segment with CAS01 = PI, CAS02 = 96 and CAS03 = SV203, the line will be considered Excluded; or When SV207 is present and = SV203, the line will be considered Excluded. When a claim Service Line contains a CAS02 = 96, the comparative values of SV203 and SV207 (if present) will be ignored. When a claim Service Line contains a CAS02 = 96 and CAS03 is not = SV203, the Line will not be considered Excluded Loop 2430 Line Adjudication Information (Excluded Lines) Excluded lines are considered to be adjusted lines. Excluded line information is provided in the 2430 Loop Line Adjudication Information, Segments SVD, CAS and DTP, as defined in the X12N Health Care Claim TR3 documents. Note that when the 2430 Loop is created, additional segments are required. These segments should be defaulted per the example below: Seg Data Description Ref Field Value SVD Service Line Adjudication Info Identification Code SVD01 Set to Monetary Amount SVD02 Set to 0 Composite Medical Procedure Identifier SVD03 Product/Service Identifier SVD03-1 Set to HC = HCPCS Not required on Institutional (X223A2) claims. Product/Service ID SVD03-2 Set to the value from the corresponding SV101-2 (Not Used by Viant) SVD03-3 thru 8 N/A Product/Service Identifier SVD04 Set to corresponding SV201 value or 999 on Institutional (X223A2) claims. Quantity SVD05 Set to 1 Not Used on Professional (X222A1) claims. CAS Service Line Adjustment Claim Adjustment Group Code CAS01 Set to PI = Payer-Initiated Copyright 2010 Viant, Inc. All Rights Reserved 22

23 4. File Information Seg Data Description Ref Field Value Claim Adjustment Reason Code CAS02 Set to 96 = Non-Covered Charge Adjustment Amount CAS03 Set to the SV102 (Professional) or SV203 (Institutional) DTP Service Adjudication Date Date/Time Qualifier DTP01 Set to 573 = (Claim Paid Date) Date/Time Period Format Qualifier DTP02 Set to D8 = CCYYMMDD Date/Time Period DTP03 Set to the value of the corresponding Service Line Date (Institutional) or Set to the value of the corresponding Service Date (Professional) General Claim Rule: If a claim Service Line contains a Loop 2430, but CAS01 is not = PI and/or CAS02 is not = 96, the Line will not be considered Excluded. Excluded Line Example Inbound Claim To Viant (Professional) CLM* *1015***21:B:1*Y*C*N*Y*B~ REF*D9*NP ~ HI*BK:78900*BF:56211~ LX*1~ SV1*HC:74160:26*328*UN*1*21**1~ DTP*472*RD8* ~ AMT*F9* ~ LX*2~ SV1*HC:72193:26*290*UN*1*21**2~ DTP*472*RD8* ~ LX*3~ SV1*HC:76380:26*397*UN*1*21**2~ Line charge(sv102) = $ DTP*472*RD8* ~ Service date = November 11, 2009 SVD*99999*0*HC:76380**1~ Adjusted line amount (SVD02) = 0.00 CAS*PI*96*397~ Adjustment amount (CAS03) = $ DTP*573*D8* ~ Adjustment date (DTP03) = Service Date Repriced Claim Outbound From Viant (Professional) CLM* *1015***21:B:1*Y*C*N*Y*B~ Submitted claim charge (CLM02) = $ REF*D9*C0E0A83063~ REF*9A*NP ~ HI*BK:78900*BF:56211~ HCP*10*525.3**BEEACP~ Claim repriced amount (HCP02) = $ LX*1~ SV1*HC:74160:26*328*UN*1*21**1~ Line #1 submitted charge (SV102) = $ DTP*472*RD8* ~ HCP*10*278.8~ Line #1 repriced amount (HCP02) = $ LX*2~ Copyright 2010 Viant, Inc. All Rights Reserved 23

24 4. File Information SV1*HC:72193:26*290*UN*1*21**2~ Line #2 submitted charge (SV102) = $ DTP*472*RD8* ~ HCP*10*246.5~ Line #2 repriced amount (HCP02) = $ LX*3~ SV1*HC:76380:26*397*UN*1*21**2~ HCP*00*0~ Excluded line not repriced DTP*472*RD8* ~ SVD*99999*0*HC:99999**1~ CAS*PI*96*397~ DTP*573*D8* ~ Loop 2430 Line Adjudication Information (UCR) Lines containing UCR information are considered to be adjusted lines. UCR is provided in the 2430 Loop Line Adjudication Information, Segments SVD, CAS and DTP, as defined in the X12N Health Care Claim TR3 documents. Note that when the 2430 Loop is created, additional segments are required. These segments should be defaulted per the example below: Seg Data Description Ref Field Value SVD Service Line Adjudication Info Identification Code SVD01 Set to Monetary Amount SVD02 Set to the value of the corresponding SV102 (Professional) or SV203 (Institutional), minus the corresponding CAS03 value Composite Medical Procedure Identifier SVD03 Product/Service Identifier SVD03-1 Set to HC = HCPCS Not required on Institutional (X223A2) claims. Product/Service ID SVD03-2 Set to the value from the corresponding SV101-2 (Not Used by Viant) SVD03-3 thru 8 N/A Product/Service Identifier SVD04 Set to corresponding SV201 value or 999 on Institutional (X223A2) claims. Quantity SVD05 Set to 1 Not Used on Professional (X222A1) claims. CAS DTP Service Line Adjustment Claim Adjustment Group Code CAS01 Set to PI = Payer-Initiated Claim Adjustment Reason Code CAS02 Set to A7 = Presumptive Payment Adjustment Adjustment Amount CAS03 Set to the UCR amount Service Adjudication Date Date/Time Qualifier DTP01 Set to 573 = (Claim Paid date) Date/Time Period Format Qualifier DTP02 Set to D8 = CCYYMMDD Date/Time Period DTP03 Set to the value of the corresponding Service Line Date (Institutional) or Set to the value of the corresponding Service Date (Professional) Copyright 2010 Viant, Inc. All Rights Reserved 24

25 4. File Information Inbound Claim To Viant (Professional) CLM* *397***21:B:1*Y*C*N*Y*B~ REF*D9*NP ~ HI*BK:78900*BF:56211~ LX*1~ SV1*HC:76380:26*397*UN*1*21**2~ Line charge (SV102) = $ DTP*472*RD8* ~ Service date = November 11, 2009 SVD*99999*197*HC:76380**1~ Adjusted line amount (SVD02) = $ CAS*PI*A7*200~ UCR (CAS03) = $ DTP*573*D8* ~ Adjustment date (DTP03) = Service Date Loop 2430 Line Adjudication Information (Partial Line Amounts) Viant does not recognize partial line amounts. Lines are either excluded or eligible for repricing at the submitted charge amount. Copyright 2010 Viant, Inc. All Rights Reserved 25

26 5. Processing/Repricing Results 5. Processing/Repricing Results When claims are processed by Viant and returned to the Trading Partner with pricing results, the Trading Partner needs to accurately interpret Viant s repricing methodology and Reject/Reason Codes associated with the claim. This section outlines the data elements the Trading Partner will be receiving from Viant. 5.1 Network Pricing Results The following table shows the additional data elements that may be populated when Viant processes a claim, depending on the processing results. Loop Segment Note 2300 DTP When DTP01 = 050, DTP02 contains the date Viant loaded the claim 2300 REF When REF01 = 9A, REF02 contains the Viant Claim Number 2300 K3 K301 contains ADD followed by a space and an external comment which provides more information about how the claim was processed 2300 NTE See section below 2300 HCP See section below 2400 NTE See section below 2400 HCP See section below Loop 2300 NTE02 Claims that pass the Viant compliance and business edit validations may be rejected during the repricing process. Rejected claims will be returned with the 2300 NTE segment formatted as follows: NTE01 = ADD NTE02 = Reject Code followed by Reject Reason If a Trading Partner submits a Loop 2300 NTE segment on a claim that cannot be repriced, the 2300 NTE segment will be set on the return file to the Reject Code and Reject Reason, and the Trading Partner will not get back the original data. Claim-Level Reject Code Descriptions Reject Code Reject Reason 001 Client ID Not Active for Date of Service Notes Claim received by Viant with a date of service prior to Client s effective date or after Client s termination date 002 Duplicate Claim Claim has already been received by Viant 013 Client ID Not Found Claim received by Viant with a Client ID not found in Viant s system Copyright 2010 Viant, Inc. All Rights Reserved 26

27 5. Processing/Repricing Results Reject Code Reject Reason Notes 102 Corrected Bill Claims with Bill Type ending in 6 or 7 are rejected if there is no prior claim history 104 Interim & Late Bill Claims with Bill Type ending in 3, 4 or 5 are rejected if there is no prior claim history 105 Invalid Bill Type Inpatient claim with no room and board lines or an outpatient claim that does have room and board lines may be rejected if appropriate pricing cannot be determined 107 Investigation Required Claims with questionable or missing data or involving undefined business rules will be rejected 109 No Number of Units Indicated for Per Diem Rates Claims submitted with room & board days equal to zero may be rejected if appropriate pricing cannot be determined 602 Non-contracted provider Provider on the claim is non-contracted under the eligible networks 603 Non-contracted services Provider on the claim is contracted, but there are no rates for the specified services on the claim Loop 2300 HCP Claims that have been submitted for repricing against a network contract will be returned with the 2300 HCP segment set as follows. Unsuccessful pricing refers to claims that have failed the Viant business edits, are non-par, or have been rejected. Viant business edits and associated error numbers are listed in Appendix A. Seg Data Description Ref Viant Description/Value HCP Health Care Pricing (Successful Repricing) Pricing Methodology HCP01 Set to 10 = Other Pricing Allowed Amount HCP02 Set to claim allowed amount Repricing Organization ID HCP04 Set to Network Code HCP Health Care Pricing (Unsuccessful Repricing) Pricing Methodology HCP01 Set to 00 = Zero Pricing Allowed Amount HCP02 Set to 0 Reject Reason Code HCP13 Set to T1 = Claim is non-par Set to T6 = Claim has failed Viant business edits or has been rejected Copyright 2010 Viant, Inc. All Rights Reserved 27

28 5. Processing/Repricing Results Viant will return a Network Code in the 2300 HCP04 on claims that have been successfully repriced using a network contract so that the client may correctly reflect the network that was used to reprice the claim on the EOB. HCP04 Possible Network Code values Network Code BEE BEEACP BEEWRP CHP FCHN FPN HCN HMAPPO HSM IHP ILP IPH IMX MMP MPI PHCS2 PH1 TRB TRM TRN TRP TTC TTCWP TTCWRAP VHNACP VHNWRP VHW Description Repriced using a provider contracted in the Beech Street Network Repriced using a provider contracted in the Beech Street Supplemental Network Repriced using a provider contracted in the Beech Street Wrap Network Repriced using a provider contracted in the IHG/HPO Network Repriced using a provider contracted in the First Choice Health Network Repriced using a provider contracted in the Fortified Provider Network Repriced using a provider contracted in the HealthEOS Network Repriced using a provider contracted in the AMN/HMN/RAN PPO Network Repriced using a provider contracted in the HealthSmart/HPO Network Repriced using a provider contracted in the CPS IHP Network Repriced using a provider contracted in the Initial Group Network Repriced using a provider contracted in the IHG/HPO Network Repriced using a provider contracted in the AMN/HMN/RAN Network Repriced using a provider contracted in the IHG/HPO Network Repriced using a provider contracted in the Multiplan Complementary Network Repriced using a provider contracted in the PHCS Network Repriced using a provider contracted in the IHG/HPO Network Repriced using a provider contracted in the THREE RIVERS-BUCKEYE Network Repriced using a provider contracted in the THREE RIVERS-MCS Network Repriced using a provider contracted in the Three Rivers Provider Network Repriced using a provider contracted in the Three Rivers Network Repriced using a provider contracted in the Texas True Choice Network Repriced using a provider contracted in the Texas True Choice Network Repriced using a provider contracted in the Texas True Choice Network Repriced using a provider contracted in the VHN LINK Network Repriced using a provider contracted in the VHN LINK Network Repriced using a provider contracted in the VHN LINK Network Copyright 2010 Viant, Inc. All Rights Reserved 28

29 5. Processing/Repricing Results Loop 2400 NTE A claim that is successfully repriced may contain a Reject Code or a Remark Code at the line level. Line-Level Reject Code Description Code Description Notes 002 Claim line # is a duplicate of claim xxxxx line # Professional claims only. The specified line is a duplicate of a line on this claim or another claim. Line-Level Explanatory Codes and Descriptions Code Description Notes 020 ALLOWANCE BASED ON MULTIPLE SURGERY GUIDELINES Procedure Codes (exception of 36415) with any of the following conditions: Modifier 51 attached to one procedure code line item procedure code and another line item contains a (excluding 36415) procedure code, modifier 51 and the same FROM DATE and THRU date of service Modifier 51 attached to one (excluding 36415) procedure code and another line item contains the procedure code no modifier and the same FROM DATE and THRU date of service. More than one (excluding 36415) procedure codes without modifiers submitted on the same FROM DATE and THRU date of service. 050 BILATERAL SURGERY RULE Procedure Codes (exception of 36415) with any of the following conditions: Modifier 50 attached to one procedure code line item procedure code and another line item contains the same procedure code, modifier 50 and the same FROM DATE and THRU Date of service Modifier 50 attached to one procedure code and another line item contains the same procedure code, and the same FROM DATE and THRU Date of Service Modifier 50 attached to one procedure code and it is the only (except 36415) Procedure Code on the claim Two exact procedure codes submitted on the same FROM DATE and THRU Date of service or the same date of service one line with units of 2 for a given procedure code. Copyright 2010 Viant, Inc. All Rights Reserved 29

30 5. Processing/Repricing Results Loop 2400 HCP Claims that have been submitted for repricing against a network contract will be returned with the 2400 HCP segments set as follows. Unsuccessful pricing refers to claims that have failed the Viant business edits, are non-par, or have been rejected. Viant business edits and associated error numbers are listed in Appendix A. Seg Data Description Ref Viant Description/Value HCP Health Care Pricing (Successful Repricing) Pricing Methodology HCP01 Set to 00 = Duplicate line, not repriced or Excluded line Set to 10 = Other Pricing Allowed Amount HCP02 Set to line allowed amount HCP Health Care Pricing (Unsuccessful Repricing) Pricing Methodology HCP01 Set to 00 = Zero Pricing Allowed Amount HCP02 Set to 0 Reject Reason Code HCP13 Set to T1 = Claim is non-par Set to T6 = Claim has failed Viant business edits or has been rejected. Claims that have been successfully repriced using a per diem or case rate methodology have determined the allowed amount for the entire claim. The allowed amount is populated in both the 2300 HCP02 and the 2400 HCP02 on the first service line. Subsequent service lines will have the 2400 HCP02 set to zero. The 2400 HCP02 on the first service line may be greater than the total charges for that line Invalid Codes When inbound claim codes contain invalid values, Viant will still accept the claim and will change the code to a generic value in order to price the claim. The original code will be returned to the client in the repriced claim. Affected codes are: Primary, Admitting, and other Diagnosis codes; Principal and other Procedure codes; and Revenue codes (Institutional only) 5.2 OON Repricing Results Claims that have been submitted for repricing using Viant s Out of Network Services will be returned with the 2300 HCP segment set as follows. OON claims will not be returned with Loop 2400 HCP segments as all OON pricing is done at the claim level. Copyright 2010 Viant, Inc. All Rights Reserved 30

31 5. Processing/Repricing Results Loop 2300 Seg Data Description Ref Viant Description/Value DTP REF NTE HCP HCP Date Date/Time Qualifier DTP01 Set to 050 = Received Date Time Period Format Qualifier DTP02 Set to D8 = CCYYMMDD Date/Time Period DTP02 Date Viant loaded the claim into its EDI database Reference Number Reference Number Qualifier REF01 Set to F8 = Original Reference Number Reference Number REF02 Viant OON claim ID number Note/Special Instruction Note Reference Code NTE01 Set to ADD = Additional Information Description NTE02 Viant OON fixed length information line: Pos 1-3 Service Code Pos 4-6 Status Code Pos 7-80 Description Health Care Pricing (Successful) Pricing Methodology HCP01 Set to 10 = Other Pricing Allowed Amount HCP02 Set to claim allowed amount Repricing Organization ID HCP04 Set to CPSREFERRAL Health Care Pricing (Unsuccessful or Ineligible) Pricing Methodology HCP01 Set to 00 = Zero Pricing Allowed Amount HCP02 Set to eligible charges * Repricing Organization ID HCP04 Set to CPSREFERRAL Reject Reason Code HCP13 Set to T6 * Note that on an unsuccessful claim, the HCP02 will reflect the amount of charges that was eligible for Viant s OON services. If the claim was ineligible for services, this amount will be 0 (zero). OON Service Codes SERVICE PNS EMA GEN IPR OPR DESCRIPTION PROFESSIONAL NEGOTIATION SERVICE EVENT MANAGEMENT GENERAL INPATIENT U&C REPRICING OUTPATIENT U&C REPRICING Copyright 2010 Viant, Inc. All Rights Reserved 31

32 5. Processing/Repricing Results OON Service/Status Code Combinations SERVICE STATUS DESCRIPTION PNS 300 CLOSED - SAVINGS PNS 400 CLOSED NO SAVINGS PNS 920 INELIGIBLE EMA 300 CLOSED - SAVINGS EMA 400 CLOSED NO SAVINGS EMA 920 INELIGIBLE GEN 920 INELIGIBLE PRIOR TO SCORING IPR 300 CLOSED - SAVINGS IPR 400 CLOSED NO SAVINGS IPR 920 INELIGIBLE OPR 300 CLOSED - SAVINGS OPR 400 CLOSED NO SAVINGS OPR 920 INELIGIBLE Copyright 2010 Viant, Inc. All Rights Reserved 32

33 6. Health Care Claim ASC X12N 837 Sender/Receiver Information 6. Health Care Claim ASC X12N 837 Sender/Receiver Information The table below provides Viant s standards for the setting of 837 segment data related to the sender and receiver information. Loop ID Ref Desc ISA ISA01 Data Description Inbound to Viant Outbound from Viant ISA Interchange Control Header Authorization Information Qualifier ISA02 Authorization Information 10 spaces 10 spaces ISA03 Security Information Qualifier ISA04 Security Information 10 spaces 10 spaces ISA05 Interchange ID Qualifier Assigned by Sender 30 ISA06 Interchange Sender ID (must be 15 positions) Assigned by Sender ISA07 Interchange ID Qualifier 30 Assigned by Receiver ISA08 Interchange Receiver ID (must be 15 positions) Assigned by Receiver ISA09 Interchange Date YYMMDD YYMMDD ISA10 Interchange Time HHMM HHMM ISA11 Repetition Separator Assigned by Sender ^ (caret) ISA12 Interchange Control Version Number ISA13 Interchange Control Number Control Number Control Number ISA14 Acknowledgement Requested 0 0 ISA15 Usage Indicator P P ISA16 Component Element Separator Assigned by Sender : (colon) GS GS Segment GS01 Functional ID Code HC HC GS02 Application Sender s Code Assigned by Sender GS03 Application Receiver s Code Assigned by Receiver GS04 Date CCYYMMDD CCYYMMDD GS05 Time HHMM HHMM GS06 Group Control Number Unique Control Number for Unique Control Number for accompanying ISA Copyright 2010 Viant, Inc. All Rights Reserved 33

34 6. Health Care Claim ASC X12N 837 Sender/Receiver Information Loop ID Ref Desc Data Description Inbound to Viant Outbound from Viant accompanying ISA GS07 Responsible Agency Code X X GS08 Version/Release/Industry Identifier Code 1000A NM1 Submitter Name X222A1 or X223A X222A1 or X223A2 NM103 Name Last or Organization Name Assigned by Sender VIANT NM109 Identification Code Assigned by Sender A PER Submitter EDI Contact Information PER02 Contact Name Assigned by Sender VIANT SYSTEMS OPERATIONS PER03 Communication Number Qualifier Assigned by Sender PER04 Communication Number Assigned by Sender [email protected] 1000B NM1 Receiver Name NM103 Name Last or Organization Name VIANT EM Assigned by Receiver NM109 Identification Code Assigned by Receiver GE Transaction Set Trailer GE01 No. of Transaction Sets Included (system-generated) GE02 Group Control Number Must match corresponding GS06 value (system-generated) Must match corresponding GS06 value IEA Interchange Control Trailer IEA01 No. of Included Functional Groups (system-generated) IEA02 Interchange Control Number Must match corresponding ISA13 value (system-generated) Must match corresponding ISA13 value Copyright 2010 Viant, Inc. All Rights Reserved 34

35 7. File Acknowledgement (999s) 7. File Acknowledgement (999s) Viant returns a 999 Implementation Acknowledgement to the Trading Partner for every inbound 837 transaction received. Additionally, Viant requires a 999 Implementation Acknowledgement for each outbound 837 claim file sent to the Trading Partner. Implementation Acknowledgements provide Trading Partners with confirmation that the transactions have been received and that they were either rejected or accepted at the batch, segment or field level. Viant returns a detailed 999 Implementation Acknowledgment with A Accepted or R rejected transactions. 7.1 Acknowledgement Response Time When a Trading Partner submits an 837 claim file, a 999 Implementation Acknowledgement will be placed in the Trading Partner s outbound directory (as outlined in FTP Directory Structure) within 12 hours after the agreed upon transmission times outlined in the Trading Partner s Client Implementation Document. Viant strongly encourages Trading Partners to send fully populated (detailed) 999s to Viant within 12 hours for all 837 transactions received. Acknowledgements will help ensure that the Trading Partner has accepted the claim file(s) sent by Viant. Copyright 2010 Viant, Inc. All Rights Reserved 35

36 8. Provider Data 8. Provider Data Viant will perform standard provider lookup processing which uses provider name, address, and tax ID. Viant accepts the NPI, however, it is not currently used in provider matching. Under standard lookup processing Viant uses the rendering provider as the initial source of information. If a match is not found, the billing provider information is used to perform provider matching. This provider data will be retrieved from the inbound 837 claim file, as described below. Institutional Claims Rendering Provider If populated, the following data from the 837 file will be used as the rendering provider information. Loop 2310E NM1 Service Facility Location Name where NM101 = 77 Loop 2310E N3 Service Facility Location Address Loop 2310E N4 Service Facility Location City/State/Zip Code Loop 2010AA REF Billing Provider Tax Identification where REF01 = EI If Loop 2310E is not populated the billing provider will be considered to also be the rendering provider. Institutional Claims Billing Provider The following data from the 837 file will be used as the billing provider information. Loop 2010AA NM1 Billing Provider Name where NM101 = 85 Loop 2010AA N3 Billing Provider Address Loop 2010AA N4 Billing Provider City/State/Zip Code Loop 2010AA REF Billing Provider Tax Identification where REF01 = EI Professional Claims Rendering Provider If populated, the following data from the 837 file will be used as the rendering provider name: Loop 2310B NM1 Rendering Provider Name where NM101 = 82 If Loop 2310B is not populated, the following data from the 837 file will be used as the rendering provider name: Loop 2010AA NM1 Billing Provider Name where NM101 = 85 If populated, the following data from the 837 file will be used as the rendering provider address: Loop 2310C N3 Service Facility Location Address where NM101 = 77 Loop 2310C N4 Service Facility Location City/State/Zip Code Copyright 2010 Viant, Inc. All Rights Reserved 36

37 8. Provider Data If Loop 2310C is not populated, the Billing Provider address will be used as the Rendering Provider address. The following data from the 837 file will be used as the rendering provider tax: Loop 2010AA REF Billing Provider Tax Identification where REF01 = EI Professional Claims Billing Provider The following data from the 837 file will be used as the billing provider information: Loop 2010AA NM1 Billing Provider Name where NM101 = 85 Loop 2010AA N3 Billing Provider Address Loop 2010AA N4 Billing Provider City/State/Zip Code Loop 2010AA REF Billing Provider Tax Identification where REF01 = EI or SY Copyright 2010 Viant, Inc. All Rights Reserved 37

38 9. Pricing Examples 9. Pricing Examples 9.1 UB claim that was successfully priced at the line level using a Beech Street network contract. CLM* *716.25***13:A:1*Y*A*Y*Y*********N DTP*434*RD8* DTP*435*DT* CL1*2*7*01 REF*D9* REF*9A* VMVMK HI*BK:84500 HI*BN:E9278 HI*BF:E9278*BF:E8499 HI*BH:05:D8: *BH:A1:D8: HI*BE:45:::13 HCP*10*644.64**BEE LX*1 SV2*274*HC:L4350*100.15*UN*1 DTP*472*D8* HCP*10*90.14 LX*2 SV2*290*HC:E0114*60.1*UN*1 DTP*472*D8* HCP*10*54.09 LX*3 SV2*320*HC:73610:LT*191.05*UN*1 DTP*472*D8* HCP*10* LX*4 SV2*450*HC:99282*215.95*UN*1 DTP*472*D8* HCP*10* LX*5 SV2*981*HC:99283*149*UN*1 DTP*472*D8* HCP*10*134.1 Copyright 2010 Viant, Inc. All Rights Reserved 38

39 9. Pricing Examples 9.2 UB claim that was successfully priced at the claim level using a Beech Street network contract. CLM* *920***13:A:1*Y*A*Y*Y*********N DTP*434*RD8* REF*D9* REF*F8* REF*9A*200616DHLGVX HI*BK:36610 HCP*10*749**HMAPPO LX*1 SV2*276*HC:Q1003*200*UN*1 DTP*472*D8* HCP*10*749 LX*2 SV2*490*HC:66984*720*UN*1 DTP*472*D8* HCP*10*0 9.3 HCFA claim that was successfully priced at the line level using a Beech Street network contract. CLM* D0CMMPS*95.05***22::1*Y*A*Y*Y*B REF*D9*10170H0069 REF*9A* WWMP6 HI*BK:V7612 HCP*10*60.71**BEE LX*1 SV1*HC:77057:26*84.15*UN*1*22**1 DTP*472*RD8* HCP*10*50.33 LX*2 SV1*HC:77052:26*10.9*UN*1*22**1 DTP*472*RD8* HCP*10*10.38 Copyright 2010 Viant, Inc. All Rights Reserved 39

40 9. Pricing Examples 9.4 HCFA claim that did not match to a contracted provider. Claim is non-contracted. CLM* *80***12::1*Y*A*Y*N*B REF*G1* REF*D9*ECI100CMB REF*9A*200614FXM8L8 NTE*ADD*602 NON CONTRACT PROVIDER HI*BK:76522*BF:7707*BF:81221 HCP*00*0***********T1 NM1*82*1*DOE*JANE****XX* NM1*77*2*ABC COMPANY LLC N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:97530:GO*40*UN*1*12**1:2:3 DTP*472*RD8* HCP*00*0***********T1 LX*2 SV1*HC:97110:GO*40*UN*1*12**1:2:3 DTP*472*RD8* HCP*00*0***********T1 9.5 UB claim that did not match to a contracted provider. Claim is non-contracted. CLM* *931.65***13:A:1*N**N*N*********Y DTP*434*RD8* DTP*435*DT* CL1*I**01 REF*D9* REF*F8* REF*9A* V12 NTE*ADD*602 NON CONTRACT PROVIDER HI*BK:38912 HI*DR:000 HCP*00*0***********T1 LX*1 SV2*0470*HC:92591*231.74*UN*1 DTP*472*D8* HCP*00*0***********T1 LX*2 SV1*0471*HC:92557*401.25*UN*1 DTP*472*D8* HCP*00*0***********T1 LX*3 SV2*0471*HC:92567*149.33*UN*1 DTP*472*D8* HCP*00*0***********T1 LX*4 SV2*0471*HC:92568*149.33*UN*1 DTP*472*D8* HCP*00*0***********T1 Copyright 2010 Viant, Inc. All Rights Reserved 40

41 9. Pricing Examples 9.6 UB claim that failed a Viant business edit. CLM* * ***11:A:1*N*A*Y*N*********Y DTP*434*RD8* REF*9A* _prd01 REF*D9* NTE*ADD*VE009 Admission Date required on inpatient claim. HI*BK:56211 HI*DR:0 HCP*00*0*0**********T6 LX*1 SV2*0121** *UN*5* DTP*472*D8* HCP*00*0*0**********T6 9.7 HCFA claim that failed a Viant business edit. CLM* *260***12::1*N*A*Y*Y*B PWK*OZ*BM***AC* REF*D9* REF*9A* _prd01 NTE*ADD*VE019 Service To Date cannot be greater than current date. HI*BK:78053 HCP*00*0*0**********T6 NM1*82*2*ABC COMPANY LLC*****XX* PRV*PE*ZZ*208D00000X NM1*77*2*ABC COMPANY LLC*****XX* N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:E0470:RR*260*UN*1*12**1 DTP*472*RD8* HCP*00*0*0**********T6 9.8 HCFA claim that matched to a provider, but could not be repriced. CLM* *95***11::1*Y*C*Y*N*C REF*D9* REF*9A* BC4QS NTE*ADD*603 Non Contract Services HI*BK:30390*BF:78079*BF:34590 HCP*00*0***********T6 LX*1 SV1*HC:36415*20*UN*1***1 DTP*472*D8* HCP*00*0***********T6 LX*2 SV1*HC:82306*75*UN*1*81**1 DTP*472*D8* HCP*00*0***********T6 Copyright 2010 Viant, Inc. All Rights Reserved 41

42 9. Pricing Examples 9.9 UB claim that matched to a provider, but could not be repriced. This claim also contains an external claim comment in the 2300 K3 segments. CLM* * ***11:A:1*N**Y*N*********Y DTP*434*RD8* DTP*435*DT* CN1*06 REF*D9* REF*9A* DFC91 K3*ADD Questionable claim data. Admission date is after the statement from and thro K3*ADD ugh dates of service. NTE*ADD*603 NON CONTRACT SERVICES HI*BK:29181 HI*BF:30391*BF:30401*BF:2920*BF:30981*BF:3004*BF:3051 HI*BR:9468:D8: HCP*00*0***********T6 NM1*72*1*DOE*JOHN****XX* LX*1 SV2*0126**1800*DA*2 DTP*472*D8* HCP*00*0***********T6 LX*2 SV2*0250**94.09*UN*69 DTP*472*D8* HCP*00*0***********T6 LX*3 SV2*0270**24.35*UN*1 DTP*472*D8* HCP*00*0***********T6 LX*4 SV2*0300** *UN*11 DTP*472*D8* HCP*00*0***********T6 LX*5 SV2*0301**102.2*UN*2 DTP*472*D8* HCP*00*0***********T6 LX*6 SV2*0305**103.7*UN*1 DTP*472*D8* HCP*00*0***********T6 LX*7 SV2*0450**530.4*UN*1 DTP*472*D8* HCP*00*0***********T6 Copyright 2010 Viant, Inc. All Rights Reserved 42

43 9. Pricing Examples 9.10 HCFA claim that is a duplicate claim. CLM* *7722***21::1*Y*C*Y*N*C REF*D9* REF*P4* REF*9A*200621B3TDZV NTE*ADD*002 Claim is a duplicate HI*BK:6111*BF:61181*BF:V103*BF:V4571 HCP*00*0***********T6 NM1*82*1*DOE*JOHN****XX* NM1*77*2*ABC COMPANY LLC*****XX* N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:19318*3861*UN*1*21**1 DTP*472*D8* NTE*ADD*002 Claim line 1 is a duplicate of claim line 1 HCP*00*0***********T6 LX*2 SV1*HC:19318:50*3861*UN*1*21**1 DTP*472*D8* NTE*ADD*002 Claim line 2 is a duplicate of claim line 2 HCP*00*0***********T UB claim that is a duplicate claim. CLM* *249***13:A:1*Y*A*Y*Y*********Y DTP*434*RD8* DTP*435*DT* REF*D9* REF*9A* XL4F7 NTE*ADD*002 Claim is a duplicate of claim HI*BK:2449 HCP*00*0***********T6 LX*1 SV2*300*HC:36415*10*UN*1 DTP*472*D8* HCP*00*0***********T6 LX*2 SV2*301*HC:84436*115*UN*1 DTP*472*D8* HCP*00*0***********T6 LX*3 SV2*301*HC:84481*124*UN*1 DTP*472*D8* HCP*00*0***********T6 Copyright 2010 Viant, Inc. All Rights Reserved 43

44 9. Pricing Examples 9.12 HCFA claim that is successfully priced but has a duplicate line. CLM* *19.8***23::1*Y*C*Y*N*C REF*D9* REF*9A* QRR7 HI*BK:78909*BF:4019 HCP*10*10.80**BEE NM1*82*1*DOE*JANE*C***XX* NM1*77*2*ABC COMPANY LLC*****XX* N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC: 80053:26*7.1*UN*1***1 DTP*472*D8* NTE*ADD*002 Claim line 1 is a duplicate of claim WEB VRQZ line 1 HCP*03*0 LX*2 SV1*HC:85025:26*7.1*UN*1***1 DTP*472*D8* HCP*03*6.04 LX*3 SV1*HC:81015:26*5.6*UN*1***1 DTP*472*D8* HCP*03* HCFA claim successfully repriced with duplicate surgery calculation CLM* *2772***99::1*Y*A*Y*Y*S REF*F8* REF*D9* REF*9A*200712DKM2TZ HI*BK:78791*BF:78906*BF:2111*BF:53560 HCP*10* **BEE NM1*82*1*DOE*JOHN*M***XX* NM1*77*2*ABC COMPANY LLC N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:45380*1121*UN*1*24**1:2 DTP*472*RD8* HCP*10* LX*2 SV1*HC:43251*853*UN*1*24**3:4:2 DTP*472*RD8* NTE*ADD*020 ALLOWANCE BASED ON MULTIPLE SURGERY GUIDELINES HCP*02* LX*3 SV1*HC:43239:59*798*UN*1*24**4:3:2 DTP*472*RD8* HCP*10* Copyright 2010 Viant, Inc. All Rights Reserved 44

45 9. Pricing Examples 9.14 HCFA out of network claim priced using Professional Negotiation Services (PNS). Negotiation was successful and savings was achieved. CLM* *400***99::1*N*C*N*N**OA DTP*439*D8* REF*F8* REF*D9* REF*9A* X631 NTE*ADD*PNS300CLOSED - SAVINGS HI*BK:7993 HCP*10*220**CPSREFERRAL NM1*82*1*DOE*JANE****XX* NM1*77*2*ABC COMPANY LLC N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:A0428:PN*300*UN*1*41**1 DTP*472*RD8* REF*6R*1 AMT*AAE*0 LX*2 SV1*HC:A0425:PN*100*UN*10*41**1 DTP*472*RD8* HCFA out of network claim priced using Professional Negotiation Services (PNS). Negotiation was unsuccessful and no savings were achieved. The eligible charges (HCP02) are less than the total charges (CLM02). CLM* *359.1***99::1*N*C*N*N**OA DTP*439*D8* REF*F8* REF*D9* REF*9A* X6ZQ NTE*ADD*PNS400CLOSED - NO SAVINGS HI*BK:311*BF:V7109 HCP*00*337.55**CPSREFERRAL*********T6 NM1*82*1*DOE*JOHN****XX* PRV*PE*ZZ*XXX NM1*77*2*ABC COMPANY LLC*****XX* N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:90808*359.1*UN*1*53**1 DTP*472*RD8* Copyright 2010 Viant, Inc. All Rights Reserved 45

46 9. Pricing Examples 9.16 HCFA out of network claim priced using Professional Negotiation Services (PNS). Negotiation was unsuccessful and no savings were achieved. The eligible charges (HCP02) are equal to the total charges (CLM02). CLM* * ***99::1*N*C*N*N**OA DTP*439*D8* REF*F8* REF*D9* REF*9A* XL49 NTE*ADD*PNS400CLOSED - NO SAVINGS HI*BK:3591*BF:51881 HCP*00* **CPSREFERRAL*********T6 NM1*82*1*DOE*JOHN****XX* LX*1 SV1*HC:E0483:RR* *UN*1*12**1 DTP*472*RD8* HCFA out of network claim that was ineligible for any out of network services. The eligible charges (HCP02) are 0. CLM* *735***99::1*N*C*N*N**OA DTP*439*D8* REF*F8* REF*D9* REF*9A* WXK NTE*ADD*GEN920INELIGIBLE - PRIOR TO SCORING HI*BK:37487 HCP*00*0**CPSREFERRAL*********T6 NM1*82*1*DOE*JOHN****XX* NM1*77*2*ABC COMPANY LLC*****XX* N3*123 MAIN STREET N4*CHICAGO*IL* LX*1 SV1*HC:00103*735*MJ*30*24**1 DTP*472*RD8* Copyright 2010 Viant, Inc. All Rights Reserved 46

47 9. Pricing Examples 9.18 UB out of network claim priced using Inpatient Repricing Services (IPR). Claim was successfully priced with savings. CLM* * ***11:A:1*N**N*N*********Y DTP*096*TM*1700 DTP*434*RD8* DTP*435*DT* REF*D9* REF*F8* REF*9A* X4V7 NTE*ADD*IPR300CLOSED - SAVINGS HI*BK:185 HI*DR:708 HI*BF:4019*BF:V5866 HI*BR:605:D8: HCP*10* **CPSREFERRAL LX*1 SV2*0121**1748*UN*1*0 DTP*472*D8* LX*2 SV2*0250** *UN*2 DTP*472*D8* LX*3 SV2*0258**132*UN*1 DTP*472*D8* LX*4 SV2*0270**362*UN*1 DTP*472*D8* LX*5 SV2*0271**148*UN*1 DTP*472*D8* LX*6 SV2*0272**64*UN*1 DTP*472*D8* LX*7 SV2*0301**252*UN*1 DTP*472*D8* LX*8 SV2*0302**221.75*UN*1 DTP*472*D8* LX*9 SV2*0305**91*UN*1 DTP*472*D8* LX*10 SV2*0310**154.75*UN*1 DTP*472*D8* LX*11 SV2*0360**28896*UN*1 DTP*472*D8* LX*12 SV2*0360**2294*UN*1 DTP*472*D8* LX*13 SV2*0710**1123.2*UN*1 DTP*472*D8* Copyright 2010 Viant, Inc. All Rights Reserved 47

48 Appendix A: Viant Business Edits Appendix A: Viant Business Edits Viant will read in the Trading Partner s 837 inbound claim file and perform the following Viant Business Edits on each claim. This validation is only done on claims that have passed the 837 syntax Level 1, Level 2 and Level 3 compliance check. Each Business Edit applies to both Institutional and Professional claims unless otherwise specifically noted. Loop Field Edit Error # Error Message 2010AA Billing Provider N402 State must be a valid 2- character US state or possession. VE021 Billing Provider State must be a valid state 2010AA Billing Provider N AA N403 must be 5 or 9 characters in length. VE002 Billing Zip Code must be 5 or 9 characters 2000B Subscriber SBR03 SBR03 must be present. (Applies to Client or Clientapproved vendor) VE023 Employer Group Number is required 2000C Patient HL Segment If 2000B SBR02 not = 18, 2000C HL segment must be present. VE005 Patient information is required Institutional 2300 Claim Information DTP If 2300 DTP01 = 434 and DTP02 = D8, DTP03 must be less than or equal to current date. If 2300 DTP01 = 434 and DTP02 = RD8, the first date in DTP03 must be less than or equal to current date. VE006 Statement From Date cannot be greater than current date Institutional 2300 Claim Information DTP If 2300 DTP01 = 434 and DTP02 = RD8, the second date in DTP03 must be less than or equal to current date. VE007 Statement To Date cannot be greater than current date Institutional 2300 Claim Information DTP If 2300 DTP01 = 434 and DTP02 = RD8, the second date in DTP03 must be greater than or equal to the first date in DTP03. VE008 Statement To Date must be greater than or equal to Statement From Date Institutional 2300 Claim Information DTP If this in an inpatient claim a DTP segment must be present with DTP01 = 435. VE009 Admission Date required on inpatient claim Institutional 2300 Claim Information DTP If 2300 DTP01 = 435, DTP03 must be less than or equal to current date. VE010 Admission Date cannot be greater than current date 2300 Claim Information CLM 2300 CLM02 must be greater than zero. VE012 Total Charges must be greater than zero Institutional 2300 Claim Information CLM 2300 CLM05-1 concatenated with CLM05-3 must be a valid Bill Type. VE013 Invalid Bill Type xxx (where xxx is the Bill Type value) Copyright 2010 Viant, Inc. All Rights Reserved 48

49 Appendix A: Viant Business Edits Loop Field Edit Error # Error Message Professional 2310C Service Facility N402 State must be a valid 2- character US state or possession VE022 Rendering Provider State must be a valid state Institutional 2310E Service Facility N402 State must be a valid 2- character US state or possession. VE022 Rendering Provider State must be a valid state Professional 2310D Service Facility N403 If 2310D N4 segment is present, 2310D N403 must be 5 or 9 characters in length. VE015 Rendering Zip Code must be 5 or 9 characters Institutional 2310E Service Facility N403 If 2310E N4 segment is present, 2310E N403 must be 5 or 9 characters in length. VE015 Rendering Zip Code must be 5 or 9 characters 2400 Service Line DTP If 2400 DTP01 = 472 and DTP02 = D8, DTP03 must be less than or equal to current date. If 2400 DTP01 = 472 and DTP02 = RD8, the first date in DTP03 must be less than or equal to current date. VE018 Service From Date cannot be greater than current date 2400 Service Line DTP If 2400 DTP01 = 472 and DTP02 = RD8, the second date in DTP03 must be less than or equal to current date. VE019 Service To Date cannot be greater than current date 2400 Service Line DTP If 2400 DTP01 = 472 and DTP02 = RD8, the second date in DTP03 must be greater than or equal to the first date in DTP03. VE020 Service To Date must be greater than or equal to Service From Date Copyright 2010 Viant, Inc. All Rights Reserved 49

50 Appendix B: Viant Business Edit Results File Proprietary Format Appendix B: Viant Business Edit Results File Proprietary Format Business Edit Results File This record will appear once for each error message. A single claim could have multiple errors, therefore multiple records. Field No. Field Name Type Len Start POS Req Comments/Mapping Info 1 Claim Number A 30 1 OUT Submitter Claim Number 2 Sequence Number A 3 31 OUT 3 Filler A 1 34 OUT 4 Error Code A 5 35 OUT 5 Filler A 1 40 OUT 6 Error Message A OUT 140 Total record length A sample of the Business Edit Results file is shown below: VE001 Billing Provider Tax ID must be 9 characters VE013 Invalid Bill Type VE009 Admission Date required on inpatient claim. Copyright 2010 Viant, Inc. All Rights Reserved 50

51 Appendix C: Trading Partner Setup Form Appendix C: Trading Partner Setup Form In order to set up EDI to exchange PGP encrypted files via FTP, the following information will be needed. Your Viant Implementation Manager will be your point of contact regarding the transfer of data between Viant and Trading Partner for this implementation. Please note that it may take Viant up to 5 business days to complete the FTP setup before any file can be exchanged. Please complete the following information and this form, PGP key, Companion Guide and supporting documentation to your designated Viant Implementation Manager or Viant Business Analyst. Date Name of Person Completing Form Trading Partner Name Viant Client Name GENERAL INFORMATION CONTACT INFORMATION Primary IT Operational Contact Information (for file exchange support) Name Days and Hours of Availability Time Zone Phone Fax Primary Technical Contact Information (for FTP setup) Name Days and Hours of Availability Time Zone Phone Fax GENERAL EDI FILE INFORMATION HIPAA Compliance Level 3? Other: 999 Acknowledgements: Receive? Send? Please indicate below if your claim file character delimiters vary from Viant s: Viant Characters Trading Partners Characters DELIMITER Character Name Character Name * Asterisk Data Element Separator : Colon Sub-element Separator ~ Tilde Segment Terminator ^ Caret Repetition Separator Copyright 2010 Viant, Inc. All Rights Reserved 51

52 Appendix C: Trading Partner Setup Form SENDER/RECEIVER INFORMATION ASC X12 Transaction Information: Please complete the following shaded values Viant will be expecting in each of the Sender/Receiver data segments. **Viant expects one ST/SE for each claim. Loop/Segment Outbound to Trading Partner Inbound to Viant ISA05 30 ISA ISA07 30 ISA GS GS GS06 Sequentially incremented Sequential incremented Unique but not sequential GS X222A1 or X223A2 1000A/NM103 VIANT 1000A/NM B/NM103 VIANT 1000B/NM In your files, is each claim enveloped individually in its own ST/SE? Do your files include nested claims? Nested claims are ones that include multiple CLM segments under one billing provider (2010AA). For example, there may be multiple SBRs with the associated CLMs, or multiple PATs with the associated CLMS, or one SBR with multiple CLMs. FTP INFORMATION Transmission Method Viant prefers to host the FTP server connection. Do you have the ability to accommodate this preference for file exchanges? See Viant s Client Companion Guide for FTP site details. Inbound Outbound If No is selected above, please fill-in the following site and directory information for Test and Production. Production Test Host Name Username Directory to Viant Directory to Partner Copyright 2010 Viant, Inc. All Rights Reserved 52

53 Appendix C: Trading Partner Setup Form Files must be encrypted and have an extension of ASC or PGP. PLEASE RETURN YOUR PGP KEY WHEN RETURNING THIS FORM. Can you comply with Viant s file naming conventions, as detailed below? If not, please detail your naming conventions. The following is Viant s standard file naming convention: XXXXXX will be the assigned code that represents the Trading Partner # represents either I for institutional or P for professional claims CCYYMMDDHHMMSS is the date and time stamp NNNN represents a unique number used to differentiate file names Inbound to Viant from Trading Partner: Claim File: XXXXXX_837#_IN_CCYYMMDDHHMMSS 999 File: XXXXXX_999_IN_CCYYMMDDHHMMSSNNNN Outbound to Trading Partner from Viant: Processed Claim File: XXXXXX_837#_OUT_CCYYMMDDHHMMSS 999 File: XXXXXX_999_OUT_CCYYMMDDHHMMSSNNNN Error File: ERRXXXXXX_837#_OUT_CCYYMMDDHHMMSS ================================================================== For Viant use only Trading Partner Type Client PGP Key Name: Copyright 2010 Viant, Inc. All Rights Reserved 53